摘要目的 探讨经皮氧分压监测在急性心力衰竭(AHF)患者预后评估中的价值.方法 回顾性分析2017年7月至2018年6月中国医科大学附属第一医院急诊科收治的各种原因导致AHF发作的91例患者的临床资料.收集所有纳入患者在AHF发作时(治疗前)及接受治疗6 h的动脉血气、经皮氧分压监测、无创心排血量监测(NICOM)的动态监测数据,包括动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、血乳酸(Lac)、经皮组织氧分压(TcPO2)、经皮组织二氧化碳分压(TcPCO2)、心排血量(CO)、每搏量(SV),并计算10 min氧负荷值(OCT)、氧偏移度和二氧化碳偏移度.根据28 d生存情况将患者分为存活组与死亡组,比较两组患者上述指标的差异;绘制受试者工作特征曲线(ROC),分析经皮氧分压监测指标对AHF患者预后的预测价值.结果 91例患者均纳入分析,其中28 d死亡26例,存活65例,病死率为28.6%.治疗前,死亡组患者10 min OCT较存活组明显降低〔mmHg(1 mmHg＝0.133 kPa):41.0±3.9比45.6±3.2,P＜0.01〕,二氧化碳偏移度较存活组明显升高〔(0.51±0.11)%比(0.37±0.11)%,P＜0.01〕;而两组PaO2、PaCO2、TcPO2、TcPCO2、氧偏移度、CO、SV和Lac比较差异均无统计学意义.治疗6 h,死亡组患者TcPCO2、氧偏移度和二氧化碳偏移度均明显高于存活组〔TcPCO2(mmHg):36.0±2.8比33.2±2.8,氧偏移度:(0.25±0.05)%比(0.22±0.06)%,二氧化碳偏移度:(0.29±0.12)%比(0.16±0.13)%,均P＜0.05〕,TcPO2、10 min OCT、CO和SV均明显低于存活组〔TcPCO2 (mmHg): 36.0±2.8比33.2±2.8,10 min OCT(mmHg):49.1±4.5比53.6±5.5,CO(L/min):4.9±0.5比5.3±0.5, SV(mL):57.8±3.5比64.4±4.8,均P＜0.01〕;而两组PaO2、PaCO2、Lac比较差异仍无统计学意义.ROC曲线分析显示,AHF发作时10 min OCT预测患者28 d死亡的ROC曲线下面积(AUC)为0.802 ;当最佳截断值为43.5 mmHg时,敏感度为77.3%,特异度为68.0%.二氧化碳偏移度的AUC为0.812;当最佳截断值为 0.46%时,敏感度为86.4%,特异度为68.0%.结论 经皮氧分压监测可作为AHF发作患者预后评价的可靠手段,二氧化碳偏移度升高、10 min OCT下降提示预后不良,应动态监测评估AHF患者的预后.

abstractsObjective To explore the value of percutaneous oxygen partial pressure monitoring in prognosis evaluation of patients with acute heart failure (AHF). Methods A total of 91 patients with AHF due to various reasons admitted to the emergency department of the First Affiliated Hospital of China Medical University from July 2017 to June 2018 were enrolled. Dynamic monitoring data of arterial blood gas, percutaneous oxygen partial pressure monitoring and noninvasive cardiac output monitoring (NICOM) of all of the patients at the time of diagnosis (before treatment) and 6 hours after treatment were recorded, including arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), blood lactic acid (Lac), percutaneous oxygen partial pressure (TcPO2), percutaneous carbon dioxide partial pressure (TcPCO2), cardiac output (CO) and stroke volume (SV). The 10-minute oxygen challenge test value (OCT), oxygen and carbon dioxide offsets were calculated. The patients were divided into survival group and non-survival group according to 28-day survival situation, and the differences in above parameters were compared between the two groups. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of percutaneous partial oxygen pressure monitoring for the prognosis of patients with AHF. Results All the 91 patients were enrolled in the analysis, among whom 26 died on 28 days and 65 survived, with a mortality of 28.6%. Before treatment, 10-minute OCT in the non-survival group was significantly lower than that in the survival group [mmHg (1 mmHg = 0.133 kPa):41.0±3.9 vs. 45.6±3.2, P < 0.01], and the carbon dioxide offset was significantly higher than that in the survival group [(0.51±0.11)% vs. (0.37±0.11)%, P < 0.01]. However, there was no statistically significant difference in PaO2, PaCO2, TcPO2, TcPCO2, oxygen offset, CO, SV or Lac between the two groups. After 6 hours of treatment, TcPCO2, oxygen offset and carbon dioxide offset in the non-survival group were significantly higher than those in the survival group [TcPCO2 (mmHg): 36.0±2.8 vs. 33.2±2.8, oxygen offset: (0.25±0.05)% vs. (0.22±0.06)%, carbon dioxide offset: (0.29±0.12)% vs. (0.16±0.13)%, all P < 0.05], TcPO2, 10-minute OCT, CO and SV were significantly lower than those in the survival group [TcPCO2 (mmHg): 36.0±2.8 vs. 33.2±2.8, 10-minute OCT (mmHg): 49.1±4.5 vs. 53.6±5.5, CO (L/min):4.9±0.5 vs. 5.3±0.5, SV (mL): 57.8±3.5 vs. 64.4±4.8, all P < 0.01]. However, there was no statistically significant difference in PaO2, PaCO2 or Lac between the two groups. ROC curve analysis showed that the area under the ROC curve (AUC) of 10-minute OCT onset predicting the 28-day death of patients with AHF was 0.802; when the optimal cut-off value was 43.5 mmHg, the sensitivity and specificity was 77.3% and 68.0%, respectively. The AUC of carbon dioxide offset was 0.812; when the optimal cut-off value was 0.46%, the sensitivity and specificity was 86.4% and 68.0%, respectively. Conclusions Percutaneous oxygen partial pressure monitoring can be used as a reliable indicator for prognosis evaluation of patients with AHF. Increased carbon dioxide offset and decreased 10-minute OCT suggest poor prognosis, and the prognosis of patients with AHF should be evaluated by dynamic monitoring.