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中华重症医学电子杂志

中华重症医学电子杂志 ›› 2020, Vol. 06 ›› Issue (01) : 77 -85. doi: 10.3877/cma.j.issn.2096-1537.2020.026

所属专题： 文献；

临床研究

主动脉流速时间积分变异度对重症脓毒症患者液体复苏的指导
张倩1, 胡振杰1, 刘丽霞1,†()   
  1. 1. 050000　石家庄，河北医科大学第四医院重症医学科
  • 收稿日期:2018-03-18 出版日期:2020-02-28
  • 通信作者: 刘丽霞

Implementation of fluid resuscitation according to aortic velocity time integral variability in severe septic patients

Qian Zhang1, Zhenjie Hu1, Lixia Liu1,†()   

  1. 1. Department of Critical Care Medicine, Fourth Hospital of Hebei Medicine University, Shijiazhuang 050000, China
  • Received:2018-03-18 Published:2020-02-28
  • Corresponding author: Lixia Liu
  • About author:
    Corresponding author: Liu Lixia, Email:
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引用本文：

张倩, 胡振杰, 刘丽霞. 主动脉流速时间积分变异度对重症脓毒症患者液体复苏的指导[J]. 中华重症医学电子杂志, 2020, 06(01): 77-85.

Qian Zhang, Zhenjie Hu, Lixia Liu. Implementation of fluid resuscitation according to aortic velocity time integral variability in severe septic patients[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2020, 06(01): 77-85.

目的

利用容量负荷试验引导主动脉流速时间积分变异度（△VTI）指导重症脓毒症患者的液体复苏，评价其在重症脓毒症患者液体复苏中的应用价值。

方法

本试验为前瞻性、随机对照、干预性研究，纳入2015年3月至2016年1月收治于河北医科大学第四医院重症医学科（ICU）的重症脓毒症患者，按照随机对照原则将其分为超声指导组和常规治疗组。2组的复苏目标按照早期目标导向治疗（EGDT）（除外中心静脉压指标）。超声指导组在液体复苏前，行容量负荷试验（5 min之内输注300 ml复方氯化钠注射液），并利用超声检测△VTI；若△VTI≥15%，提示患者存在容量反应性，可继续给予复方氯化钠注射液500 ml，30 min左右输注体内，反复重复此过程，直到完成EGDT；若△VTI<15%，提示患者无容量反应性，不积极行液体复苏，由临床医师评价后自行决定后续治疗。常规治疗组由临床医师决定治疗。观察2组患者治疗前后各时间点重要生理及实验室指标、各时间段液体出入量及平衡、EGDT达标率、住院时间、住ICU时间、机械通气时间、血管活性药物应用量及使用时间、7 d病死率及28 d病死率。

结果

本试验共纳入了70例重症脓毒症患者，按照随机对照原则分为超声指导组（37例）和常规治疗组（33例）2组，最终完成超声指导组和常规治疗组分别有34例、29例。0~6 h时间段内，超声指导组复苏液体入量及正平衡量明显高于常规治疗组；0~7 d时间段内，超声指导组液体平衡明显低于常规治疗组，差异均有统计学意义（P均<0.05）。而在0~12 h、0~24 h、0~72 h、0~5 d，2组的液体出入量及平衡量比较，差异均无统计学意义（P均>0.05）。2组患者EGDT达标率比较，超声指导组达标率高于常规治疗组，但差异无统计学意义（76.5% vs. 58.6%，P=0.129）。2组患者住院时间比较，差异无统计学意义（P>0.05）；超声指导组机械通气时间及住ICU时间较常规治疗组明显缩短，差异有统计学意义（P<0.05）。血管活性药物应用量显著少于常规治疗组，使用时间显著较常规治疗组缩短，差异有统计学意义（P<0.05）。2组患者7 d病死率及28 d病死率比较，差异均无统计学意义（P均>0.05）。

结论

利用容量负荷试验引导△VTI评价重症脓毒症患者的容量反应性，从而指导液体复苏，比常规治疗在液体管理方面更加精确，降低血管活性药物的用量、缩短使用时间及机械通气时间。

关键词: 主动脉流速时间积分变异度, 重症脓毒症, 液体复苏, 容量负荷试验, 容量反应性
Objective

To evaluate the role of aortic velocity time integral variability (△VTI) in severe septic patients for fluid resuscitation.

Methods

This is a prospective, randomized controlled, intreventional study. Severe septic patients in the intensive care unit of the Fourth Hospital of Hebei Medical University from March 2015 to January 2016 were enrolled and randomly divided into two groups according to the randomized controlled principles: ultrasound-guided group and routine care group. For the patients in the ultrasound-guided group, we used ultrasound to detect aortic velocity time integral variability after fluid challenge (within 5 minutes of the infusion of 300 ml compound sodium chloride) and then determined whether to start fluid resuscitation; if △VTI≥15%, it meant these patients had fluid responsiveness, then they would be intravenously infused with 500 ml compound sodium chloride injection within 30 minutes. This pattern of ultrasound-guided resuscitation would be repeated until the accomplishment of EGDT. If △VTI <15%, it meant patients hadn′t fluid responsiveness, they would not be given fluid resuscitation. For the patients in the routine care group, the clinicians determined their therapeutic regimen. The physiological and laboratory variables, amount of fluid resuscitation, achievement rate of EGDT, length of hospital stay, length of ICU stay, length of mechanical ventilation, length of vasopressor requirement, amount of vasopressor, 7-days mortality and 28-days mortality were collected.

Result

We enrolled 70 patients and randomly divided them into two groups according to the randomized controlled principles: ultrasound-guided group (n=37) and routine care group (n=33). We finally completed the ultrasound guide group (n=34) and routine care group (n=29). The amount of fluid intake and fluid positive balance within 0-6 h in the ultrasound guide group increased significantly compared with the routine care group (P<0.05). The amount of fluid balance within 0-7 days in the ultrasound guide group was significantly less than that of usual care group (P<0.05). There were no significant differences between the two groups in fluid intake, fluid discharge and fluid balance in 0-6 h, 0-12 h, 0-24, 0-72 h, 0-5 days. There were no significant differences between the two groups (P=0.129), but the ultrasound-guided group had higher achievement rate of EGDT(except CVP) than the usual care group (76.5 vs. 58.6%) .There were no significant differences between the two groups in length of hospital stay. Length of mechanical ventilation and ICU stay was significantly reduced in the ultrasound-guided group compared with the routine care group (P<0.05). The amount of vasopressor in the ultrasound-guided group was significantly less than that of routine care group, and the length of vasopressor requirement was significantly reduced in the ultrasound-guided group compared with the routine care group (P<0.05). There were no significant differences between the two groups in the 7-day mortality and the 28-day mortality.

Conclusion

The aortic velocity time integral variability can be used to evaluate the volume responsiveness in severe sepsis patients and guide fluid resuscitation. It is more precise in terms of fluid management than the routine care, and it can reduce the amount of vasopressor, shorten length of vasopressor requirement and mechanical ventilation.

Key words: Aortic velocity time integral variability, Severe septic, Fluid resuscitation, Fluid challenge, Fluid responsiveness
表1 2组重症脓毒症患者一般资料比较
组别 例数 年龄（岁，±s） 男性［例（%）］ 体质量（kg，±s） APACHEⅡ评分（分，±s） SOFA评分（分，±s） 不同感染源病例
肺部感染 腹腔感染 其他
超声指导组 34 59.97±15.30 25（73.5） 69.47±12.40 17.00±5.85 7.29±4.17 18（52.94） 13（38.24） 3（8.82）
常规治疗组 29 59.71±17.45 19（69.0） 63.62±10.52 19.67±11.85 7.57±2.89 15（51.72） 11（37.93） 3（10.34）
统计值   t=0.057 χ2=0.113 t=1.797 t=-0.961 t=-0.482 χ2=0.009 χ2=0.001 χ2=0.042
P值   0.835 0.794 0.078 0.345 0.632 1.000 1.000 1.000
表2 2组重症脓毒症患者复苏前后不同时间点生理及实验室指标比较（±s）
指标 0 h 6 h 12 h 24 h 48 h
HR（次/分）          
  超声指导组 112.55±18.52 104.65±19.53a 104.82±19.76a 103.32±18.84a 100.00±22.07a
  常规治疗组 111.52±19.03 100.19±22.62a 100.42±19.21a 94.76±24.61a 90.57±29.35a
  时点间 F=12.83，P值=0.000
  组间 F=1.097，P值=0.348
  组间•时点间 F=1.869，P值=0.177
RR（次/分）          
  超声指导组 27.35±5.98 22.74±6.14a 21.79±5.05a 22.03±5.26a 22.32±4.76a
  常规治疗组 25.19±7.45 22.62±5.93a 21.52±4.33a 23.24±7.16 21.95±2.11a
  时点间 F=14.02，P值=0.000
  组间 F=0.012，P值=0.984
  组间•时点间 F=1.552，P值=0.194
MAP（mm Hg）          
  超声指导组 91.44±23.31 91.53±11.85 89.50±18.17 92.65±14.31 92.12±17.09
  常规治疗组 89.67±22.30 87.29±9.80 92.76±10.34 92.48±15.13 87.76±15.58
  时点间 F=0.823，P值=0.487
  组间 F=0.297，P值=0.588
  组间•时点间 F=1.398，P值=0.241
SpO2（%）          
  超声指导组 90.02±6.85 97.97±1.90a 97.12±2.56a 97.32±2.51a 96.53±6.96a
  常规治疗组 93.64±6.79 95.64±6.87a 96.73±5.44a 94.64±8.10 95.64±6.79a
  时点间 F=4.771，P值=0.009
  组间 F=0.612，P值=0.438
  组间•时点间 F=1.179，P值=0.322
CVP（mmHg）          
  超声指导组 6.67±3.70 9.38±3.04a 10.09±4.22a 9.18±3.22a 10.21±4.33a
  常规治疗组 6.76±2.03 8.19±4.47a 9.05±4.03a 9.43±3.92a 8.86±3.35a
  时点间 F=13.939，P值=0.000
  组间 F=1.121，P值=0.294
  组间•时点间 F=1.277，P值=0.283
pH（动脉）          
  超声指导组 7.35±0.06 7.35±0.10 7.37±0.08 7.37±0.07 7.37±0.07
  常规治疗组 7.34±0.08 7.31±0.09 7.34±0.08 7.33±0.11 7.36±0.07
  时点间 F=2.898，P值=0.034
  组间 F=3.701，P值=0.059
  组间•时点间 F=1.169，P值=0.323
BE（动脉）          
  超声指导组 -6.11±3.90 -6.13±5.03 -5.25±4.65 -4.33±4.57a -3.70±4.49a
  常规治疗组 -6.83±4.48 -6.90±5.07 -6.92±5.76 -6.42±6.24 -5.02±5.98
  时点间 F=11.255，P值=0.000
  组间 F=1.179，P值=0.317
  组间•时点间 F=1.169，P值=0.323
乳酸（mmol/L）          
  超声指导组 3.45±2.73 1.90±1.36a 1.80±1.46a 1.69±0.93a 1.59±1.21a
  常规治疗组 3.28±2.41 2.43±1.02a 2.00±1.94a 1.70±1.54a 1.50±2.00a
  时点间 F=17.372，P值=0.000
  组间 F=0.575，P值=0.452
  组间•时点间 F=0.938，P值=0.403
ScvO2（%）        
  超声指导组 65.10±10.09 70.10±8.15a 70.23±7.04a 71.32±6.16a 72.03±6.77a
  常规治疗组 63.56±12.68 68.42±9.05a 69.28±8.77a 70.69±9.33a 71.86±9.34a
  时点间 F=18.349，P值=0.000
  组间 F=0.372，P值=0.544
  组间•时点间 F=0.206，P值=0.800
Pcv-aCO2（mmHg）          
  超声指导组 6.87±3.53 5.79±2.80a 4.43±2.03a 3.93±2.45a 3.90±3.90a
  常规治疗组 5.92±3.09 4.84±2.73a 4.60±2.49a 4.45±2.97a 4.27±2.65a
  时点间 F=18.433，P值=0.000
  组间 F=2.655，P值=0.599
  组间•时点间 F=0.009，P值=0.926
表3 2组重症脓毒症患者不同时间段液体量比较（±s）
项目 0~6 h 0~12 h 0~24 h 0~48 h 0~72 h 0~5 d 0~7 d
液体入量（ml）              
  超声指导组 3372.28±2128.23 4930.70±2624.28 6476.67±3199.44 8920.66±3454.41 10236.06±4388.20 11476.74±5305.98 13086.70±5604.22
  常规治疗组 2051.57±1251.98 3664.29±2010.83 6045.57±3522.67 8445.67±2722.17 9729.00±3666.69 11626.28±4682.16 14600.61±5180.92
  t值 3.187 2.304 1.019 1.005 0.056 -0.012 -1.125
  P值 0.002 0.025 0.312 0.319 0.683 0.924 0.371
液体出量（ml）              
  超声指导组 762.38±567.34 1418.44±788.14 2845.44±1192.38 5800.15±2344.91 7303.47±2634.28 13338.33±4484.88 19011.72±7300.85
  常规治疗组 580.61±416.25 1036.19±666.54 2244.64±1440.73 4497.23±2257.04 8910.68±3337.04 12775.14±4001.84 17332.20±4991.37
  t值 1.237 1.517 1.136 2.341 -2.107 0.065 1.976
  P值 0.221 0.134 0.193 0.023 0.088 0.673 0.408
液体平衡（ml）              
  超声指导组 2609.89±2173.37 3012.25±2739.34 3616.52±3085.77 3061.69±3891.51 1548.27±4018.29 -1861.59±3990.41 -5931.44±7325.98
  常规治疗组 1485.23±1077.90 2128.09±2002.34 3800.92±3530.06 3948.44±3161.07 2425.52±2837.05 -1148.85±1939.95 -2731.58±2845.41
  t值 2.957 1.076 -0.081 -0.579 -2.032 -1.034 -3.001
  P值 0.014 0.206 0.839 0.565 0.421 0.427 0.045
表4 2组重症脓毒症患者相关实验结果比较
组别 例数 EGDT［例（%）］ 7 d病死［例（%）］ 28 d病死［例（%）］ 住ICU时间（h，±s） 住院时间（d，±s） 血管活性药物应用比率［例（%）］ 血管活性药物时间［h，M（QL，QU）］ 血管活性药物量（mg，±s） 机械通气时间［h，M（QL，QU）］
超声指导组 34 26（76.5） 6（17.6） 8（23.5） 147.42±62.56 28.62±24.89 25（73.5） 23.50（0.00，54.50） 33.73±31.03 40.16（10.00，91.81）
常规治疗组 29 17（58.6） 5（17.2） 11（37.9） 220.13±105.13 26.67±19.84 16（76.2） 34.00（8.50，83.00） 54.23±42.39 80.35（48.84，160.84）
统计值   χ2=2.301 χ2=0.011 χ2=1.541 t=-2.979 t=0.742 χ2=2.321 Z=-1.984 t=-2.066 Z=-2.246
P值   0.179 1.000 0.278 0.005 0.461 0.185 0.047 0.044 0.025
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