摘要目的:探讨左室内压最大上升速率（dp/dtmax）评价脓毒性心肌病（SIC）患者心率下降前后心功能变化的价值。方法:采用单中心、前瞻性、随机对照研究。纳入2020年4月1日至2022年2月28日天津市第三中心医院重症医学科收治的脓毒症/脓毒性休克成人患者，入组患者完成1?h-Bundle集束化治疗后即刻进行斑点追踪超声心动图（STE）和脉搏指示连续心排血量（PiCCO）监测，筛选出心率>100次/min的SIC患者作为研究对象，并按随机数字表法分为艾司洛尔组和常规治疗组，每组55例。所有患者均于入重症监护病房（ICU）6、24和48 h完成STE及PiCCO监测，并计算急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）及序贯器官衰竭评分（SOFA）。主要结局指标：艾司洛尔控制心率后dp/dtmax的变化值。次要结局指标：dp/dtmax与左心室整体纵向应变（GLS）的相关性；艾司洛尔治疗后血管活性药物用量、氧输送（DO 2）、氧消耗（VO 2）及每搏量（SV）的变化；艾司洛尔治疗后心室率控制达目标值的比例；两组患者28 d及90 d病死率。 结果:艾司洛尔组与常规治疗组年龄、性别、体质量指数、SOFA评分、APACHEⅡ评分、心率、平均动脉压、乳酸、24 h液体平衡量、脓毒症病因及既往合并症等基线数据相似，差异均无统计学意义。SIC患者应用艾司洛尔治疗24 h后均达到目标心率，且与常规治疗组相比，艾司洛尔组GLS、全心射血分数（GEF）及dp/dtmax等反映心肌收缩的参数均明显升高〔GLS：（-12.55±4.61）%比（-10.73±4.82）%，GEF：（27.33±4.62）%比（24.18±5.35）%，dp/dtmax（mmHg/s）：1?312.1±312.4比1?140.9±301.0，均 P<0.05〕，N末端脑钠肽前体（NT-proBNP）明显降低〔μg/L：1?364.52（754.18，2?389.17）比3?508.85（1?433.21，6?988.12）， P<0.05〕，DO 2、SV明显升高〔DO 2（mL·min -1·m -2）：647.69±100.89比610.31±78.56，SV（mL）：49.97±14.71比42.79±15.77，均 P<0.05〕；且即使两组患者在去甲肾上腺素用量相似的情况下，艾司洛尔组外周血管阻力指数（SVRI）也明显高于常规治疗组（kPa·s·L -1：287.71±66.32比251.17±78.21， P<0.05）。Pearson相关性分析显示，入ICU 24 h和48 h时SIC患者的dp/dtmax与GLS均呈显著负相关（ r值分别为-0.916和-0.935，均 P<0.05）。虽然艾司洛尔组与常规治疗组患者28 d病死率差异无统计学意义〔30.9%（17/55）比49.1%（27/55）， χ2＝3.788， P＝0.052〕，但是28 d死亡患者艾司洛尔使用率低于生存患者〔38.6%（17/44）比57.6%（38/66）， χ2＝3.788， P＝0.040〕；另外，艾司洛尔对患者90 d病死率也无影响。Logistic回归分析显示，在校正了SOFA评分及DO 2因素后，使用艾司洛尔的患者相对于未使用艾司洛尔的患者28 d死亡风险明显下降〔优势比（ OR）＝2.700，95%可信区间（95% CI）为1.038~7.023， P＝0.042〕。 结论:PiCCO参数中dp/dtmax因其简单易操作，可以作为一项床旁评估SIC患者心功能的指标。SIC患者应用艾司洛尔控制心室率后心功能改善，且能降低短期病死率。

abstractsObjective:To investigate the value of maximal rate of left ventricular pressure (dp/dtmax) in evaluating the changes of cardiac function before and after heart rate reduction in patients with sepsis-induced cardiomyopathy (SIC).Methods:A single-center, prospective randomized controlled study was conducted. Adult patients with sepsis/septic shock admitted to the department of intensive care unit (ICU) of Tianjin Third Central Hospital from April 1, 2020 to February 28, 2022 were enrolled. Speckle tracking echocardiography (STE) and pulse indication continuous cardiac output (PiCCO) monitoring were performed immediately after the completion of the 1 h-Bundle therapy. The patients with heart rate over 100 beats/minutes were selected and randomly divided into esmolol group and regular treatment group, 55 cases in each group. All patients underwent STE and PiCCO monitoring at 6, 24 and 48 hours after admission in ICU and calculated acute physiology and chronic health evaluationⅡ(APACHEⅡ) and sequential organ failure assessment (SOFA). Primary outcome measure: change in dp/dtmax after reducing heart rate by esmolol. Secondary outcome measures: correlation between dp/dtmax and global longitudinal strain (GLS); changes of vasoactive drug dosage, oxygen delivery (DO 2), oxygen consumption (VO 2) and stroke volume (SV) after the administration of esmolol; proportion of heart rate reaching the target after the administration of esmolol; 28-day and 90-day mortality in two groups. Results:Baseline data on age, gender, body mass index, SOFA score, APACHEⅡ score, heart rate, mean arterial pressure, lactic acid, 24-hour fluid balance, sepsis etiology and prior comorbidities were similar between esmolol group and regular treatment group, there were no significant differences between the two groups. All SIC patients achieved the target heart rate after 24 hours of esmolol treatment. Compared with regular treatment group, parameters reflecting myocardial contraction such as GLS, global ejection fraction (GEF) and dp/dtmax were significantly increased in esmolol group [GLS: (-12.55±4.61)% vs. (-10.73±4.82)%, GEF: (27.33±4.62)% vs. (24.18±5.35)%, dp/dtmax (mmHg/s): 1312.1±312.4 vs. 1140.9±301.0, all P < 0.05], and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased [μg/L: 1364.52 (754.18, 2389.17) vs. 3508.85 (1433.21, 6988.12), P < 0.05], DO 2 and SV were significantly increased [DO 2 (mL·min -1·m -2): 647.69±100.89 vs. 610.31±78.56, SV (mL): 49.97±14.71 vs. 42.79±15.77, both P < 0.05]. The system vascular resistance index (SVRI) in esmolol group was significantly higher than that in regular treatment group (kPa·s·L -1: 287.71±66.32 vs. 251.17±78.21, P < 0.05), even when the dosage of norepinephrine was similar between the two groups. Pearson correlation analysis showed that dp/dtmax was negatively correlated with GLS in SIC patients at 24 hours and 48 hours after ICU admission ( r values were -0.916 and -0.935, respectively, both P < 0.05). Although there was no significant difference in 28-day mortality between esmolol group and regular treatment group [30.9% (17/55) vs. 49.1% (27/55), χ2 = 3.788, P = 0.052], the rate of esmolol use in patients who died within 28 days was lower than that in patients who survived [38.6% (17/44) vs. 57.6% (38/66), χ2 = 3.788, P = 0.040]. In addition, esmolol has no effect on the 90-day mortality of patients. Logistic regression analysis showed that after adjusting for SOFA score and DO 2 factors, patients who used esmolol had a significantly lower risk of 28-day mortality compared with patients who did not use esmolol [odds ratio ( OR) = 2.700, 95% confidence interval (95% CI) was 1.038-7.023, P = 0.042]. Conclusions:dp/dtmax in PiCCO parameter can be used as a bedside indicator to evaluate cardiac function in SIC patients due to its simplicity and ease of operation. Esmolol control of heart rate in SIC patients can improve cardiac function and reduce short-term mortality.