摘要
目的 探讨艾司洛尔对感染性休克患者容量反应性及血流动力学的影响.方法 采用前瞻性自身前后对照研究,选择2015年1月至8月弋矶山医院重症医学科收治的15例行机械通气感染性休克患者为研究对象.所有患者均按照2012年美国胸科医师协会/危重病医学会重症感染和感染性休克指南给予相应治疗;静脉输注艾司洛尔,起始速率为6 mg·kg-1·h-1,调整输注速率使目标心率较基础值下降约10％.于艾司洛尔给药前及给药后2h,采用脉搏指示连续心排血量监测仪（PiCCO）监测患者的血流动力学和全身氧代谢指标,以每搏量变异度（SVV）评估患者的容量反应性,SVV≥10％为容量反应性阳性.结果 15例患者中男性9例、女性6例;年龄（65±16）岁;肺感染10例、腹腔感染5例;急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分为（21±9）分,序贯器官衰竭评分（SOFA）为（8±4）分;28d病死率为40.0％.与给药前相比,艾司洛尔给药后SVV[（14±5）％比（17±7）％,t=2.400,P=0.031]、心率[HR（次/min）：100±4比112±8,t=8.161,P=0.000]、心排血量[CO （L/min）：6.13±1.45比7.88±1.82,t=4.046,P=0.001]、心排血指数[CI（mL·s-1·m-2）：51.51±11.00比66.18±11.48,t=4.131,P=0.001]、每搏量指数[SI（mL/m2）：31.0±6.4比35.4±6.5,t=2.577,P=0.020]、左室内压上升最大速率[dp/dt max（mmHg/s）：927±231比1 194±294,t=3.775,P=0.002]、全心射血分数（GEF：0.21±0.05比0.24±0.06,t=3.091,P=0.008）、心功能指数（CFI：5.03±1.37比6.59±1.92, t=4.769,P=0.000）均显著下降,中心静脉压[CVP （mmHg,1 mmHg=0.133 kPa）：9±3比8±3,t=-3.617,P=0.003]、舒张压[DBP （mmHg）：69±15比66±13,t=-2.656,P=0.019]以及外周血管阻力指数[SVRI （kPa·s·L-1·m-2）：206.8±69.8比157.7±46.7, t=-3.255,P=0.006]均显著上升,而收缩压[SBP （mmHg）：120±25比123±18,t=0.678,P=0.509]、平均动脉压[MAP （mmHg）：86±18比85±14,t=-0.693,P=0.500]、全心舒张期末容积指数[GEDVI（mL/m2）：614±84比618±64,t=0.218,P=0.830]、血管外肺水指数[EVLWI（mL/kg）：5.99±1.50比5.73±1.14,t=-1.329,P=0.205]以及组织灌注指标中心静脉血氧饱和度（ScvO2：0.711±0.035比0.704±0.048,t=-0.298,P=0.773）、动脉血乳酸[Lac（mmol/L）：3.1±0.3比3.0±0.4,t=-0.997,P=0.345]、中心静脉-动脉血二氧化碳分压差[Pcv-aCO2（mmHg）：4.1±0.9比4.7±0.5,t=1.445,P=0.182]均无明显改变.结论 艾司洛尔能够降低感染性休克患者的容量反应性,降低心肌收缩功能、减慢心率、使CO下降,但对组织灌注无明显影响.
Objective To study the effects of esmolol on fluid responsiveness and hemodynamic parameters in patients with septic shock.Methods A prospective self-control study was conducted.Fifteen septic shock patients undergoing mechanical ventilation admitted to Department of Critical Care Medicine of Yijishan Hospital from January 2015 to August 2015 were enrolled.All patients enrolled in this study were given the treatment based on American College of Chest Physicians/Society of Critical Care Medicine （ACCP/SCCM） Consensus 2012.Esmolol was intravenously injected at a beginning rate of 6 mg·kg-1·h-1, and then the dose was adjusted to reduce heart rate by 10% from baseline.The changes in hemodynamic and systemic oxygen metabolism indexes were monitored by pulse indicator continuous cardiac output （PiCCO） before and 2 hours after the esmolol administration, and the fluid responsiveness was evaluated by stroke volume variation （SVV）.SVV ≥ 10% was considered to be a positive fluid responsiveness.Results In 15 patients, 9 were male and 6 female, with an age of 65 ± 16.Among them 10 patients suffered from pulmonary infection, and 5 patients with abdominal infection.Acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score was 21 ±9;sequential organ failure score （SOFA） was 8 ±4.28-day mortality was 40.0%.SVV was significantly decreased after esmolol infusion as compared with baseline [（14 ± 5）% vs.（17 ±7）%, t =2.400, P =0.031].Heart rate [HR （bpm）： 100±4 vs.112±8, t =8.161, P =0.000], cardiac output [CO （L/min）：6.13 ± 1.45 vs.7.88 ± 1.82, t =4.046, P =0.001], cardiac index [CI （mL·s-1·m-2）： 51.51 ± 11.00 vs.66.18 ± 11.48, t =4.131, P =0.001], stroke volume index [SVI （mL/m2）： 31.0 ± 6.4 vs.35.4 ± 6.5, t =2.577, P =0.020], the maximum rate of left ventricular pressure rise [dp/dt max （mmHg/s）： 927±231 vs.1 194±294, t =3.775, P =0.002], global ejection fraction （GEF： 0.21 ±0.05 vs.0.24±0.06, t =3.091, P =0.008）, cardiac function index （CFI： 5.03 ± 1.37 vs.6.59 ± 1.92, t =4.769, P =0.000） showed significant decrease during esmolol infusion.On the other hand, central venous pressure [CVP （mmHg, 1 mmHg =0.133 kPa）： 9±3 vs.8±3, t =-3.617, P =0.003], diastolic blood pressure （DBP, mmHg： 69± 15 vs.66± 13, t =-2.656, P =0.019）, systemic vascular resistance index （SVRI, kPa·s·L-1·m-2：206.8±69.8 vs.206.8±69.8, t =-3.255, P =0.006） were significantly increased during esmolol infusion.No significant difference was found in systolic blood pressure [SBP （mmHg）： 120 ± 25 vs.123 ± 18, t =0.678, P =0.509],mean arterial pressure [MAP （mmHg）： 86 ± 18 vs.85 ± 14, t =-0.693, P =0.500], global end diastolic volume index [GEDVI （mL/m2）： 614 ± 84 vs.618 ± 64, t =0.218, P =0.830], extravascular lung water index [EVLWI （mL/kg）：5.99±1.50 vs.5.73±1.14, t =-1.329, P =0.205], central venous oxygen saturation （ScvO2： 0.711±0.035 vs.0.704 ± 0.048, t =-0.298, P =0.773）, arterial blood lactate [Lac （mmol/L）： 3.1± 0.3 vs.3.0 ± 0.4, t =-0.997, P =0.345],and difference of central venous-arterial carbon dioxide partial pressure [Pcv-aCO2 （mmHg）： 4.1 ± 0.9 vs.4.7 ± 0.5,t =1.445, P =0.182] as compared with those before esmolol treatment.Conclusion Heart rate control with esmolol infusion may reduce fluid responsiveness, cardiac function, heart rate and cardiac output without adverse effect on systemic perfusion in septic shock patients.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2015年第11期885-889,共5页
Chinese Critical Care Medicine
基金
安徽省自然科学基金（1508085MH180）
安徽省高等学校省级质量工程项目（AH201410368106）
安徽省芜湖市科技计划项目（2012hm35）
