重症超声对脓毒性休克患者小剂量容量负荷试验容量反应性的评估价值

Evaluation of fluid responsiveness in patients with septic shock by critical ultrasound with small dose fluid challenge

目的探索重症超声对脓毒性休克患者小剂量容量负荷试验容量反应性的评估价值。方法筛选大同市第三人民医院2021年1月至12月收治的36例脓毒性休克患者作为研究对象,以盲抽签方式将患者分为对照组和观察组,每组18例。对照组采用传统容量负荷试验(30 min内输入晶体液500 mL);观察组采用小剂量容量负荷试验(1 min内输入晶体液100 mL)。两组均行血流动力学指标〔中心静脉压(CVP)、有创平均动脉压(MAP)、颈动脉血流速度-时间积分(VTI)〕变化及肺部超声评分监测,观察两组患者的转归相关指标,评估上述指标与容量负荷试验剂量的相关性。结果与对照组比较,观察组患者试验后心率(HR)和CVP均明显低于对照组〔HR(次/min):99.74±3.22比107.65±3.14,CVP(mmHg,1 mmHg≈0.133 kPa):7.55±0.22比10.26±0.52,均P<0.05〕,有创MAP和VTI均明显高于对照组〔有创MAP(mmHg):77.36±2.14比69.81±2.56,VTI(cm/s):68.85±1.26比44.71±1.28,均P<0.05〕。观察组双肺1~5区各区超声评分均明显优于对照组(均P<0.05)。转归方面,观察组重症监护病房(ICU)住院时间、机械通气时间、尿量达≥0.5 mL·kg-1·h-1时间均较对照组明显缩短〔ICU住院时间(h):138.26±1.25比205.73±1.26,机械通气时间(h):36.80±0.25比47.65±0.36,尿量达≥0.5 mL·kg-1·h-1时间(h):27.38±1.25比38.61±1.30,均P<0.05〕,去甲肾上腺素使用剂量较对照组明显减少(mg:45.26±1.85比53.73±1.92,P<0.05),血流动力学方面复苏平衡液体量较对照组明显减少(mL:1532.62±12.38比1755.52±12.30,P<0.05)。相关性分析显示,晶体液输注量与M-BLUE肺部超声评分(2区、4区、5区)、机械通气时间、去甲肾上腺素用量、尿量达标时间及ΔVTI的相关性高度一致(均P<0.05)。结论脓毒性休克患者应用重症超声监测小剂量容量负荷试验对容量反应性有较高的评估价值,可更好地降低液体过负荷所致组织明显水肿进而造成器官损伤甚至危及生命的风险,使容量治疗更加合理恰当,从而提高救治的成功率。

Objective To explore the value of critical ultrasound in evaluating the fluid responsiveness of small dose volume challenge in patients with septic shock.Methods Thirty-six patients with septic shock admitted to the Third People's Hospital of Datong from January 2021 to December 2021 were enrolled,and the patients were randomly divided into control group and observation group,with 18 patients in each group.The control group was treated with traditional fluid challenge(500 mL of crystalloid injected within 30 minutes);the observation group received a small dose fluid challenge(100 mL of crystalloid injected within 1 minute).The hemodynamic indexes[central venous pressure(CVP),invasive mean arterial pressure(MAP),velocity-time integra(VTI)]and bilateral lung ultrasound scores were measured by critical ultrasound in both groups.The outcome related indicators of patients in the two groups were observed.The correlation between the above indexes and the fluid challenge was evaluated.Results Compared with the control group,the heart rate(HR)and CVP of patients in the observation group after the challenge were significantly lower than those in the control group[HR(times/min):99.74±3.22 vs.107.65±3.14,CVP(mmHg,1 mmHg≈0.133 kPa):7.55±0.22 vs.10.26±0.52,both P<0.05],invasive MAP and VTI were significantly higher than those in the control group[invasive MAP(mmHg):77.36±2.14 vs.69.81±2.56,VTI(cm/s):68.85±1.26 vs.44.71±1.28,both P<0.05].The ultrasonic score of the observation group was significantly better than those of the control group(all P<0.05).In terms of outcome,the length of intensive care unit(ICU)stay,mechanical ventilation time and the time for urine volume more than 0.5 mL·kg-1·h-1 of the observation group were significantly shorter than those in the control group[the length of ICU stay(hours):138.26±1.25 vs.205.73±1.26,mechanical ventilation time(hours):36.80±0.25 vs.47.65±0.36,time to reach urine volume more than 0.5 mL·kg-1·h-1(hours):27.38±1.25 vs.38.61±1.30,all P<0.05],The dosage of norepinephrine was significantly decreased in the observation group compared with the control group(mg:45.26±1.85 vs.53.73±1.92,P<0.05),and the amount of resuscitation crystalloid was significantly reduced compared with the control group(mL:1532.62±12.38 vs.1755.52±12.30,P<0.05).Correlation analysis showed that the volume of crystalloid was highly consistent with M-BLUE pulmonary ultrasound(zone 2,4 and 5),mechanical ventilation time,norepinephrine dose,time to reach the standard of urine volume andΔVTI(all P<0.05).Conclusions Small dose fluid challenge evaluated by critical ultrasound in septic shock patients has a high value for fluid responsiveness,which can better reduce the risk of obvious tissue edema caused by fluid overload,organ damage and even life-threatening,make fluid challenge more reasonable and appropriate,thereby improving the success of treatment.