超声评估分流在低氧血症患者中的发生率及其对右心功能的影响

发布时间：2018-04-18 10:30

  本文选题：低氧血症 + 右向左分流　； 参考：《河北医科大学》2017年硕士论文

【摘要】：目的:本研究拟通过床旁经胸超声心动图对低氧血症患者进行心内分流及肺内分流的诊断及右心功能的评估,主要目的为:1、评估低氧血症患者心内分流和肺内分流发生率;2、探讨分流对右心功能的影响;3、分析分流对低氧血症患者预后,包括机械通气天数、ICU住院天数、总住院天数、28天全因死亡率的影响。方法:本研究为前瞻性临床观察性研究,纳入2016年4-12月在河北医科大学第四医院重症医学科收治的急性低氧血症的患者。入选标准:1)各种原因导致的急性低氧血症,氧合指数300mm Hg;2)入住ICU时间≥24小时;3)年龄≥18周岁。排除标准:1)入住ICU时间24小时;2)年龄18周岁;3)肺栓塞患者;4)右心室梗塞患者;5)慢性肺源性心脏病患者、肺性脑病患者;6)孕产妇及哺乳期妇女;7)由于各种原因超声图像显示不清晰的患者。所有入组患者由临床主管医生决定治疗方案。根据生理盐水微气泡造影试验结果分为无分流组、心内分流组、肺内分流组,记录三组患者24小时内的急性生理慢性健康评分II(Acute Physiology And Chronic Health Evaluation II,APACHEII)、序贯器官衰竭评分(Sequential Organ Failure Assessment,SOFA),行超声检查时的生命体征、呼吸机模式及参数;入组24小时内的液体出入量;血气分析指标、超声心动图结果、机械通气天数、ICU住院天数、总住院天数、28天全因死亡率等。结果:1本研究共纳入80名患者,无分流组57例,心内分流组12例(15%),肺内分流组11例(13.75%)。其中,ARDS患者35例:分别包括无分流组25例,心内分流组5例(14.29%),肺内分流组5例(14.29%);非ARDS患者45例:分别包括无分流组32例,心内分流组7例(15.56%),肺内分流组6例(13.33%)。2低氧血症患者无分流组、心内分流组、肺内分流组右心功能及预后的比较。2.1无分流、心内分流、肺内分流三组患者年龄差异有统计学意义,分别为69.33years±10.41years vs 54.64years±16.27years vs 65.73years±11.87years,P=0.002。性别、APACHEII评分、SOFA评分、生命体征、液体出入量、呼吸机支持条件等差异无统计学意义(P0.05)(Table1)。2.2三组患者动脉血气分析显示,p H值、二氧化碳分压(Pa CO2)、中心静脉-动脉二氧化碳分压差(Gap)、碱剩余(BE)、氧合指数(Pa O2/Fi O2)、乳酸(Lac)差异无统计学意义(P0.05)(Table 1)。2.3三组患者超声结果显示,E峰、A峰、E/A、e’、E/e’、RVarea/LVarea、PASP、TAPSE、IVC内径差异均无统计学意义(P0.05)(Table 2)。2.4三组患者机械通气天数、ICU住院天数、总住院天数及28天全因死亡率差异均无统计学意义(P0.05)(Table 3)。3 ARDS患者无分流组、心内分流组、肺内分流组右心功能及预后的比较。3.1无分流组、心内分流组、肺内分流组三组患者CVP差异有统计学意义,分别为10.80mm Hg±3.03mm Hg vs 8.04mm Hg±2.49mm Hg vs 10.40mm Hg±1.67mm Hg,P=0.032;性别、年龄、APACHEII、SOFA评分、其余生命体征、液体出入量、呼吸机支持条件等差异无统计学意义(P0.05)(Table4)。3.2三组患者血气分析各项指标无统计学差异(P0.05)(Table 4)。3.3三组患者超声结果无统计学差异(P0.05)(Table 5)。3.4三组患者机械通气天数、ICU住院天数、总住院天数及28天全因死亡率无统计学差异(P0.05)(Table 6)。4 ARDS与非ARDS患者比较4.1两组患者性别、年龄、APACHEII、SOFA评分、生命体征、液体出入量、呼吸机支持条件等差异无统计学意义(P0.05)(Table 7)。4.2两组患者血气分析氧合指数差异有统计学意义,分别为:174.16mm Hg±74.58mm Hg vs 242.44mm Hg±90.74mm Hg,P=0.001;乳酸差异有统计学意义,分别为:2.39mmol/L±1.64 mmol/L vs 1.78 mmol/L±0.89mmol/L,P=0.037,其余指标差异无统计学意义(P0.05)。4.3两组患者超声结果差异无统计学意义(P0.05)(Table 7)。4.4两组患者机械通气天数、ICU住院天数、总住院天数及28天全因死亡率差异无统计学意义(P0.05)(Table 7)。4.5两组患者心内分流及肺内分流发生率差异无统计学意义(Table 7)5低氧血症患者存活组与死亡组患者比较5.1存活组与死亡组比较,死亡组女性患者所占比例较大,分别为15.87%vs 50%,P=0.047,年龄较大,分别为60.77years±13.52years vs 69.09years±11.24years,P=0.007,APACHE II评分及SOFA评分均高于存活组分别为18.26±4.58 vs 23.82±7.44,P=0.003;7.10±2.60 vs 10.55±3.75,P0.001,心率较存活组更快分别为95.67 beats/min±26.98 beats/min vs 116.32beats/min±28.83 beats/min,P=0.004,其余生命体征差异无统计学意义(P0.05)(Table 8)。5.2两组患者液体量相比较,存活组较死亡组液体平衡量更少,分别为-59.00ml±1257.13ml vs 881.41ml±1162.96ml,P=0.002,潮气量更小,分别为414.95ml±88.71ml vs 481.43ml±104.11ml,P=0.011,其余液体指标、机械通气指标及血气分析各项指标差异无统计学意义(P0.05)(Table 8)。5.3两组患者超声结果比较显示,存活组较死亡肺动脉收缩压更低,分别为29.28mm Hg±12.97 mm Hg vs 36.14 mm Hg±13.93 mm Hg,P=0.049,其余超声指标差异无统计学意义(P0.05)(Table 8)。5.4两组患者比较,存活组机械通气天数更少,分别为4.66d±2.78d vs6.96d±4.16d,P=0.005,ICU住院天数及总住院天数差异无统计学意义(Table 8)。5.5两组患者心内分流及肺内分流发生率、ARDS发生率比较差异均无统计学意义(P0.05)(Table 8)。6 28天全因死亡率的相关危险因素分析结果以28天全因死亡率作为因变量,纳入血流动力学或呼吸参数指标中具有显著差异的变量进行Logistic回归分析,提示主要危险因素为年龄、入组24小时内的液体平衡量、潮气量。(Table 9)结论:1低氧血症患者出现心内分流的发生率为15%,肺内分流发生率为13.75%;ARDS患者心内分流发生率为14.29%,肺内分流发生率为14.29%;非ARDS心内分流发生率15.56%,肺内分流发生率为13.33%。2未发现心内分流或肺内分流对低氧血症患者、ARDS患者右心功能的影响。3未发现心内分流或肺内分流对低氧血症患者、ARDS患者机械通气天数、ICU住院天数、总住院天数、28天全因死亡率的关系。4低氧血症存活患者中入组24小时内的液体出入量更少,潮气量更小,肺动脉压更低。
[Abstract]:Objective: This study by bedside transthoracic echocardiographic evaluation of intracardiac shunt and shunt diagnosis and right ventricular function of hypoxemia in patients with map, the main purpose is to: 1, to assess the incidence of hypoxemia in patients with heart shunt and pulmonary shunt; 2, to investigate the effect of shunt on right ventricular function; 3 Analysis on the prognosis of patients with shunt, hypoxemia, duration of mechanical ventilation, ICU length of stay, total hospital stay, 28 day all-cause mortality. Methods: This study was a prospective clinical observational, in 2016 4-12 months in the ICU of Hebei Medical University Fourth Hospital of acute hypoxemia in patients with inclusion criteria: 1). Acute hypoxemia caused by a variety of reasons, the oxygenation index 300mm Hg; 2) ICU stay longer than 24 hours; 3) aged 18 years of age. Exclusion criteria: 1) in the ICU time for 24 hours; 2) aged 18 years); 3 patients with pulmonary embolism; 4) of right heart In patients with ventricular infarction; 5) in patients with chronic pulmonary heart disease, patients with pulmonary encephalopathy; 6) pregnant women and lactating women; 7) due to various reasons, the ultrasonic images of patients is not clear. All of the patients were determined by clinical doctor in charge of treatment. According to physiological saline microbubble contrast test results divided into shunt group, group of intracardiac shunt, intrapulmonary shunt group, acute physiology records of three groups of patients within 24 hours of chronic health evaluation II (Acute Physiology And Chronic Health Evaluation II, APACHEII), sequential organ failure assessment (Sequential Organ Failure Assessment, SOFA), ultrasound vital signs, ventilation modes and parameters into; group within 24 hours of liquid intake; blood gas analysis index, the results of echocardiography, mechanical ventilation time, ICU length of stay, total hospital stay, 28 day all-cause mortality. Results: 1 this study included 80 patients No, the shunt group 57 cases, 12 cases of intracardiac shunt group (15%), 11 cases with intrapulmonary shunt group (13.75%). Among them, 35 cases of ARDS patients were included non shunt group 25 cases, 5 cases of intracardiac shunt group (14.29%), 5 cases with intrapulmonary shunt group (14.29%); 45 cases of non ARDS patient: including the free flow group 32 cases, 7 cases of intracardiac shunt group (15.56%), 6 cases with intrapulmonary shunt group (13.33%).2 group without shunt hypoxemia, cardiac shunt group, pulmonary shunt.2.1 group right heart function and prognosis of non diversion, intracardiac shunt, shunt in three patients age differences in lung has statistical significance, respectively, 69.33years + 10.41years vs 54.64years + 16.27years vs 65.73years + 11.87years P=0.002., sex, APACHEII score, SOFA score, vital signs, fluid intake and output, there was no significant difference of ventilator support condition (P0.05).2.2 (Table1) three groups of patients with arterial blood gas analysis showed that the p value of H (Pa, partial pressure of carbon dioxide CO2),涓�蹇冮潤鑴�-鍔ㄨ剦浜屾哀鍖栫⒊鍒嗗帇宸，

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