摘要
目的探讨感染性休克患者早期目标导向治疗后动脉血乳酸清除率与预后及心肌损伤的关系。方法回顾性研究。收集2013年8月至2016年7月北京协和医院重症医学科收治的脓毒症休克患者157例，入ICU后6 h内达到复苏目标，即中心静脉压（CVP）8~12 mmHg（1 mmHg=0.133 kPa），平均动脉压（MAP）〉65 mmHg，中心静脉血氧饱和度（ScvO2）〉70%，尿量〉0.5 ml·kg-1·h-1。选早期复苏完成时动脉血乳酸〉2 mmol/L者，根据ScvO2和脉搏氧灌注指数（PI）将患者分为4组，ScvO2〉80%和PI〉1.4组（A组）、ScvO2〉80%和PI〈1.4组（B组）、ScvO2〈80%和PI〉1.4组（C组）、ScvO2〈80%和PI〈1.4组（D组）。测4组患者完成早期复苏后2 h、4 h、6 h血乳酸水平及乳酸清除率，测4组患者入ICU后24 h、48 h、72 h肌钙蛋白I，记录4组患者转归和ICU留治时间。结果（1）C组患者完成早期复苏2 h、4 h、6 h的乳酸清除率分别为34.57%（21.44%，44.20%）、58.33%（30.19%，70.79%）、71.43%（53.75%，82.79%）。（2）入ICU 24 h，B组患者肌钙蛋白I升高的发生率最高（85.0%），A组最低（45.7%），差异有统计学意义（P〈0.008）；入ICU 72 h，C组患者肌钙蛋白I升高的发生率最低（29.3%），B组最高（70.0%），差异有统计学意义（P〈0.008）。（3）logistics回归分析显示，B组4 h乳酸清除率与入ICU 48 h和72 h心肌损害发生率相关（OR=0.917，95%CI 0.851~0.988；OR=0.920，95%CI 0.854~0.992）。（4）4组患者ICU留治时间、28 d病死率差异无统计学意义（P〉0.05）。结论动脉血乳酸清除率与完成早期目标导向复苏的脓毒症休克患者心肌损伤的发生具有相关性。
ObjectiveTo evaluate the prognostic value of arterial blood lactate clearance based on central venous oxygen saturation and perfusion index in patients with septic shock related myocardial injury after early goal-directed therapy.MethodsOne hundred and fifty-seven patients with septic shock after early resuscitation were enrolled from August 2013 to July 2016 in ICU at Peking Union Medical College Hospital. Parameters indicating early resuscitation included central venous pressure （CVP） 8-12 mmHg （1 mmHg=0.133 kPa）,mean arterial pressure （MAP） 〉65 mmHg, central venous oxygen saturation（ScvO2）〉70% and urine volume （UO） 〉0.5ml·kg-1·h-1 and arterial blood lactate （Lac） 〉2 mmoL/L.Patients were divided into group A [ScvO2〉80% and perfusion index （PI）〉1.4], group B（ScvO2〉80% and PI〈1.4）,group C（ScvO2〈80% and PI〉1.4）,group D（ScvO2〈80% and PI〈1.4）.Hemodynamic parameters and tissue perfusion indexes at 2 hours（T2）,4 hours（T4） and 6 hours（T6） after early resuscitation and troponin I which indicated myocardial damage, on day 1 2 3 in ICU were recorded.Results⑴Lac clearance in group C was the quickest, which was 34.57% （21.44%, 44.20%） , 58.33% （30.19%, 70.79%） , 71.43% （53.75%, 82.79%） at T2, T4, T6 respectively.⑵The maximal incidence of myocardial damage was in group B（85.0%） and the lowest in group A （45.7%） on day 1 in ICU.Whereas on day 2, group C showed the lowest incidence of myocardial damage （29.3%） and group B the highest（70.0%）. On day 3,the proportion of elevated troponin I in group B was 70.0%, which was significantly higher than that of group B （29.3%,P〈0.008）.⑶Logistic regression analysis suggested that the rate of Lac clearance at T4 in group B was related to the incidence of myocardial damage on day 2 and 3 in ICU.ConclusionsThe combination of PI and ScvO2 as a resuscitation target in patients with septic shock facilitates Lac clearance as the goal of resuscitation.The rate of arterial Lac clearance based on ScvO2 and PI is correlated with myocardial injury in patients with septic shock after early goal-directed therapy.
作者
尚秀玲
刘大为
王小亭
何怀武
张宏民
苏龙翔
潘盼
Shang Xiuling;Liu Dawei;Wang Xiaoting;He Huaiwu;Zhang Hongmin;Su Longxiang;Pan Pan(Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China)
出处
《中华内科杂志》
CAS
CSCD
北大核心
2018年第5期345-350,共6页
Chinese Journal of Internal Medicine
