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中华重症医学电子杂志

中华重症医学电子杂志 ›› 2016, Vol. 02 ›› Issue (03) : 193 -198. doi: 10.3877/cma.j.jssn.2096-1537.2016.03.012

所属专题： 文献；

临床研究

全心舒张末期容积指数在慢性阻塞性肺疾病合并感染性休克患者中的应用价值
於江泉, 郑瑞强†, 林华, 陈齐红, 邵俊   
  • 收稿日期:2016-07-26 出版日期:2016-08-28
  • 通信作者: 郑瑞强

GEDI vs. CVP-directed fluid resuscitation for septic shock in COPD patients: a randomized controlled trial

Jiangquan Yu, Ruiqiang Zheng†, Hua Lin, Qihong Chen, Jun Shao   

  • Received:2016-07-26 Published:2016-08-28
  • Corresponding author: Ruiqiang Zheng
  • About author:
    Corresponding author: Zheng Ruiqiang, Email:
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於江泉, 郑瑞强, 林华, 陈齐红, 邵俊. 全心舒张末期容积指数在慢性阻塞性肺疾病合并感染性休克患者中的应用价值[J]. 中华重症医学电子杂志, 2016, 02(03): 193-198.

Jiangquan Yu, Ruiqiang Zheng, Hua Lin, Qihong Chen, Jun Shao. GEDI vs. CVP-directed fluid resuscitation for septic shock in COPD patients: a randomized controlled trial[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2016, 02(03): 193-198.

目的

探讨全心舒张末期容积指数（global end-diastolic volume index，GEDI）指导的慢性阻塞性肺疾病（chronic obstructive pulmonary disease，COPD）合并感染性休克患者液体复苏的临床效果。

方法

将苏北人民医院重症医学科2012年1月至2014年4月连续收治的71例COPD合并感染性休克的患者，按随机数字表法分为两组进行对照研究。对照组（n=37）根据严重感染/感染性休克指南制定的中心静脉压（central venous pressure，CVP）标准进行液体复苏，研究组（n=34）根据GEDI进行液体复苏，使GEDI达到800 ml/m2。观察两组患者6 h及24 h液体复苏量、去甲肾上腺素用量，24 h血乳酸清除率，72 h急性生理与慢性健康状况评分Ⅱ（acute physiology and chronic health evaluation，APACHEⅡ）和序贯脏器衰竭评分（sequential organ failure assessment，SOFA），机械通气时间，ICU住院时间，ICU病死率，90 d存活率。

结果

6 h及24 h平均液体复苏量，研究组均多于对照组（P<0.05）；6 h及24 h平均去甲肾上腺素用量，对照组均多于研究组（P<0.05）；治疗24 h后，对照组血乳酸（4.79±1.95）mmol/L，研究组（3.44±1.45） mmol/L，两组比较差异有统计学意义（t=2.59，P<0.05），24 h血乳酸清除率对照组19.79%±8.95%，研究组48.74%±9.2%，两组比较差异有统计学意义（t=4.29，P<0.05）；72 h后APACHEⅡ评分、SOFA评分：对照组均高于研究组（P<0.05）；平均机械通气时间对照组（101.22±44.77） h，研究组（74.71±20.25） h （t=2.234，P<0.05）；ICU住院时间对照组（11.3±2.1）d，研究组（7.4±1.9） d（P<0.05）。在ICU治疗过程中，对照组有10例患者死亡（病死率27.0%），研究组有7例患者死亡（病死率20.6%），两组患者病死率无统计学意义（χ2=0.03，P>0.05）；两组患者90 d存活率比较无统计学意义（χ2=1.083，P>0.05）。

结论

长期COPD的患者往往合并右心功能不全，CVP很难真实反映患者的容量状态，脉搏指示连续心输出量（puise indicator continuous cardiac output，PiCCO）监测的GEDI能正确指导此类患者进行液体复苏，明显降低患者升压药物的用量，改善组织缺氧状态，减少患者机械通气时间以及ICU住院时间，具有较好的临床应用意义。

关键词: 慢性阻塞性肺疾病, 感染, 休克
Objective

To evaluate the clinical efficiencies of GEDI (global end-diastolic volume index) -directed fluid resuscitation in chronic obstructive pulmonary disease (COPD) patients with septic shock.

Methods

A total of 71 cases with COPD associated with septic shock were enrolled from the Intensive Care Unit of the Northern Jiangsu People′s Hospital from January, 2012 to April, 2014 and randomly assigned to 2 groups for controlled study. In the control group (n=37), fluid resuscitation was performed according to the measurements of central venous pressure (CVP). In the study group (n=34), fluid resuscitation was performed until GEDI reached 800 ml/m2. The following indices were recorded in 2 groups: fluid volume resuscitated in 6 hrs and in 24 hrs, norepinephrine dosage, blood lactate clearance rate in 24 hrs, 72-hour acute physiology and chronic health evaluation (APACHE II) score and sequential organ failure assessment (SOFA) score, duration of mechanical ventilation, length of stay in ICU (intensive care unit), ICU mortality, and 90 d survival rate.

Results

Whether in 6 hrs or in 24 hrs, the fluid volume resuscitated was lower and NE dosage was higher in the control group than in the study group (P<0.05). After 24 h of treatment, the blood lactate was (4.79±1.95) mmol/L in the control group and (3.44±1.45) mmol/L in the study group (t=2.59, P<0.05); mean 24-hour blood lactate clearance rate was 19.79%±8.95% in the control group and 48.74%±9.2% in the study group (t=4.29, P<0.05); 72-hour APACHE II score and SOFA score were higher in the control group than in the study group (P<0.05). Mean duration of mechanical ventilation was (101.22±44.77) h in the control group and (74.71±20.25) h in the study group (t=2.234, P<0.05); Mean length of stay in ICU was (11.3±2.1) d in the control group and (7.4±1.9) d in the study group (P<0.05). During the treatment in ICU, 10 (27.0%) in the control group and 7 (20.6%) in the study group died, and there was no significant difference between 2 groups regarding the mortality rate (χ2=0.03, P>0.05). In addition, 90-day survival rate was not significantly different between 2 groups (χ2=1.083, P>0.05).

Conclusion

Most patients with long-term COPD are associated with right ventricular dysfunction, therefore CVP is difficult to reflect the real blood volume. GEDI-directed fluid resuscitation shows better clinical results than CVP-directed fluid resuscitation in COPD patients with septic shock without reducing mortality rate.

Key words: Chronic obstructive pulmonary disease, Infection, Shock
图1 患者入选流程图
表1 治疗前对照组及研究组患者一般资料比较
组别 例数 年龄（岁） APACHE Ⅱ评分 SOFA评分 入ICU时MAP（mmHg） 入ICU时CVP（mmHg） 入ICU时乳酸（mmol/l） 性别（例） 感染来源（例） 其他（例）
男 女 肺 腹腔 皮肤软组织
对照组 37 71±5.7 20.1±4.0 18.0±3.2 47.8±7.6 6.9±2.9 6.3±2.1 21 16 27 4 2 4
研究组 34 70±6.5 19.9±5.1 17.7±4.6 48.1±7.4 7.2±2.8 6.9±3.4 20 14 25 4 1 4
t值 0.58 0.75 0.50 0.63 1.05 0.98 0.14 0.21 0.00 0.32 1.28 0.32
P值 0.372 0.218 0.390 0.321 0.163 0.187 0.542 0.466 0.72 0.402 0.133 0.406
表2 治疗后两组患者液体复苏量、去甲肾上腺素用量、血乳酸、机械通气时间及病死率比较
组别 例数 6 h液体复苏量（ml） 24 h液体复苏量（ml） 6 h去甲肾上腺素用量［μg/（min?kg）］ 24 h去甲肾上腺素用量［μg/（min?kg）］ 血乳酸（mmol/l） 24 h血乳酸清除率（%）
对照组 37 1224.2±198.1 4761.4±328.5 0.56±0.17 0.43±0.19 4.79±1.95 19.79±8.95
研究组 34 1824.9±241.1ml 6327.3±265.9ml 0.29±0.07 0.18±0.06 3.44±1.45 48.74±9.2
t/χ2值 -4.35 -5.71 2.45 4.99 2.59 4.29
P值 0.000 0.000 0.023 0.000 0.013 0.003
组别 例数 72 h APACHE Ⅱ评分 72 h SOFA Ⅱ评分 机械通气时间（h） ICU住院时间（d） 病死率（%）
对照组 37 18.7±6.1 14.2±3.9 101.22±44.77 11.3±2.1 27.0（10/37）
研究组 34 12.6±4.3 8.6±2.2 74.71±20.25 7.4±1.9 20.6（7/34）
t/χ2值 1.91 2.28 2.23 -3.83 1.08
P值 0.047 0.031 0.032 0.003 0.298
图2 两组慢性阻塞性肺疾病含感染性休克患者90 d生存情况分析
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