床旁超声与脉搏指示连续心排血量监测在脓毒症休克患者早期液体复苏治疗中的疗效比较

Comparison of the efficacy of bedside ultrasound and pulse-indicated continuous cardiac output monitoring for guiding early fluid resuscitation in patients with septic shock

摘要:

目的 对比床旁超声与脉搏指示剂连续心排血量监测（PiCCO）指导脓毒性休克患者行液体复苏的效果。方法 选取2018年12月—2020年5月在南昌大学第二附属医院急诊重症监护室（ICU）诊疗的脓毒性休克患者30例，按照不同治疗方法分成超声组、PiCCO组，每组15例。超声组采用床旁超声检测左心室舒张期容积、左心室收缩期容积，并计算每搏输出量（SV）；PiCCO组通过PiCCO测得SV，分析超声与PiCCO测得SV的相关性。将SV在被动直腿抬高试验期间升高值（ΔSv）≥ 10%定义为容量有反应性，< 10%定义为容量无反应性，分别进入液体复苏阶段。以28 d病死率、住院时间、机械通气时间为主要观察指标，以治疗后6 h和12 h中心静脉压（CVP）、平均动脉压（MAP）、氧合指数、乳酸、补液量及尿量为次要观察指标，分析两种方法在指导脓毒症患者早期液体复苏上有无差异。结果 两组治疗后28 d病死率、住院时间比较，差异无统计学意义（P >0.05）；超声组机械通气时间短于PiCCO组（P <0.05）。床旁超声测得SV与PiCCO测得SV呈正相关（r =0.983，P =0.002）。超声组与PiCCO组治疗前、治疗后6 h和12 h测量MAP、CVP、氧合指数、乳酸比较，采用重复测量设计的方差分析，结果 ①不同时间点MAP、CVP、氧合指数、乳酸有差异（F =8.596、7.485、10.236和8.124，均P =0.000）；②超声组与PiCCO组MAP、CVP、氧合指数、乳酸无差异（F =0.567、0.639、0.496和0.496，P =0.457、0.532、0.375和0.375）；③两组MAP、CVP、氧合指数、乳酸变化趋势有差异（F =5.485、4.125、3.985和5.452，P =0.015、0.023、0.034和0.034）。PiCCO组治疗后6 h和12 h补液量少于超声组，尿量多于超声组（P <0.05）。超声组和PiCCO组治疗后12 h补液量、尿量多于治疗后6 h（P <0.05）。结论 床旁超声与PiCCO测得SV一致性较好，两者病死率及ICU住院时间无差异，但床旁超声能减少肺水肿形成及所致机械通气时间。

Abstract:

Objective To compare the efficacy of bedside ultrasound and pulse-indicated continuous cardiac output (PiCCO) monitoring in guiding fluid resuscitation in patients with septic shock.Methods A total of 30 patients with septic shock diagnosed and treated by the emergency ICU of the Second Affiliated Hospital of Nanchang University from December 2018 to May 2020 were included and randomly divided into an ultrasound group and a PiCCO group, with 15 cases in each group. The left ventricular end-diastolic volume and the left ventricular end-systolic volume were detected via bedside ultrasound and the stroke volume (SV) was calculated in the ultrasound group. The PiCCO group was monitored via PiCCO to detect the SV, and the correlation between the SV measured via ultrasound and that measured via the PiCCO was analyzed. The patients were regarded as fluid responsive or not according to whether SV increased by 10% or greater during the passive leg raise (PLR) test, and then the patients were subject to fluid resuscitation therapy, respectively. The 28-day mortality, length of ICU stay, and duration of mechanical ventilation were the primary outcome, while central venous pressure (CVP), mean arterial pressure (MAP), oxygenation index, lactate level, the amount of fluid resuscitation and urine volume measured at 6 and 12 h after treatment were the secondary outcomes. The efficacy of the two approaches for guiding early fluid resuscitation in patients with septic shock was compared.Results There was no significant difference in the 28-day mortality and length of hospital stay between the two groups (P > 0.05). The duration of mechanical ventilation in ultrasound group was shorter than that in PiCCO group (P < 0.05). The SV detected via bedside ultrasound was positively correlated with that determined by PiCCO (r = 0.983, P = 0.002). The MAP, CVP, oxygenation index and lactate level were measured before treatment, and 6 h and 12 h after the treatment in ultrasound group and PiCCO group. The repeated measures ANOVA showed that there were differences in MAP, CVP, oxygenation index and lactate level among time points (F =8.596, 7.485, 10.236, and 8.124, all P =0.000), while there was no difference in MAP, CVP, oxygenation index or lactate level between ultrasound group and PiCCO group (F =0.567, 0.639, 0.496 and 0.496, P =0.457, 0.532, 0.375 and 0.375). Besides, the change trends of MAP, CVP, oxygenation index and lactate level were also different between ultrasound group and PiCCO group (F =5.485, 4.125, 3.985 and 5.452, P =0.015, 0.023, 0.034 and 0.034). The amounts of fluid resuscitation at 6 h and 12 h after treatment in PiCCO group were lower than those in ultrasound group, whereas the urine volume in the PiCCO group was more than that in the ultrasound group (P < 0.05). In addition, the amount of fluid resuscitation and urine volume at 12 h after treatment were higher than those at 6 h after treatment in both ultrasound group and PiCCO group (P < 0.05).Conclusions The SV measured via bedside ultrasound is consistent with that determined via PiCCO. When applied for guiding early fluid resuscitation, there is no difference in the mortality and the length of hospital stay between the two approaches, yet bedside ultrasound contributes to the lower risk of pulmonary edema and a shorter duration of mechanical ventilation.