床旁超声在儿童脓毒性休克液体复苏中的应用价值

Clinical application of bedside ultrasound measurement of inferior vena cava diameter combined with lung ultrasound in fluid resuscitation of children with septic shock

目的探讨床旁超声在脓毒性休克患儿液体复苏中的临床价值。方法选取2021年12月至2023年1月收治河北医科大学附属河北省儿童医院重症医学一科诊断为脓毒性休克的患儿50例,采用随机数字表法分为常规组和超声组,每组25例。患儿入院后均给予抗感染、呼吸支持等对症治疗。2组均给予初始液体复苏(20 mL/kg醋酸钠林格液)。常规组在初始液体复苏后按照指南(早期目标导向治疗6 h目标)继续液体复苏;超声组在初始液体复苏后根据超声测下腔静脉内径及肺部超声检查指导后续液体复苏。比较2组液体复苏6、12 h后心率、平均动血压(mean arterial pressure,MAP)及中心静脉血氧饱和度(Systemic central venous oxygen saturation,ScvO_(2))指标变化,并比较2组患儿24 h液体入量及血管药物评分、液体复苏12、24、48 h氧合指数变化、肺水肿发生例数及28 d病死率。结果液体复苏6、12后2组患儿的心率、MAP、ScvO_(2)指标比较,差异无统计学意义(P>0.05)。超声组24 h液体总入量少于常规组,差异有统计学意义(P<0.05),24 h血管活性药物评分低于常规组,但差异无统计学意义(P>0.05)。液体复苏12 h超声组氧合指数高于常规组,但差异无统计学意义(P>0.05),液体复苏24、48 h超声组患儿的氧合指数明显高于常规组,差异有统计学意义(P<0.05)。超声组液体复苏期间发生肺水肿的例数少于常规组,差异有统计学意义(P<0.05);2组患儿的28 d病死率比较,差异无统计学意义(P>0.05)。结论床旁超声测下腔静脉内径联合肺部超声可以指导儿童脓毒性休克的液体管理,减少液体入量,优化容量状态,改善血流动力指标,降低肺水肿发生的风险,因超声具有无创性,在儿科临床应用更广泛,益于儿童。

Objective To investigate the clinical value of bedside ultrasound in fluid resusciation of children with septic shock.Methods Fifty children diagnosed with septic shock in the First Department of Critical Medicine,Hebei Children’s Hospital Affiliated to Hebei Medical University from December 2021 to January 2023 were recruited.They were assigned into the routine group and the ultrasound group by random number table method,with 25 cases in each group.After admission,all children were given symptomatic treatment like anti-infection and respiratory support.Children in both groups were given an initial fluid resuscitation(20mL/kg sodium acetate Ringer’s injection).After initial fluid resusciation,children in the routine group were continuously managed by fluid resuscitation according to the guideline,with the early goal-directed therapy for 6h,and those in the ultrasound group were managed by fluid resuscitation guided by the ultrasound examination of inferior vena cava diameteRand lung ultrasound examination.Heart rate at 6h and 12h after fluid resuscitation,mean arterial pressure(MAP)and systemic central venous oxygen saturation(ScvO_(2))were compared between the two groups.Total fluid intake at 24h and vascular drug scores,oxygenation index at 12h,24h and 48h after fluid resuscitation,case number of pulmonary edema and 28-day mortality were also compared between the two groups.Results There were no significant differences in the heart rate,MAP and ScvO_(2) at 6h and 12h of fluid resuscitation between the two groups(P>0.05).Total fluid intake at 24h in the ultrasound group was significantly lower than that of the routine group(P<0.05).The score of vasoactive drugs at 24h was lower in the ultrasound group than that of the routine group,although a significant difference was not detectable(P>0.05).At 12h of liquid resuscitation,the oxygenation index in the ultrasound group was higher than that of the routine group,although a significant difference was not detectable(P>0.05).The oxygenation indexes at 24h and 48h of liquid resuscitation in the ultrasound group were significantly higher than those of the routine group(P<0.05).The case number of pulmonary edema during liquid resuscitation in the ultrasound group was significantly less than that of the routine group(P<0.05).There was no significant difference in the 28-day mortality between groups(P>0.05).Conclusion Bedside ultrasound measurement of inferior vena cava diameteRcombined with lung ultrasound can guide fluid management of septic shock in children,reduce fluid intake and risk of pulmonary edema,optimize volume status,and improve hemodynamic indicators.The non-invasive ultrasonography is more suitable for children and widely applied in pediatric clinic.