摘要目的 探讨经皮二氧化碳分压(PcCO2)与呼气末二氧化碳分压(PetCO2)梯度P(c-et) CO2监测对脓毒症休克早期诊断、治疗及预后的临床意义.方法 前瞻性比较2014年5月至2016年10月南通市通州区人民医院收治的35例早期脓毒症休克患者(治疗组,休克发病24 h内)及18例非休克患者(对照组,手术后麻醉苏醒期)资料,比较入院时、治疗组实施早期目标导向性治疗(EGDT)后P(c-et) CO2与动脉血乳酸浓度(LAC)等的变化.结果 二组患者P(c-et) CO2基线值分别为(26.0±16.2):(11.0 ±5.6) mmHg(1 mmHg =0.133 kPa),LAC基线值分别为(4.0±1.7)、(1.6 ±0.6)mmol/L,均P=0.000,ROC曲线下面积分别为0.924(95％ CI:0.851 ～0.996)和0.931(95％ CI:0.872 ～1.000),P(c-et)CO2＞ 12.6 mmHg和LAC＞2.5 mmol/L诊断脓毒症休克的敏感度均为97％、特异度分别为83％和78％;以P(c-et) CO2和LAC基线值预测脓毒症休克患者28 d死亡,ROC曲线下面积分别为0.709(95％ CI:0.533 ～0.886)和0.714(95％ CI:0.545 ～0.883),P(c-et)CO2＞20.0 mmHg和LAC＞ 3.6 mmol/L预测患者死亡的敏感度均为92％、特异度均为76％.治疗组入院6h内均完成EGDT,20例(57.1％)达标,15例(42.9％)未达标;达标组17例存活(85.0％),未达标组4例存活(26.7％),F =9.844,P=0.001.EGDT后P(c-et) CO2和LAC分别为(21.0 ±9.5)mmHg和(3.3 ±2.5)mmol/L,比基线值均显著下降(P=0.008和P=0.046),此时ROC曲线下面积分别为0.905 (95％ CI:0.792～1.000)和0.747 (95％ CI:0.576 ～0.917),P(c-et) CO2＞16.5 mmHg和LAC＞3.1 mmol/L时预测患者28 d死亡的敏感性分别为97％和91％、特异度分别为78％和69％.结论 入院时P(c-et) CO2＞12.6 mmHg可作为区分早期脓毒症休克与非休克患者的指标,诊断作用与LAC相似;P(c-et) CO2可反映EGDT救治疗效;EGDT前P(c-et) CO2＞ 20 mmHg、EGDT后P(c-et) CO2＞16.5 mmHg可作为预测脓毒症休克患者28 d死亡指标,EGDT前预测作用与LAC作用相似,EGDT后作用比LAC强.

abstractsObjective To investigate the significance of monitoring the gradients between transcutaneous PCO2 and end-tidal PCO2 [P(c-et) CO2] in patients with septic shock.Method Thirty-five mechanically ventilated patients with early septic shock were enrolled as the study group and 18 non-septic shock patients with stable hemodynamics as the control group between May 2014 and October 2016.The patients with septic shock were treated by early goal-directed therapy (EGDT) within 6 hours since hospitalization.The differences of baseline level of P(c-et) CO2 and arterial lactate concentration (LAC) between the two groups and the variations of these indexes after EGDT in the study group were compared respectively.Results The baseline levels of P (c-et) CO2 and LAC in patients with septic shock were significantly higher than those of the control group [(26.0 ± 16.2) mmHg vs (11.0 ± 5.6) mmHg (1 mmHg =0.133 kPa) and (4.0 ± 1.7) mmol/L vs (1.6 ±0.6) mmol/L,all P=0.000].The area under receiver operator characteristic (ROC) curve (AUC) for baseline P (c-et) CO2 and LAC was 0.924 (95％ CI:0.851-0.996) and 0.931 (95％ CI:0.872-1.000),respectively.P(c-et) CO2 ＞ 12.6 mmHg and LAC ＞ 2.5 mmol/L could discriminate septic shock patients from those without shock with the same sensibility of 97％ and the specificity of 83％ and 78％ respectively.With regard to the prognosis (Day 28) of the patients with septic shock,AUC for baseline P (c-et) CO2 and LAC was 0.709 (95 ％ CI:0.533-0.886) and 0.714 (95％ CI:0.545-0.883),respectively.P (c-et) CO2 ＞ 20.0 mmHg and LAC ＞ 3.6 mmol/L could discriminate survivors from non-survivors with the same sensibility of 92％ and the same specificity of 76％.All the patients in the study group completed EGDT within 6 hours after admission,20 (57.1％) passed EGDT and 17 (85.0％) survived,15 (42.9％) failed EGDT and 4 (26.7％) survived,and the survival rates were significantly different (F =9.844,P =0.001).After EGDT,P(c-et) CO2 (21.0 ± 9.5 mmHg) and LAC (3.3 ± 2.5 mmol/L) reduced significantly compared with the baselines (P =0.008 and P =0.046),and the associated AUC was 0.905 (95％ CI:0.792-1.000) and 0.747 (95％ CI:0.576-0.917)respectively.P(c-et) CO2 ＞ 16.5 mmHg and LAC ＞ 3.1 mmol/L could discriminate survivors from non-survivors with the sensibility of 97％ and 91％,and the specificity of 78％ and 69％,respectively.Conclusions P(c-et) CO2 ＞ 12.6 mmHg could play the same role as LAC in recognizing early septic shock.EGDT was an effective therapy for the septic shock and P(c-et) CO2 reflected efficacy.P(c-et)CO2 ＞20 mmHg before EGDT and ＞ 16.5 mmHg after EGDT both could predict the 28 d prognosis of patients with septic shock,and the effect of the former was equal to that of LAC,but the latter was better than LAC.