床旁超声评估脓毒症患者膈肌和肢体骨骼肌的动态变化及其与血尿素/肌酐比值的相关性

Dynamic changes of diaphragm and limb skeletal muscle in patients with sepsis assessed by bedside ultrasound and their correlation with blood urea/creatinine ratio

目的应用床旁超声探讨脓毒症患者入重症监护病房(ICU)7 d内膈肌和肢体骨骼肌的动态变化及其与血尿素/肌酐比值(UCR)的相关性。方法采用前瞻性观察性研究方法,选择2022年6月至2023年2月入住宁夏医科大学总医院ICU的55例脓毒症患者作为研究对象。观察患者的一般资料、入ICU第1、4、7天实验室检查指标〔血尿素、血肌酐(SCr)、UCR〕和预后指标;应用床旁超声动态评估患者入ICU第1、4、7天膈肌形态学动态变化〔包括膈肌移动度(DE)、吸气末膈肌厚度(DTei)、呼气末膈肌厚度(DTee)〕,以及肢体骨骼肌(股四头肌)形态学动态变化〔包括股直肌厚度(RF-MLT)、股中间肌厚度(VI-MLT)和股直肌横截面积(RF-CSA)〕。计算膈肌增厚分数(DTF)和RF-CSA萎缩率,并统计膈肌功能障碍和肢体骨骼肌功能障碍的发生率。采用Pearson相关性分析患者入ICU 7 d内各时间点膈肌和股四头肌超声形态学参数与UCR的相关性。结果共纳入55例脓毒症患者,其中29例为脓毒性休克。随入ICU时间延长,脓毒症患者膈肌功能障碍发生率呈先升高后下降趋势(入ICU第1、4、7天分别为63.6%、69.6%、58.6%),肢体骨骼肌功能障碍发生率呈升高趋势(入ICU第4天和第7天分别为54.3%、62.1%),入ICU第4天和第7天两者同时发生的概率分别为32.6%、34.5%。脓毒症患者入ICU第7天UCR明显高于第1天〔121.77(95.46,164.55)比97.00(70.26,130.50)〕,RF-CSA萎缩率明显高于第4天〔%:-39.7(-52.4,-22.1)比-26.5(-40.2,-16.4)〕,RF-CSA明显低于第1天〔cm2:1.3(1.0,2.5)比2.1(1.7,2.9)〕,差异均有统计学意义(均P<0.05)。Pearson相关性分析显示,脓毒症患者入ICU第7天RF-CSA与当日UCR呈显著负相关(r=-0.407,P=0.029)。结论脓毒症患者膈肌功能障碍发生早,可改善;肢体骨骼肌功能障碍发生相对滞后,呈进行性加重。入ICU第7天的RF-CSA可能是衡量脓毒症患者肢体骨骼肌功能障碍的可靠指标,能够成为早期识别与诊断ICU获得性衰弱(ICU-AW)的指标。脓毒症患者发生持续性肌肉质量损失主要与持续的机体分解代谢相关,且在入ICU 1周左右呈显著变化。

Objective To investigate the dynamic changes of diaphragm and limb skeletal muscle in patients with sepsis by bedside ultrasound and their correlation with the ratio of blood urea/creatinine ratio(UCR)in 7 days after intensive care unit(ICU)admission.Methods A prospective observational study was conducted.A total of 55 patients with sepsis admitted to ICU of General Hospital of Ningxia Medical University from June 2022 to February 2023 were selected as the research objects.General information,laboratory indicators[urea,serum creatinine(SCr),and UCR]on days 1,4,and 7 of ICU admission,and prognostic indicators were observed.Bedside ultrasound was used to assess the dynamic changes of diaphragm morphology[including diaphragmatic excursion(DE),end-inspiratory diaphragm thickness(DTei),and end-expiratory diaphragm thickness(DTee)]on days 1,4,and 7 of ICU admission,as well as limb skeletal muscle(quadriceps femoris)morphology[including rectus femoris-muscle layer thickness(RF-MLT),vastus intermedius-muscle layer thickness(VI-MLT),and rectus femoris-cross sectional area(RF-CSA)].Diaphragm thickening fraction(DTF)and RF-CSA atrophy rate were calculated,and the incidence of diaphragm and limb skeletal muscle dysfunction was recorded.The correlation between ultrasound morphological parameters of diaphragm and quadriceps and UCR at each time points in 7 days after ICU admission was analyzed by Pearson correlation.Results A total of 55 patients with sepsis were included,of which 29 were in septic shock.As the duration of ICU admission increased,the incidence of diaphragm dysfunction in patients with sepsis increased first and then decreased(63.6%,69.6%,and 58.6%on days 1,4,and 7 of ICU admission,respectively),while the incidence of limb skeletal muscle dysfunction showed an increasing trend(54.3%and 62.1%on days 4 and 7 of ICU admission,respectively),with a probability of simultaneous occurrence on days 4 and 7 of ICU admission were 32.6%and 34.5%,respectively.The UCR on day 7 of ICU admission was significantly higher than that on day 1[121.77(95.46,164.55)vs.97.00(70.26,130.50)],and RF-CSA atrophy rate on day 7 was significantly higher than that on day 4[%:-39.7(-52.4,-22.1)vs.-26.5(-40.2,-16.4)].RF-CSA was significantly lower on day 7 compared to day 1[cm2:1.3(1.0,2.5)vs.2.1(1.7,2.9)],with all differences being statistically significant(all P<0.05).Pearson correlation analysis showed that RF-CSA on day 7 of ICU admission was negatively associated with the UCR on the same day(r=-0.407,P=0.029).Conclusions Diaphragmatic dysfunction in patients with sepsis occurred early and can be improved.Limb skeletal muscle dysfunction occurred relatively later and progresses progressively.The RF-CSA on day 7 of ICU admission may be a reliable measure of limb skeletal muscle dysfunction in patients with sepsis,can be an indicator of early identification and diagnosis of ICU-acquired weakness(ICU-AW).Continuous loss of muscle mass occurring in septic patients is mainly associated with persistent organismal catabolism,and undergoes significant changes around a week in ICU.