Pcv-aCO_(2)/Ca-cvO_(2)联合血气乳酸水平指导院前创伤性休克患者早期复苏的目标

Pcv-aCO_(2)/Ca-cvO_(2)combined with arterial lactate level as early resuscitation goals in patients with traumatic shock

目的探讨中心静脉-动脉血二氧化碳分压差(central venous-arterial carbondioxide difference,Pcv-aCO_(2))与动脉-中心静脉血氧含量差(arterial-central venous oxygen content difference,Ca-cvO_(2))的比值(Pcv-aCO_(2)/Ca-cvO_(2))联合血气乳酸水平作为院前创伤性休克患者早期复苏目标对预后的意义。方法回顾性分析常德市第一人民医院120急救中心2021年9月—2022年9月院前接诊的145例创伤性休克患者,其中男性73例,女性72例;年龄19~78岁,平均58.4岁;道路交通伤49例,高处坠落伤28例,击打伤17例,跌倒伤27例,其他24例。在120救护车上完成动脉置管和中心静脉置管术测定Pcv-aCO_(2)/Ca-cvO_(2)值,同时采取床旁即时检验进行血气乳酸水平的监测。于休克复苏后1h(T1)按Pcv-aCO_(2)/Ca-cvO_(2)和血气乳酸值结果分为4组:A组(n=45):Pcv-aCO_(2)/Ca-cvO_(2)>1.8、乳酸水平>2mmol/L;B组(n=31):Pcv-aCO_(2)/Ca-cvO_(2)>1.8、乳酸水平≤2mmol/L;C组(n=37):Pcv-aCO_(2)/Ca-cvO_(2)≤1.8、乳酸水平>2mmol/L;D组(n=32):Pcv-aCO_(2)/Ca-cvO_(2)≤1.8、乳酸水平≤2mmol/L。比较各组间液体治疗开始时间(T0)和液体复苏后1h(T1)心率、中心静脉压、平均动脉压、中心静脉血氧饱和度水平,入院后24h及第3天急性生理与慢性健康(acute physiology and chronic health evaluation,APACHE)II和序贯器官衰竭评分(sequential organ failure assessment,SOFA)评分、住院时间、28d病死率。结果四组患者T0时心率、中心静脉压、平均动脉压、中心静脉血氧饱和度差异无统计学意义(P>0.05)。与T0相比,T1时的心率、中心静脉压、平均动脉压、中心静脉血氧饱和度比较差异有统计学意义(P<0.05)。D组在第3天的APACHE II(13.7±4.1)分和SOFA评分(5.2±2.1)分最低,住院时间最短(6.4±2.5)d,28d病死率(9.3%)最低,生存时间中位数最长,与A组比较差异有统计学意义(P<0.05)。T1时的Pcv-aCO_(2)/Ca-cvO_(2)和血气乳酸水平是28d病死率的独立预测因子。Pcv-aCO_(2)/Ca-cvO_(2)联合血气乳酸水平的受试者工作特征(ROC)曲线下面积显著大于单独Pcv-aCO_(2)/Ca-cvO_(2)或血气乳酸水平的ROC曲线下面积(P<0.05)。结论Pcv-aCO_(2)/Ca-cvO_(2)联合血气乳酸水平可预测创伤性休克患者不良结局,并为院前评估创伤性休克早期复苏的充分性提供有用信息。

Objective To investigate the ratio of central venous-arterial carbon dioxide difference(Pcv-aCO_(2))to arterial-central venous oxygen content difference(Ca-cvO_(2)),i.e.,Pcv-aCO_(2)/Ca-cvO_(2),combined with arterial lactate level as early resuscitation goals in traumatic shock and its predictive value for the 28-day mortality.Methods This retrospective analysis was conducted on 145 patients with traumatic shock admitted to our department from Sep.2021 to Sep.2022,including 73 male and 72 female aged 19-78 years,mean 58.4 years.Among them,49 were due to road traffic accidents,28 falls from height,17 strike injuries,27 falls and 24 others.At the 120 ambulance,arterial and central vein catheterization was conducted to calculate the Pcv-aCO_(2)/Ca-cvO_(2)value.The lactate level was monitored by bedside point-of-care testing.Patients were classified into 4 groups according to Pcv-aCO_(2)/Ca-cvO_(2)value and lactate level at 1 h after resuscitation(T1):Group A(Pcv-aCO_(2)/Ca-cvO_(2)>1.8 and lactate level>2 mmol/L,n=45);Group B(Pcv-aCO_(2)/Ca-cvO_(2)>1.8 and lactate level≤2mmol/L,n=31);Group C(Pcv-aCO_(2)/Ca-cvO_(2)≤1.8 and lactate level>2mmol/L,n=37)and Group D(Pcv-aCO_(2)/Ca-cvO_(2)≤1.8 and lactate level≤2mmol/L,n=32).T0 and T1 heart rate,central venous pressure,mean arterial pressure,and central venous oxygen saturation,acute physiology and chronic health evaluationⅡ(APACHEⅡ)scores and sequential organ failure assessment(SOFA)scores at 24 h and day 3 after admission,length of hospital stay and 28-day mortality were compared among groups.Results No significant differences in baseline(T0)heart rate,central venous pressure,mean arterial pressure,and central venous oxygen saturation were observed between the four groups(P>0.05).There were significant differences in heart rate,central venous pressure,mean arterial pressure,and central venous oxygen saturation after resuscitation induction(T1)compared with baseline.Group D revealed the lowest APACHEⅡscore(13.7±4.1)and SOFA score(5.2±2.1)at day 3,had the shortest length of intensive care unit stay(d,6.4±2.5),the lowest 28-day mortality(9.3%)and the longest median survival time.The difference was significant compared with Group A(P<0.05).Pcv-aCO_(2)/Ca-cvO_(2)and lactate level at T1 were independent predictors for the 28-day mortality.The area under ROC curve for Pcv-aCO_(2)/Ca-cvO_(2)combined with lactate level was significantly larger than either Pcv-aCO_(2)/Ca-cvO_(2)or lactate level alone(both P<0.05).Conclusion Pcv-aCO_(2)/Ca-cvO_(2)and lactate level can combinedly predict the 28-day mortality in traumatic shock patients,which may provide useful information for assessing the adequacy of resuscitation in early phase.