摘要目的 探讨早期目标导向治疗(EGDT)中液体管理策略对休克患者预后的影响.方法 回顾性分析79例本院急诊重症监护病房( EICU)感染性休克或失血性休克患者的临床资料.按理论计算大概的输液量持续液体复苏,并根据血压、心率、脉搏血氧饱和度( SpO2)及尿量来决定输液速度,复苏终点是自主循环功能恢复、血管活性药物撤离的患者为持续液体复苏组(41例)；在早期给予一定量(20 ml/kg)液体复苏后采用血管活性药物来维持血压的患者为保守液体复苏组(38例),比较2组患者28 d病死率和升压药物使用时间.按28 d预后分为存活组(37例)和死亡组(42例),比较急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分等相关指标,对影响患者预后的因素进行logistic回归分析,确定和描述休克患者的预后与液体复苏方法策略间的关系.结果 持续液体复苏组28d病死率明显低于保守液体复苏组(14.63％比94.74％,P＜0.01),升压药物使用时间(h)明显缩短(33.24±17.56比58.29±34.78,P＜0.05).42例死亡患者中选择保守液体复苏36例(85.7％),37例存活患者中选择持续液体复苏35例(94.6％).Logistic回归分析显示,出ICU或死前的脑钠肽优势比(OR)=0.9136,95％可信区间(95％CI)为(0.8125,0.9986),回归系数-0.0931,P=0.0478;出 ICU或死前降钙素原OR=0.9095,95％ CI为(0.8294,0.9973),回归系数-0.0949,P=0.0436;出ICU或死前血乳酸OR=0.5023,95％CI为(0.2833,0.8905),回归系数-0.6885,P=0.0184.结论 按理论计算输液量早期持续进行液体复苏,并根据患者的血压、心率、SpO2及尿量来决策输液速度,及时撤离血管活性药物的休克患者病死率明显降低.

abstractsObjective To evaluate the effects of fluid management strategies in early goal directed therapy (EGDT) on the prognosis of patients with shock.Methods Clinical data of 79 patients with septic shock or hemorrhagic shock admitted to emergency intensive care unit ( EICU ) of the First People's Hospital of Yunnan Province were retrospectively analyzed.Patients were divided into continual fluid administrating group (n =41 ) in accordance with protocol calculating approximating fluid volume and adjust the infusion speed based on blood pressure,heart rate,pulse saturation of blood oxygen (SpO2) and urine output with the end of fluid resuscitation was set to restore spontaneous circulation function and wean off vasoactive drugs,and the conservative fluid resuscitation group ( n=38 ) by means of using vasoactive agents to maintenance blood pressure after infusing amount ( 20 ml/kg ) of liquid early,respectively.The 28-day mortality and the time of using pressure agents were compared between two groups.According to the 28-day mortality,patients were further divided into the survival group ( n=37 ) and death group ( n=42 ),and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score was compared between two groups.Logistic regression analysis of prognostic factors was conducted to identify and describe the relationship between the prognosis and fluid resuscitation methods and strategies.Results The 28-day mortality of continual fluid administrating group was significantly lower than thai of the conservative fluid resuscitation group (14.63％ vs.94.74％,P＜0.01 ),total drugs supporting time ( hours ) was significantly shorter than that in conservative fluid resuscitation group ( 33.24 ± 17.56vs.58.29 ± 34.78,P＜0.05 ).Thirty-six cases of 42 death patients received conservative fluid resuscitation (85.7％),but 35 cases of 37 survival patients received continual fluid administration ( 94.6％ ).Logistic regression analvsis showed that odds ratio ( OR ) of brain natriuretic peptide before death or shifted out ICU was 0.9136,95％ confidence interval (95％CI) was 0.8125 to 0.9986,regression coefficient was-0.0931,P=0.0478,OR of procalcitonin before death or shifted out ICU was 0.9095,95％CI was 0.8294 to 0.9973,regression coefficient was-0.0949,P=0.0436,and OR of blood lactate level before death or shifted out ICU was 0.5023,95％CI was 0.2833 to 0.8905,regression coefficient was -0.6885,P=0.0184.Conclusion Ongoing fluid resuscitation early in accordance with method to theoretically calculate fluid volume and to adjust infusion speed based on blood pressure,heart rate,SpO2 and urine,withdrawal of vasoactive drugs,the mortality of patients with shock was significantly reduced.