摘要
目的：探讨脓毒症导致的心肌功能障碍对脓毒性休克患者血流动力学、器官功能及预后的影响。方法采用前瞻性队列研究方法，选择2013年6月至2014年6月北京大学第三医院危重医学科收治的、发病时间＜24 h的脓毒性休克患者44例，以入ICU时超声心动图（UCG）左室射血分数（LVEF）将患者分为脓毒症心肌抑制组（LVEF＜0.50，11例）和无心肌抑制组（LVEF≥0.50，33例）。分别于入ICU 1、3、7 d采用UCG和脉搏指示连续心排血量（PiCCO）监测技术进行心功能评价和血流动力学监测，并检测心肌损伤标志物血浆肌钙蛋白T（TnT）和N末端B型尿钠肽前体（NT-proBNP）的水平，以及反映器官功能的指标，并记录患者28 d预后。结果入ICU 1 d时，无心肌抑制组除中心静脉压（CVP）、左室舒张期末内径（LVEDD）明显低于心肌抑制组〔CVP（mmHg，1 mmHg＝0.133 kPa）：10±4比14±6，P＜0.05；LVEDD（mm）：45.0±5.3比51.8±7.1，P＜0.01〕外，其他血流动力学参数比较差异无统计学意义。入ICU 3 d时，两组各项心功能指标和血流动力学参数比较差异均无统计学意义。入ICU 7 d时，无心肌抑制组除心排血指数（CI）和肺血管通透性指数（PVPI）明显高于心肌抑制组〔CI（mL·s-1·m-2）：63.3±13.3比48.3±10.0，P＜0.05；PVPI：1.5（1.4，1.9）比1.1（0.7，1.1），P＜0.01〕外，其余指标比较差异均无统计学意义。两组患者各时间点血浆TnT和NT-proBNP水平变化差异均无统计学意义。两组患者入ICU时，无论是功能障碍的器官数，还是肺脏、肾脏、肝脏和凝血系统功能等单个器官功能障碍的程度差异均无统计学意义。心肌抑制组和无心肌抑制组患者28 d生存率比较差异无统计学意义〔81.8%（9/11）比72.7%（24/33），χ2＝0.398，P＝0.528〕。结论脓毒症心肌抑制是一种可逆性器官功能损害，可以直接导致左室收缩功能降低和心室扩大，但不减少心排血量，不影响其他器官功能，也不导致患者病死率增加。
ObjectiveTo investigate the impacts of sepsis-induced cardiac dysfunction on hemodynamics, organ function and prognosis in the patients with septic shock.Methods A prospective cohort study was conducted in 44 patients suffering from septic shock with the duration〈 24 hours admitted to the Department of Critical Care Medicine of Peking University Third Hospital during June 2013 to June 2014. The patients were divided into two groups according to the left ventricular ejection fraction （LVEF） as recorded in echocardiogram at time of admission to the intensive care unit （ICU） as sepsis-induced myocardial dysfunction group （LVEF〈 0.50,n= 11） and normal cardiac function group （LVEF≥0.50,n= 33）. The cardiac function evaluation and hemodynamics monitoring were performed with echocardiogram and pulse-induced contour cardiac output （PiCCO） on 1, 3, 7 days after the ICU admission. The plasma levels of the biomarkers of myocardial damage, troponin T （TnT） and N-terminal pro-brain natriuretic peptide （NT-proBNP） were measured, and the parameters representing organ function and the 28-day prognosis were collected as well.Results On the ICU admission, central venous pressure （CVP） and left ventricular end-diastolic diameter （LVEDD） were obviously lower in normal cardiac function group than those of myocardial dysfunction group [CVP （mmHg, 1 mmHg = 0.133 kPa）： 10 ±4 vs. 14 ±6,P〈 0.05; LVEDD （mm）： 45.0 ±5.3 vs. 51.8 ±7.1,P〈 0.01], and there was no significant difference in other hemodynamic parameters between two groups. On the 3rd day, all the cardiac function and hemodynamic parameters showed no significant differences between the two groups. On the 7th day, the cardiac index （CI） and pulmonary vascular permeability index （PVPI） of normal cardiac function group were significantly higher than those of myocardial dysfunction group [CI （mL·s-1·m-2）： 63.3 ±13.3 vs. 48.3 ±10.0,P〈 0.05;PVPI： 1.5 （1.4, 1.9） vs. 1.1 （0.7, 1.1）,P〈 0.01], and no significant difference was found in the other parameters. The plasma levels of TnT and NT-proBNP were found to have no difference at three time points between two groups. There was no difference in the number or the extent of organ dysfunction, including lung, kidney, liver and coagulation system, between the groups at the time of ICU admission. There was no obvious difference in the 28-day survival rate between the myocardial dysfunction group and normal cardiac function group [81.8% （9/11） vs. 72.7% （24/33）,χ2= 0.398, P= 0.528].Conclusions Sepsis-induced myocardial dysfunction is a reversible organ dysfunction. It can directly induce decreased left ventricular systolic function and enlargement of ventricle in patients with septic shock without reducing cardiac output or impairing the functions of other organs, or elevating the mortality rate.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2015年第3期180-184,共5页
Chinese Critical Care Medicine
基金
国家自然科学基金面上项目（81372043）
首都医学发展科研基金项目（2009-1014）
