被动抬腿试验联合经胸超声心动图指导脓毒性休克患者早期液体复苏的临床意义

摘要

Objective To explore the clinical value of early fluid resuscitation guided by passive leg-raising test (PLR) combined with transthoracic echocardiography (TTE) in patients with septic shock. Methods A prospective randomized controlled trial (RCT) was conducted. Seventy-four patients with septic shock admitted to China-Japan Friendship Hospital from January 2017 to October 2018 were enrolled. The patients were randomly divided into control group and experimental group with 37 patients in each group. Both groups of patients were treated with broad-spectrum antibiotics empirically, while received fluid resuscitation via the subclavian vein catheter. The patients of control group were given rapid fluid replacement, and those of experimental group received fluid replacement according to result of PLR combined with TTE. The stroke volume (SV) was measured by TTE before and after PLR, volumetric response of patients was judged by stroke volume variation (SVV). If the SVV≥15%, it was considered that there was a volume responsiveness, and fluid loading was given. If SVV﹤15%, it was considered that there was no volume shortage, and the restrictive fluid replacement was given. The goal of fluid resuscitation in both groups were to simultaneously meet the central venous pressure (CVP) of 8-12 mmHg (1 mmHg = 0.133 kPa), mean arterial pressure (MAP) ≥65 mmHg, urine volume ≥ 0.5 mL·kg-1·h-1, and central venous blood oxygen saturation (ScvO2) ≥ 0.70 within 6 hours. Vasoactive drugs were used when the patients could not achieve the treatment goals. The MAP, lactic acid (Lac), oxygenation index (PaO2/FiO2) and ScvO2 of the patients were determined at 6 hours of treatment, and serum C-reactive protein (CRP) and chest CT were reviewed at 48 hours of treatment, and compared with those before treatment. The total hospital stay and the mortality were recorded. Results There was no significant difference in gender, age, body weight and etiological structure between the two groups, which indicated that the baseline data were generally balanced. There was no statistical difference in MAP, Lac, PaO2/FiO2, ScvO2 and CRP before infusion between the two groups. After 6 hours of treatment, the MAP, Lac, PaO2/FiO2 and ScvO2 of the two groups were all better than those before infusion. Except for the difference in MAP between the experimental group and the control group (mmHg: 78.76±5.22 vs. 76.35±6.66, P > 0.05), the other three parameters in the experimental group were significantly better than those in the control group [Lac (mmol/L): 2.52±1.15 vs. 3.89±1.42, PaO2/FiO2 (mmHg):338.14±27.47 vs. 303.35±22.52, ScvO2: 0.70±0.04 vs. 0.63±0.05, all P < 0.01]. After 48 hours of treatment, CRP levels of both groups were lower than those before infusion, and the experimental group was better than the control group (mg/L: 110.12±39.80 vs. 137.98±31.23, P < 0.01). Chest CT showed that the incidence of pulmonary edema in the experimental group was significantly lower than that in the control group [13.5% (5/37) vs. 37.8% (14/37), P < 0.01]. The hospital stay of the experimental group was shorter than that of the control group (days: 21.47±5.58 vs. 28.33±4.93, P < 0.01), but no significant difference in mortality was found between the two groups [18.9% (7/37) vs. 18.9% (7/37), P > 0.05]. Conclusion Compared with the traditional rapid fluid replacement, early fluid resuscitation treatment strategies guided by the PLR combined with TTE, could better improve perfusion and oxygenation level of tissues and organs, avoid pulmonary edema caused by rapid fluid replacement, shorten the hospital stay in patients with septic shock, but had no significant effect on hospital mortality.%目的 探讨被动抬腿试验(PLR)联合经胸超声心动图(TTE)指导脓毒性休克患者早期液体复苏的临床意义.方法 采用前瞻性随机对照研究(RCT)方法,选择2017年1月至2018年10月中日友好医院收治的脓毒性休克患者74例,按照随机数字表法将患者分为对照组和试验组,每组37例.两组患者均经验性应用广谱抗菌药物,同时通过锁骨下静脉置管补液治疗.对照组采用传统快速充分补液方案.试验组采用PLR联合TTE评估指导补液方案,用床旁TTE测量PLR前后患者的每搏量(SV),根据每搏量变异度(SVV)判断患者的容量反应,若SVV≥15%,认为患者有容量反应,给予快速充分补液策略;若SVV＜15%,认为无容量反应,给予限制性补液策略.两组患者液体复苏的目标均为6 h内同时满足中心静脉压(CVP)8～12 mmHg (1 mmHg＝0.133 kPa)、平均动脉压(MAP)≥65 mmHg、尿量≥0.5 mL·kg-1·h-1、中心静脉血氧饱和度(ScvO2)≥0.70.补液仍不能纠正低血压者,再酌情使用血管活性药物.补液治疗6 h后检测患者的MAP、血乳酸(Lac)、氧合指数(PaO2/FiO2)、ScvO2 ;补液治疗48 h后复查患者血清C-反应蛋白(CRP)和胸部CT,并与治疗前对比分析;统计患者住院时间和住院病死率.结果 两组患者性别、年龄、体重、病因构成比较差异无统计学意义,说明基线资料大致均衡.补液前两组患者MAP、Lac、PaO2/FiO2、ScvO2、CRP比较差异均无统计学意义.补液治疗6 h后,两组患者MAP、Lac、PaO2/FiO2、ScvO2均较补液前明显好转;试验组除MAP与对照组比较差异无统计学意义外(mmHg :78.76±5.22比76.35±6.66,P＞0.05),其他3项指标均明显优于对照组〔Lac(mmol/L):2.52±1.15比3.89±1.42,PaO2/FiO2(mmHg):338.14±27.47比303.35±22.52,ScvO2:0.70±0.04比0.63±0.05,均P＜0.01〕.补液治疗48 h后,两组患者CRP均较补液前明显下降,且试验组优于对照组(mg/L:110.12±39.80比137.98±31.23,P＜0.01),胸部CT提示试验组肺水肿发生率显著低于对照组〔13.5%(5/37)比37.8%(14/37), P＜0.01〕.试验组患者住院时间较对照组明显缩短(d :21.47±5.58比28.33±4.93,P＜0.01);而两组住院病死率比较差异无统计学意义〔18.9%(7/37)比18.9%(7/37),P＞0.05〕.结论 与传统单纯快速补液策略比较, PLR联合TTE评估脓毒性休克患者容量反应指导早期补液治疗,可以更好地改善组织器官的血液灌注和氧合水平,避免单纯快速补液造成的肺水肿,缩短了住院时间,但对于住院病死率无明显影响.