脓毒症患者心功能障碍及对预后的影响

发布时间：2018-05-28 08:45

本文选题：脓毒症 + 心功能障碍　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:脓毒症在重症加强监护病房发病率很高,脓毒症3.0将脓毒症定义为针对感染的失调的宿主反应引起的危及生命的器官功能障碍,更加强调器官功能障碍的重要性,其引起的器官功能障碍包括呼吸系统、中枢神经系统、血液系统及心血管系统等,脓毒症的心功能障碍是心血管系统对疾病过程、宿主反应和复苏的动态适应所表现的最复杂的器官衰竭之一。随着床旁超声心动图技术在重症监护病房中的应用,许多研究已经描述了在脓毒症中存在不同类型的心功能障碍。人们已经从只关注左心室(LV)收缩功能障碍向识别其他类型的心功能障碍转变,作为心功能障碍的一部分类型可能有不同的治疗方案及对患者预后产生影响。脓毒症性心功能障碍包括左室收缩功能障碍,左室舒张功能障碍和右心室功能障碍。各类型心功能障碍可以单独或组合存在,并且在恢复期是可逆性的。尽管不同类型的心功能障碍已在某种程度上被评估,但其定义和临床表现缺乏共识。心功能障碍对脓毒症患者的预后影响尚不明确,本课题应用经胸床旁超声心动图对脓毒症患者心功能障碍进行观察并评价其对28天和60天死亡率的影响。方法:选择2016年1月1日至2016年12月31日河北省沧州市中心医院急诊重症监护室(EICU)收治的53例脓毒症患者进行了前瞻性观察研究。入住重症监护室24小时以内首次行床旁超声心动图检测,记录左心室收缩功能指标:左室射血分数、左心室舒张功能指标:采用脉冲多普勒测定的二尖瓣舒张早期峰流速与组织多普勒测定的二尖瓣环舒张早期速度比值(E/E’),右心收缩功能指标:三尖瓣收缩期位移(TAPSE),同时记录一般临床资料、生理参数、包括血流动力学参数、和血管活性用量,并进行APACHE II及SOFA评分,根据超声结果将患者分为心功能正常组、心功能障碍组、心功能障碍进一步分为左心室(LV)收缩、舒张功能障碍和右心室(RV)功能障碍。计算各类心功能障碍的发生率,并比较无心功能障碍和不同类型的心功能障碍在人口学、血流动力学、生理变量和28天、60天死亡率的差异。结果:共纳入53例患者。平均年龄62±17岁,男性27例,女性26例。记录到病原学结果30例(57%),其中血培养阳性10例结果占19%,其他标本包括痰、尿、引流液、分泌物等的微生物阳性培养源20例(38%),18例(33%)进行培养未得到明确阳性病原学结果,5例(10%)由于各种原因未进行培养。所有脓毒症患者中肺部感染10例(17%),胆囊炎3例(6%),肝脓肿3例(6%),菌血症4例(8%),软组织感染7例(13%)、消化道感染7例(13%)、泌尿系感染3例(6%)、流行性出血热2例(4%)、神经系统感染4例(8%)、混合感染8例(15%)、未明确感染源2例(4%)。根据心脏超声结果将病人分成四组,分别为心功能正常组、左心室收缩功能障碍组、左心室舒张功能障碍组、右心室功能障碍组,其中心功能正常的患者有19例患者(36%),有心功能障碍的为34例,占总人数的64%。左室收缩功能不全的有14例(26%),左心室舒张功能障碍的有20例(38%),和右心室功能不全的16例(30%)。心功能障碍类型之间存在相互重叠,3例(6%)存在左心室收缩和舒张功能障碍,右心室功能正常,5例(9%)有双心室收缩功能障碍,舒张功能正常,4例(8%)存在左心室舒张及右心室功能障碍,2例(4%)显示存在舒张功能障碍,合并左心室和右心室收缩功能障碍,总共有19例(36%)28天内死亡,有30例(57%)在60内死亡,正常心功能组与心功能障碍组28天和60天的病死率分别为42%、32%和53%、57%(P=0.31 vs P=0.83)无统计学意义。结论:1心功能障碍在脓毒症中是常见的,包括左室收缩,左室舒张,和右心室功能障碍,以左室射血分数(LVEF)下降作为脓毒症性心功能障碍评价唯一标准具有局限性。2床旁超声心动图观察脓毒症性心功能障碍患者和无心功能障碍患者在28天或60天的病死率无显著差异。3在重症加强监护病房,床旁超声心动图的应用有助于为脓毒症性心功能障碍的诊断和分型及干预措施提供重要依据。
[Abstract]:Objective: the incidence of sepsis in intensive care unit is very high. Sepsis 3 defines sepsis as a life threatening organ dysfunction caused by a host response to the imbalance of infection and emphasizes the importance of organ dysfunction, which includes the respiratory system, the central nervous system, the blood system and the system of organ dysfunction. Cardiac dysfunction, such as the cardiovascular system, is one of the most complex organ failure of the cardiovascular system for the disease process, the dynamic adaptation of the host response and the resuscitation. With the application of the bedside echocardiography in the intensive care unit, many studies have described the existence of different types of cardiac function in sepsis. Obstacles. People have changed from only concerned with the left ventricular (LV) systolic dysfunction to identifying other types of cardiac dysfunction. As a part of the heart dysfunction, there may be different treatments and effects on the prognosis. Septic cardiac dysfunction includes left ventricular systolic dysfunction, left ventricular diastolic dysfunction, and right heart. Ventricular dysfunction. Various types of cardiac dysfunction may exist alone or in combination, and are reversible in the recovery period. Although different types of cardiac dysfunction have been evaluated to some extent, their definition and clinical manifestations are lacking consensus. The effect of cardiac dysfunction on the prognosis of septic patients is not clear. Echocardiography was used to observe cardiac dysfunction in patients with sepsis and to evaluate its effect on mortality at 28 and 60 days. Methods: a prospective study of 53 cases of sepsis in the emergency intensive care unit (EICU) of Cangzhou Central Hospital in Hebei province from January 1, 2016 to December 31, 2016 was studied. 24 small patients were admitted to the intensive care unit. The left ventricular systolic function index: left ventricular ejection fraction and left ventricular diastolic function index: the early peak velocity of mitral valvular diastolic velocity measured by pulsed Doppler and the early diastolic velocity ratio of mitral annulus measured by tissue Doppler (E/E '), and the index of right cardiac contractile function: three apical valve contraction. Phase shift (TAPSE), also recorded general clinical data, physiological parameters, including hemodynamic parameters, and vasoactive dosage, and APACHE II and SOFA scores. According to ultrasound results, the patients were divided into normal cardiac function group, heart dysfunction group, and cardiac dysfunction was divided into left ventricular (LV) contraction, diastolic dysfunction and right ventricle (RV). The incidence of various types of cardiac dysfunction was calculated, and the differences in demography, hemodynamics, physiological variables and 28 day, 60 day mortality were compared with non cardiac dysfunction and different types of cardiac dysfunction. Results: a total of 53 patients were included. The average age was 62 + 17 years, 27 men and 26 women. The results were recorded in 30 cases (57%). The results of 10 cases of positive medium blood culture were 19%, other specimens included sputum, urine, drainage and secretion, 20 cases (38%), 18 cases (33%) had no definite positive pathogenic results, 5 cases (10%) were not cultured for various reasons. All the patients with sepsis were pulmonary infection in 10 cases (17%), cholecystitis 3 (6%), hepatic abscess 3 Cases (6%), 4 cases of bacteremia (8%), 7 cases of soft tissue infection (13%), 7 cases of digestive tract infection (13%), 3 cases of urinary tract infection (6%), 2 cases of epidemic hemorrhagic fever (4%), 4 cases of nervous system infection (8%), mixed infection in 8 cases, and no definite source of infection. Disorder group, left ventricular diastolic dysfunction group, right ventricular dysfunction group, 19 patients with normal central function (36%), 34 cases with cardiac dysfunction, 14 cases (26%) of 64%. left ventricular systolic dysfunction, 20 cases of left ventricular diastolic dysfunction (38%), and 16 cases of right ventricular dysfunction (30%). Cardiac function 3 cases (6%) had left ventricular systolic and diastolic dysfunction, right ventricular function, 5 cases (9%) had diastolic dysfunction, normal diastolic function, 4 cases (8%) with left ventricular diastolic and right ventricular dysfunction, 2 cases (4%) showed diastolic dysfunction, and left ventricular and right ventricular systolic work in 2 cases (4%). A total of 19 cases (36%) died within 28 days, 30 (57%) died within 60, and 28 days and 60 days in the normal cardiac function group and cardiac dysfunction group were 42%, 32% and 53%, and 57% (P=0.31 vs P=0.83) were not statistically significant. Conclusion: 1 cardiac dysfunction is common in sepsis, including left ventricular systolic, left ventricular diastolic, and right ventricular work. Impairment of left ventricular ejection fraction (LVEF) as the sole criterion for evaluation of septic cardiac dysfunction with limited.2 bedside echocardiography observation of the mortality of patients with septic cardiac dysfunction and careless dysfunction at 28 days or 60 days.3 in intensive care intensive care unit, bedside echocardiography should It can help to provide important evidence for diagnosis, typing and intervention of septic cardiac dysfunction.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7

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