PICCO监测在脓毒症休克患者中的应用

发布时间：2018-03-11 21:50

  本文选题：PICCO　切入点：脓毒症休克　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：脓毒症休克是机体对感染反应失调出现器官功能障碍,且合并严重的循环障碍和细胞代谢紊乱。脓毒症休克患者病情十分凶险,死亡率极高,是导致重症监护室患者死亡的重要原因之一。早期进行液体复苏仍是治疗脓毒症休克患者的关键措施,通过增加有效循环血容量来增加心输出量,提高组织器官灌注,增加氧供,改善预后。但是盲目补液易导致容量负荷增加,加重心脏负担,出现肺水肿,增加病死率。因此,我们需要探求一种简单、迅速、有效的监测手段指导液体复苏。目的:旨在研究脉搏指示连续心输出量(PICCO)在脓毒症休克患者液体复苏中的应用价值。方法:收集2014年1月至2016年12月收入大连医科大学附属第一医院急诊重症监护室的61例脓毒症休克患者,依据治疗方案不同分为早期目标导向治疗组(EGDT组)及脉搏指示连续心输出量组(PICCO组),其中EGDT组有30例,PICCO组有31例。EGDT组根据早期目标导向治疗方案来指导液体复苏,PICCO组则依据PICCO监测的参数进行液体复苏指导。观察并记录两组患者入院时、治疗12h、治疗24h及治疗72h的心率、平均动脉压、血乳酸值及尿量,同时进行SOFA评分,并使用独立样本t检验对比两组之间的差异;记录并比较比较两组患者机械通气时间、ICU留置时间、液体复苏成功率及其28天死亡率的差异。应用PICOO组根据存活与否,分为生存组及死亡组,对比两组Oh的血流动力学指标、OhSOFA评分、24hSOFA评分及24h乳酸清除率的差异;结果:在治疗12h、24h和72h时,PICCO组MAP与尿量明显高于EGDT组(P0.05),而HR、Lac、SOFA评分明显低于EGDT组(P0.05);PICCO组机械通气时间和ICU留置时间明显低于EGDT组,差异具有统计学意义(P0.05);PICCO组的12h液体复苏成功率明显高于EGDT组,差异有统计学意义(P0.05),PICCO组的死亡率明显低于EGDT组,差异有统计学意义(P0.05)。应用PICCO的生存组和死亡组Oh血流动力学参数进行对比,生存组血管外肺水指数(EVLWI)明显低于死亡组,而每搏外周血管阻力指数(SSVRI)、脉压与每搏指数比值(PP/SVI)明显高于死亡组,差异具有统计学意义(P0.05);死亡组Oh SOFA及24h SOFA明显高于生存组,差异具有统计学意义(P0.05);生存组24h乳酸清除率明显高于死亡组,差异具有统计学意义(P0.05);利用Spearman相关性分析法得到Oh PP/SVI与Oh SOFA评分呈负相关性(r=-0.732,P0.05),与24h乳酸清除率呈正相关(r=0.484,P0.05);Oh SSVRI 与 Oh SOFA 评分呈负相关性(r=-0.762,P0.05),与24h乳酸清除率呈正相关(r=0.40,P0.05)。结论:PICC0监测在指导脓毒症休克患者液体复苏方面,具有其独特的优势,可以提高早期液体复苏成功率;脓毒症休克患者治疗开始前的血管弹性指标PP/SVI、SSVRI与SOFA评分具有负相关性,提示PP/SVI、SSVRI值愈低,脓毒症休克患者预后愈差;PP/SVI、SSVRI与24h乳酸清除率具有正相关性,提示PP/SVI、SSVRI值愈低,24h乳酸清除率愈低,预后值愈差,值得在临床工作中推广,有助于进一步评估脓毒症休克患者的预后。
[Abstract]:Septic shock is the body's response to infection with disorder of organ dysfunction, circulatory disorder and cell metabolic disorders. Severe septic shock patients is very dangerous, with high mortality, is one of the leading causes of death in ICU patients. Early is still the key measures for treatment of septic shock in patients with fluid resuscitation. By increasing the effective circulating blood volume to increase cardiac output, improve organ perfusion, increase the oxygen supply, improve the prognosis. But blindly rehydration easily lead to increased volume load, increase the burden on the heart, pulmonary edema, increase the mortality rate. Therefore, we need to find a simple, rapid and effective monitoring means to guide fluid resuscitation. Objective: To study the pulse indicator continuous cardiac output (PICCO) application value in septic shock fluid resuscitation in patients. Methods: from January 2014 to December 2016 Emergency ICU of the First Affiliated Hospital of Dalian Medical University, the income of 61 cases of patients with septic shock, according to the different treatment were divided into early goal-directed therapy group (EGDT group) and pulse indicator continuous cardiac output group (PICCO group), EGDT group had 30 cases, 31 cases of PICCO group.EGDT group to guide fluid resuscitation according to the early goal-directed therapy scheme, guiding PICCO group based on the parametric PICCO monitoring for fluid resuscitation. The two groups were observed and recorded at the time of admission, treatment 12h, treatment 24h and treatment 72h the heart rate, mean arterial pressure, blood lactate and urine volume at the same time, SOFA score, and use different independent samples t test comparison between the two groups; recorded and compared between the two groups of patients with mechanical ventilation time, indwelling time of ICU, different fluid resuscitation success rate and mortality in 28 days. The application of PICOO group according to survival or not, divided into survival group and death group, The hemodynamic indexes were compared between the two groups, Oh OhSOFA score, 24hSOFA score and the difference of lactate clearance rate of 24h; results: in the treatment of 12h, 24h and 72h, PICCO group MAP and urine volume was significantly higher than EGDT group (P0.05), HR, Lac, SOFA score was significantly lower than that of EGDT group (P0.05); PICCO group the mechanical ventilation time and indwelling time of ICU was significantly lower than that in EGDT group, the difference was statistically significant (P0.05); 12h PICCO resuscitation group success rate was significantly higher than that of EGDT group, the difference was statistically significant (P0.05), the mortality of PICCO group was significantly lower than that of EGDT group, the difference was statistically significant (P0.05). By comparing the PICCO survival group the death group and the Oh hemodynamic parameters, the survival group of extravascular lung water index (EVLWI) was significantly lower than the death group, while the stroke peripheral vascular resistance index (SSVRI), pulse pressure and stroke volume index (PP/SVI) was significantly higher than the death group, the difference was statistically significant (P0.05); death Oh SOFA and 24h SOFA death group was significantly higher than the survival group, the difference was statistically significant (P0.05); survival group 24h lactic acid clearance rate was significantly higher than that of death group, the difference was statistically significant (P0.05); analysis by Oh PP/SVI and Oh SOFA score was negatively associated with Spearman correlation (r=-0.732, P0.05), positive rate associated with 24h lactate clearance (r=0.484, P0.05); Oh SSVRI and Oh SOFA scores were negatively correlated (r=-0.762, P0.05), the rate of 24h was positively correlated with the lactate clearance (r=0.40, P0.05). Conclusion: PICC0 monitoring in guiding the septic shock patients fluid resuscitation, has its unique advantages, can improve the early the success rate of resuscitation; blood vessel elasticity index PP/SVI shock treatment of sepsis patients before, SSVRI and SOFA score had negative correlation, suggesting that PP/SVI, SSVRI value is low in patients with septic shock after the pre PP/SVI, SSVRI and 24h; lactate clearance rate with There is a positive correlation, suggesting that the lower the PP/SVI and SSVRI value, the lower the 24h lactate clearance rate and the worse prognosis. It is worth promoting in clinical work, and helps to further evaluate the prognosis of septic shock patients.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7
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本文编号：1600062