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

doi:10.3877/cma.j.issn.2096-1537.2020.026

Abstract

Abstract:

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

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.

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URL: https://icu.cma-cmc.com.cn/EN/10.3877/cma.j.issn.2096-1537.2020.026

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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
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）	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

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
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）	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

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±19.53^a	104.82±19.76^a	103.32±18.84^a	100.00±22.07^a
	常规治疗组	111.52±19.03	100.19±22.62^a	100.42±19.21^a	94.76±24.61^a	90.57±29.35^a
	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±6.14^a	21.79±5.05^a	22.03±5.26^a	22.32±4.76^a
	常规治疗组	25.19±7.45	22.62±5.93^a	21.52±4.33^a	23.24±7.16	21.95±2.11^a
	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±1.90^a	97.12±2.56^a	97.32±2.51^a	96.53±6.96^a
	常规治疗组	93.64±6.79	95.64±6.87^a	96.73±5.44^a	94.64±8.10	95.64±6.79^a
	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±3.04^a	10.09±4.22^a	9.18±3.22^a	10.21±4.33^a
	常规治疗组	6.76±2.03	8.19±4.47^a	9.05±4.03^a	9.43±3.92^a	8.86±3.35^a
	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±4.57^a	-3.70±4.49^a
	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±1.36^a	1.80±1.46^a	1.69±0.93^a	1.59±1.21^a
	常规治疗组	3.28±2.41	2.43±1.02^a	2.00±1.94^a	1.70±1.54^a	1.50±2.00^a
	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±8.15^a	70.23±7.04^a	71.32±6.16^a	72.03±6.77^a
	常规治疗组	63.56±12.68	68.42±9.05^a	69.28±8.77^a	70.69±9.33^a	71.86±9.34^a
	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±2.80^a	4.43±2.03^a	3.93±2.45^a	3.90±3.90^a
	常规治疗组	5.92±3.09	4.84±2.73^a	4.60±2.49^a	4.45±2.97^a	4.27±2.65^a
	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

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±19.53^a	104.82±19.76^a	103.32±18.84^a	100.00±22.07^a
	常规治疗组	111.52±19.03	100.19±22.62^a	100.42±19.21^a	94.76±24.61^a	90.57±29.35^a
	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±6.14^a	21.79±5.05^a	22.03±5.26^a	22.32±4.76^a
	常规治疗组	25.19±7.45	22.62±5.93^a	21.52±4.33^a	23.24±7.16	21.95±2.11^a
	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±1.90^a	97.12±2.56^a	97.32±2.51^a	96.53±6.96^a
	常规治疗组	93.64±6.79	95.64±6.87^a	96.73±5.44^a	94.64±8.10	95.64±6.79^a
	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±3.04^a	10.09±4.22^a	9.18±3.22^a	10.21±4.33^a
	常规治疗组	6.76±2.03	8.19±4.47^a	9.05±4.03^a	9.43±3.92^a	8.86±3.35^a
	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±4.57^a	-3.70±4.49^a
	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±1.36^a	1.80±1.46^a	1.69±0.93^a	1.59±1.21^a
	常规治疗组	3.28±2.41	2.43±1.02^a	2.00±1.94^a	1.70±1.54^a	1.50±2.00^a
	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±8.15^a	70.23±7.04^a	71.32±6.16^a	72.03±6.77^a
	常规治疗组	63.56±12.68	68.42±9.05^a	69.28±8.77^a	70.69±9.33^a	71.86±9.34^a
	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±2.80^a	4.43±2.03^a	3.93±2.45^a	3.90±3.90^a
	常规治疗组	5.92±3.09	4.84±2.73^a	4.60±2.49^a	4.45±2.97^a	4.27±2.65^a
	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

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

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