摘要目的 探讨脉搏指示连续心排血量(PiCCO)监测指导下病情极危重脓毒性休克患者的心功能变化.方法 采用前瞻性观察性研究方法,选择2011年8月至2013年12月北京大学第三医院危重医学科收治的脓毒性休克患者36例.根据患者病情危重程度,按是否需要PiCCO监测分为PiCCO监测组和常规监测组,应用PiCCO监测的血流动力学指标指导液体复苏及血管收缩药物和正性肌力药物的使用.观察PiCCO监测组患者入重症加强治疗病房(ICU)1 d、3d时的心排血指数(CI)、全心射血分数(GEF)、左心室压力上升最大速率(dp/dt max)、超声心动图指标及血清肌钙蛋白T(TnT)、B型钠尿肽(BNP)变化.比较是否使用米力农两组患者的中心静脉压(CVP)、平均动脉压(MAP)水平和达标时间,以及去甲肾上腺素及3 d液体入量的差异.比较PiCCO监测和常规监测两组患者的病情程度及治疗结局.结果 36例患者中PiCCO监测组15例,常规监测组21例.①使用PiCCO监测的15例患者中,入ICU 1 d时心脏收缩功能指标CI、GEF、dp/dt max降低者分别占40.0％、93.3％、33.3％;入 ICU 3 d时,CI、GEF、dp/dt max降低者分别占60.0％、93.3％、60.0％,提示入ICU 3 d时CI、GEF、dp/dt max降低无明显改善.超声心动图显示,入ICU 1 d时,35.7％的患者左室射血分数(LVEF)低于正常,分别有71.4％、71.4％的患者二尖瓣舒张早期血流速度/运动速度比值(E/Em)、左心室舒张早期/舒张晚期最大血流比值(E/A)减低;入ICU 3 d时,有80％入ICU 1 d LVEF低于正常的患者LVEF恢复至正常,有50％入 ICU 1 d舒张功能减低的患者舒张功能较前好转.入ICU 1 d时,有92.9％的患者血清TnT升高,100％的患者BNP升高;入ICU 3 d时,分别有71.4％的患者TnT和78.6％的患者BNP较1d时下降.②使用PiCCO监测患者中,米力农组(8例)与非米力农组(7例)入ICU初始CVP、MAP水平及其达标时间,以及去甲肾上腺素用量差异均无统计学意义,但3d液体入量较非米力农组显著增加(mL:8 324±3 962比4 372±2 081,t=-2.362,P=0.034).③与常规监测组比较,PiCCO监测组急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、序贯器官衰竭评分(SOFA)、机械通气时间、ICU住院时间及住院28 d病死率均显著增加[APACHEⅡ(分):20.67±6.15比14.71±4.67,t=-3.304,P=0.002;SOFA(分):9.53±3.00比7.52±1.97,t=-2.433,P=0.020;机械通气时间(h):132 (54 ～ 310)比63(14 ～ 284),Z=-2.295,P=0.022;ICU住院时间(d):7(4～15)比5(1～14),Z=-2.360,P=0.018;住院28 d病死率:26.7％比0,P=0.023].结论 对极危重脓毒性休克患者使用PiCCO监测血流动力学,可以更全面地进行血容量、全身血管阻力和心功能监测,科学指导患者液体复苏、血管收缩药物和正性肌力药物的应用.

abstractsObjective To investigate the value of employing pulse indicator continuous cardiac output (PiCCO) for cardiac function monitoring in patients with severe septic shock.Methods A prospective observation was conducted.Thirty-six septic shock patients in Department of Critical Care Medicine of Peking University Third Hospital admitted from August 2011 to December 2013 were enrolled.According to the degree of severity,the patients were divided into PiCCO monitor group and routine monitor group.The PiCCO monitor provided a continuous assessment of fluid resuscitation,vasopressors and inotropes infusion in the patients with severe septic shock.The following cardiac function parameters were assessed in severe septic shock patients on the 1st and 3rd day after intensive care unit (ICU)admission:cardiac index (CI),global ejection fraction (GEF),rate of left ventricular pressure increase (dp/dt max),echocardiography,and blood troponin T (TNT) and B-type natriuretic peptide (BNP).The central venous pressure (CVP),mean arterial pressure (MAP) and the time reaching their standard values,and the norepinephrine dosage and 3-day fluid balance in severe septic shock patients were compared between milrinone and non-milrinone usage groups.The severity degree and outcome were compared between PiCCO monitor group and routine monitor group.Results There were 15 patients in PiCCO monitor group and 21 in routine monitor group among 36 septic shock patients.① In 15 patients with PiCCO monitoring,the patients with decreased CI,GEF,and dp/dt max accounted for 40.0％,93.3％,and 33.3％ at 1 day after ICU admission,and accounted for 60.0％,93.3％,and 60.0％ at 3 days after ICU admission,and it showed that CI,GEF,and dp/dt max was not improved at 3 days after ICU admission.Echocardiography showed that 35.7％ patients had lower left ventricular ejection fraction (LVEF) at 1 day after ICU admission,71.4％ and 71.4％ of patients,respectively,had lower early diastolic mitral flow velocity/early diastolic myocardial velocity (E/Em) and early diastolic mitral flow velocity/end diastolic mitral flow velocity (E/A).Three days after ICU admission,80％ of patients with low LVEF value turned to normal,and diastolic dysfunction was ameliorated in 50％ patients.At 1 day after ICU admission,higher TNT was found in 92.9％ of patients,higher BNP in 100％ of patients,and 3 days after ICU admission,71.4％ and 78.6％ patients showed a decrease in TNT and BNP,respectively.② In PiCCO monitor group,there were no significant differences in initial CVP,MAP and their time reaching standard values,norepinephrine dosage between milrinone group (n =8) and non-milrinone group (n =7).However,3-day intake of liquid in milrinone group was significantly higher than that in non-milrinone group (mL:8 324±3 962 vs.4 372±2 081,t =-2.362,P =0.034).③ Compared with routine monitor group,there was a significant elevation in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,duration of mechanical ventilation,length of ICU stay and 28-day hospital mortality in PiCCO monitor group [APACHE Ⅱ score:20.67 ± 6.15 vs.14.71 ±4.67,t =-3.304,P =0.002; SOFA score:9.53±3.00 vs.7.52± 1.97,t =-2.433,P =0.020; duration of mechanical ventilation (hours):132 (54-310) vs.63 (14-284),Z =-2.295,P =0.022; length of ICU stay (days):7 (4-15) vs.5 (1-14),Z =-2.360,P =0.018; 28-day hospital mortality:26.7％ vs.0,P =0.023].Conclusion With the use of the PiCCO hemodynamic monitoring in patients with severe septic shock,more comprehensive values of blood volume,systemic vascular resistance and cardiac function can be obtained for guiding fluid resuscitation and selection of vasopressor and inotropic drugs.