脉搏指示连续心排血量监测液体复苏对脓毒性休克急性肾损伤患者血流动力学及肾功能的影响

Effects of fluid resuscitation under PiCCO monitoring on hemodynamics and renal function in patients with septic shock complicating acute kidney injury

摘要:

目的 探讨脉搏指示连续心排血量监测（PiCCO）液体复苏对脓毒性休克急性肾损伤（AKI）患者血流动力学及肾功能的影响。方法 选取2019年1月—2022年1月遵义市第一人民医院重症监护病房（ICU）收治的脓毒性休克AKI患者112例，将患者分为观察组和对照组，每组56例。两组患者分别实施PiCCO液体复苏策略和早期目标导向治疗液体复苏策略。比较两组患者复苏前及复苏24 h、48 h心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、血乳酸（Lac）、血尿素氮（BUN）、血肌酐（Scr）和脑钠肽（BNP）水平，分析两组患者复苏6 h、24 h、48 h液体平衡量和尿量，比较两组患者连续性肾脏替代治疗（CRRT）情况、机械通气（MV）时间、ICU住院时间和治疗后28 d病死率。结果 两组患者性别、年龄、体质量指数、急性生理学和慢性健康状况评分Ⅱ、序贯器官衰竭评估评分比较，差异无统计学意义（P >0.05）。两组患者复苏前、复苏24 h和48 h的HR、MAP、CVP、Lac比较，经重复测量设计的方差分析，结果 ①不同时间点的HR、MAP、CVP、Lac有差异（P <0.05）；②两组患者CVP有差异（P <0.05），两组HR、MAP、Lac无差异（P <0.05）；③两组患者HR、MAP、CVP、Lac变化趋势有差异（P <0.05）。两组患者复苏6 h、24 h、48 h的液体平衡量和尿量比较，经重复测量设计的方差分析，结果 ①不同时间点的液体平衡量、尿量有差异（P <0.05），②两组患者液体平衡量、尿量有差异（P <0.05），观察组液体平衡量较对照组低、尿量较对照组多，相对改善效果较好；③两组患者液体平衡量、尿量变化趋势有差异（P <0.05）。两组患者复苏前、复苏24 h和48 h的BUN、Scr比较，经重复测量设计的方差分析，结果 ①不同时间点的BUN、Scr有差异（P <0.05）；②两组患者BUN、Scr有差异（P <0.05），观察组较对照组低，改善效果相对较好；③两组患者BUN、Scr变化趋势有差异（P <0.05）。两组患者复苏前、复苏24 h和48 h的BNP比较，经重复测量设计的方差分析，结果 ①不同时间点的BNP有差异（P <0.05）；②两组患者BNP有差异（P <0.05）；③两组患者BNP变化趋势有差异（P <0.05）。两组患者CRRT、治疗后28 d病死率比较，差异无统计学意义（P >0.05）。观察组CRRT治疗时间、MV时间、ICU住院时间短于对照组（P <0.05）。结论 PiCCO液体复苏策略能有效减少脓毒性休克AKI患者液体负荷量，维持血流动力学稳定，改善心肾功能，缩短CRRT治疗时间、MV时间和ICU住院时间。

Abstract:

Objective To investigate the effects of fluid resuscitation under pulse-indicated continuous cardiac output (PiCCO) monitoring on hemodynamics and renal function in patients with septic shock complicating acute kidney injury (AKI).Methods A total of 112 patients with septic shock complicating AKI admitted to the intensive care unit (ICU) of our hospital from January 2019 to January 2022 were selected, and the patients were divided into the observation group and the control group, with 56 cases in each group. The fluid resuscitation under PiCCO monitoring and early goal-directed therapy were applied in the observation group and control group, respectively. The heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), blood lactic acid (Lac), blood urea nitrogen (BUN), serum creatinine (Scr) and brain natriuretic peptide (BNP) were compared between the two groups before fluid resuscitation and 24 h and 48 h after fluid resuscitation. The fluid balance and urine volume of patients in the two groups were analyzed at 6 h, 24 h and 48 h after fluid resuscitation, and continuous renal replacement therapy (CRRT), mechanical ventilation (MV) duration, length of ICU stay and mortality at 28 d were compared between the two groups.Results There was no significant difference in gender composition, age, body mass index (BMI), Acute Physiology And Chronic Health EvaluationⅡ (APACHEⅡ) score, or Sequential Organ Failure Assessment (SOFA) score between the two groups (P > 0.05). HR, MAP, CVP and Lac levels before resuscitation and 24 h and 48 h after resuscitation were compared between the two group via repeated measures ANOVA, and the results demonstrated that HR, MAP, CVP and Lac levels were different at distinct time points (P < 0.05) and that CVP rather than HP, MAP, or Lac levels was different between the observation group and control group (P < 0.05). Besides, there were significant differences in the change trends of HR, MAP, CVP and Lac levels between the observation group and the control group (P < 0.05). The fluid balance and urine volume were measured at 6 h, 24 h and 48 h after the fluid resuscitation in the two groups, and there were significant differences in the fluid balance and urine volume at different time points (P < 0.05) and between the groups, where the fluid balance was lower and urine volume was higher in the observation group compared with the control group (P < 0.05). The change trends of the fluid balance and urine volume were also different between the groups (P < 0.05). BUN and Scr levels of the observation group and the control group were measured before and 24 h and 48 h after resuscitation. The comparisons revealed that BUN and Scr levels were different among the time points (P < 0.05) and between the observation group and control group (P < 0.05), and that the levels of these indicators were lower in the observation group which indicated greater efficacy. The change trends of BUN and Scr levels were different between the observation group and the control group (P < 0.05). In addition, BNP levels of observation group and control group were also observed before and 24 h and 48 h after resuscitation. BNP levels were different among the time points (P < 0.05) and between the two groups (P < 0.05), and the change trends of BNP levels were different between the observation group and the control group (P < 0.05). There was no difference in the frequency of CRRT and 28-day mortality between the two groups (P > 0.05). The duration of CRRT, MV duration and length of ICU stay in the observation group were shorter than those in the control group (P > 0.05).Conclusions The fluid resuscitation under PiCCO monitoring can effectively reduce the fluid load of patients with septic shock complicating AKI, maintain the hemodynamic stability, improve the cardiac and renal functions, and shorten the duration of CRRT, MV duration and length of ICU stay.