“早期血流动力学干预”对不明原因低血容量性休克容量管理价值的临床研究

Clinical study on the value of early hemodynamic intervention in the management of hypovolemic shock with unknown cause

摘要:

目的：探讨“早期血流动力学干预”对不明原因低血容量性休克的容量管理，为早期治疗提供科学依据。方法：选择2013年9月至2017年1月我科收治的符合入选标准的56例低血容量休克患者，按随机数字表法分为实验组和对照组，每组28例。其中实验组中有2例病人治疗过程中要求转上级医院治疗，1人放弃治疗；对照组中有2例病人放弃治疗，3人转上级医院治疗。故最终纳入分析的实验组为25人，对照组为23人。实验组患者采用早期目标导向性液体治疗（early goal-directed therapy，EGDT），利用中心静脉压（central venous pressure，CVP）指导容量复苏及治疗，对照组患者根据经验采用传统容量复苏方法治疗，2组均在达到目标治疗后适当脱水降低心脏前负荷以便保护心肺功能。观察2组患者治疗前后急性生理与慢性健康评分Ⅱ（acute physiology and chronic health evaluation Ⅱ，APACHEⅡ）、平均动脉压（mean arterial pressure，MAP）、CVP、血乳酸清除率、复苏液体量、使用血管活动药物的例数、肾功能损害例数、肺水肿例数及心衰发生例数；同时观察72 h内反复出现容量不足需再次扩容的例数；3、6 h的休克纠正达标率例数；2组患者重症监护室（intensive care unit，ICU）入住天数及死亡例数。结果：2组APACHEⅡ评分都逐步下降，24 h后实验组评分明显低于对照组（P＜0.05）；72 h后血管活动药物使用例数、肾功能损害例数及再次出现休克需扩容纠正例数明显少于对照组（P＜0.05）；72 h肺水肿、心衰发生例数治疗组多于对照组（P＜0.05）。6、24 h实验组液体总入量明显多于对照组，而72 h液体总量明显少于对照组（均P＜0.05）；治疗6、24 h后实验组乳酸清除率明显优于对照组（P＜0.05）。2组CVP、MAP均较治疗前有明显改善，CVP在6、24、72 h实验组优于对照组，MAP在6、24 h实验组优于对照组（P＜0.05）。治疗后3、6 h的休克纠正达标率例数，实验组明显优于对照组（P＜0.05）。2组患者ICU入住时间及死亡例数的差异无统计学意义（P>0.05）。结论：不明原因低血容量性休克在“早期血流动力学干预下”采取EGDT液体治疗有显著疗效，但仍有不足。在复苏过程中因液体负荷过高发生心衰、肺水肿的医源性再损伤概率较大。故容量治疗阶段提出了寻找最佳心脏前负荷的设想。

Abstract:

Objective：To investigate the ‘early hemodynamic intervention’ in the management of hypovolemic shock with unknown cause for providing scientific basis for early treatment. Methods：A total of 56 patients with hypovolemic shock admitted to the De－partment of Critical Care Medicine of The People’s Hospital of Dazu District from September 2013 to January 2017 were enrolled and randomly divided into the experimental group and the control group，with 28 patients in each. In the experimental group，2 patients asked to go to the superior hospital for treatment，and 1 gave up the treatment，while in the control group，2 gave up the treat－ment and 3 were transferred to the superior hospital for treat－ment. Therefore，25 patients in the experimental group and 23 in the control group were finally included in the analysis. The ex－perimental group underwent the early target-directed liquid ther－apy（EGDT） and the fluid resuscitation was guided by central venous pressure（CVP），while the control group adopted the traditional method of volume resuscitation. Both groups were properly de－hydrated to reduce the pre-cardiac load in order to protect the cardiopulmonary function. The scores on acute physiology and chronic health evaluation system Ⅱ（APACHE Ⅱ） before and after treatment，mean arterial pressure（MAP），CVP，lactate clearance rate，the quantity of liquid，and the numbers of patients using vasoactive drugs，with renal damage，pulmonary edema or congestive heart failure were recorded respectively. Meanwhile，the case numbers of patients with repeated insufficient blood volume undergoing re-added blood volume within 72 hours and patients whose standard rate of compliance was corrected at 3 h and 6 h after treatment were also recorded，as well as the ICU admission days and death numbers of both groups. Results：APACHEⅡ scores decreased gradually in both groups，and scores in the experimental group were significantly lower than those in the control group after 24 hours（P<0.05）. Seventy-two hours after treatment，patients on vasoactive drugs，with renal dysfunction or re-shock in the experimental group were fewer than those of the control group respectively（P<0.05），while the patients with pulmonary edema or congestive heart failure in the experimental group were more than those of the control group respectively（P<0.05）. The amount of recovery liquid within 6 h and 24 h of the experimental group was obviously more than that of the control group，while it in 72 h was less than that of the control group（P<0.05）. The lactate clearance rates of the experimental group at 6 h and 24 h after treatment were both superior to those of the control group（P<0.05）. The CVP and MAP in both groups were significantly improved after treatment，and CVP of the experimental group at 6 h，24 h and 72 h after treatment were superior to those of the control group（P<0.05），and MAP of the experimental group at 6 h and 24 h after treatment were superior to those of the control group（P<0.05）. The numbers of cases whose standard rate of com－pliance was corrected at 3 h and 6 h after treatment in the experimental group were higher than those of the control group（P<0.05）. There was no significant difference of the ICU admission days and death numbers between the two groups（P>0.05）. Conclusion：The ‘early hemodynamic intervention’ with EGDT liquid therapy for hypovolemic shock with unknown cause is of significant effect，but still not sufficient in the recovery process due to the fluid overload heart failure and the high incidence of pulmonary edema iatrogenic injury. Therefore，a hypothesis of searching the best pre-cardiac load in the capacity treatment phase is proposed.