摘要目的 评估感染性休克患者使用胶体液或晶体液进行容量负荷试验(扩容试验)后短期内血流动力学变化特点,探讨判断容量反应性的恰当时机.方法 采用前瞻性观察研究方法,选择北京协和医院内科重症加强治疗病房(ICU)2016年7月至2018年12月收治的接受肺动脉漂浮导管监测的感染性休克患者并进行扩容试验.按使用的扩容液体类型将患者分为晶体组(500 mL的生理盐水)和胶体组(500 mL的4%琥珀酰明胶),扩容液的选择由主治医师决定.记录扩容前及扩容后0(即刻)、10、30、45、60、90和120 min的血流动力学指标,包括心排血指数(CI)、心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)及肺动脉楔压(PAWP)等.以扩容试验后CI增加值(ΔCI)≥10%定义为容量反应阳性.分析不同类型扩容液体组患者和有无容量反应性患者的血流动力学指标变化趋势.结果 研究纳入40例患者,胶体组和晶体组患者各20例.26例患者容量反应阳性,其中胶体组12例,晶体组14例;容量反应阴性患者14例,其中胶体组8例,晶体组6例.① 与扩容前比较,胶体组和晶体组扩容即刻CI(mL·s-1·m-2)即显著增加(71.7±16.7比65.0±16.7,68.3±25.0比63.3±23.3,均P＜0.05),其中胶体组CI在扩容后30 min达峰值(76.7±18.3),至120 min(70.0±16.7)仍显著高于扩容前(P＜0.05),ΔCI≥10%持续至扩容后60 min;晶体组CI在扩容后10 min达峰值(73.3±28.3),于60 min时恢复到基线水平,ΔCI≥10%持续至扩容后10 min.两组扩容后各时间点ΔCI差异均无统计学意义.② 对于无容量反应性的患者,无论是在晶体组或是胶体组,扩容前后CI均无显著变化.对于有容量反应性的患者,CI与扩容前相比有差异的时间点及达峰时间点与两组患者整体变化趋势相同;但胶体组有容量反应性的患者ΔCI≥10%可持续至120 min,而晶体组有容量反应性的患者ΔCI≥10%持续至30 min.此外,胶体组有容量反应性的患者扩容后30、45、60及90 min的ΔCI显著高于晶体组有容量反应性的患者(mL·s-1·m-2 :18.3±3.3比8.3±1.7,18.3±3.3比5.0±1.7,13.3±1.7比3.3±1.7,11.7±3.3比3.3±1.7,均P＜0.01).③ CVP和PAWP在两组中均于扩容后即刻达峰值,其中胶体组CVP和PAWP维持至120 min仍与扩容前有显著差异;而晶体组CVP和PAWP均在30 min时降至基线水平.胶体组MAP于扩容后即刻达峰值,在45 min时降至基线水平;晶体组MAP以及两组患者HR均随时间延长无明显变化.结论 感染性休克患者使用晶体液或胶体液扩容后血流动力学的变化趋势存在显著差异,扩容后容量反应性的评估时间应区别对待.对于胶体液的判断时机可以适当延长至30 min,而晶体液的恰当判断时间在扩容后10 min.

abstractsObjective To explore the short-term hemodynamic change of fluid challenge (FC) with crystalloid or colloid and define fluid responsiveness at the optimal time in patients with septic shock. Methods A prospective observational study was conducted. Septic shock patients monitored with pulmonary catheters admitted to medical intensive care unit (ICU) of the Peking Union Medical College Hospital from July 2016 to December 2018 were enrolled. All included patients received FC and were divided into two groups according to the type of fluid used, i.e. crystalloid group (normal saline for 500 mL) and colloid group (4% succinyl gelatin for 500 mL). The choice of fluid type was decided by the attending physician. Hemodynamic variables were measured at baseline, and 0 (immediately), 10, 30, 45, 60, 90, 120 minutes after FC, included cardiac index (CI), heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP) and pulmonary arterial wedge pressure (PAWP). Fluid responsiveness was defined as CI increased by more than 10% after FC. The data were analyzed by repeated measurements of variance between the two groups as well as responders and nonresponders. Results Forty patients were included, 20 cases each in colloid group and crystalloid group; of whom 26 were fluid responders with 12 of colloid group and 14 of crystalloid group. Of the 14 nonresponders, 8 were of colloid group and 6 of crystalloid group. ① Compared with before FC, CI (mL·s-1·m-2) was significantly increased in crystalloid and colloid groups after FC (71.7±16.7 vs. 65.0±16.7, 68.3±25.0 vs. 63.3±23.3, both P < 0.05). In the colloid group, volume expansion increased the CI to maximum (76.7±18.3) at 30 minutes after FC, at 120 minutes after FC, a significantly higher CI (70.0±16.7) was also observed (P < 0.05), an increased in CI≥10% was observed at 60 minutes after FC. In the crystalloid group, CI was increased to maximum at 10 minutes (73.3±28.3) and decreased to baseline at 60 minutes, an increased in CI≥10% was also observed at 10 minutes after FC. In addition, there was no significant difference in CI changes between colloidal group and crystalloid group at different time points after FC. ② CI did not change over time in nonresponders groups, whereas in responders CI increased parallelly to that in both crystalloid and colloid groups over time. However, an increased in CI≥10% was observed through the 120 minutes after FC in responders of colloid group compared with that of at 30 minutes after FC in crystalloid group. There was significant difference in CI changes between colloidal group and crystalloid group at 30, 45, 60, 90 minutes after FC (mL·s-1·m-2: 18.3±3.3 vs. 8.3±1.7, 18.3±3.3 vs. 5.0±1.7, 13.3±1.7 vs. 3.3±1.7, 11.7±3.3 vs. 3.3±1.7, all P <0.05). ③ The maximal values of CVP and PAWP were observed at the end of FC. In colloid group, both the two variables were notably higher than that before FC over 120 minutes compared with that of only at 10 minutes in crystalloid group. The MAP in colloid increased to maximum immediately at the end of FC and decreased to baseline at 45 minutes, however, the MAP in crystalloid group and HR of both groups showed no differences over 120 minutes. Conclusions Hemodynamic changes were significantly different between crystalloid and colloid after FC in patients with septic shock. Therefore, the timing of fluid responsiveness assessment should be different individually. The assessment time of colloid group may be prolonged to 30 minutes after FC while that of crystal group can be at 10 minute after FC.