PiCCO指导液体复苏联合前列地尔治疗脓毒性休克致急性肾损伤的临床研究

Clinical efficacy of PiCCO-guided fluid resuscitation combined with alprostadil in the treatment of septic shock-induced acute kidney injury

摘要:

目的：观察脉搏指数连续心排量监测技术（pulse indicator continous cardiac output，PiCCO）指导液体复苏联合前列地尔治疗脓毒性休克合并急性肾损伤（acute kidney injury，AKI）的临床疗效，探讨其肾脏保护机制。方法：选择2015至2017年重庆医科大学附属第二医院和重庆市中医院ICU入住的脓毒性休克患者64例，采用随机分组分为PiCCO监测治疗组（P组）32例和PiCCO监测联合前列地尔治疗组（PA组）32例。待液体复苏血压达标后，PA组静脉给予前列地尔10 μg+100 mL生理盐水，缓慢静注，2次/d，连续应用5 d；P组患者以同样方式、剂量及速度静脉给予生理盐水。比较2组复苏6 h的平均动脉压（Mean arterial pressure，MAP）、全心舒张末容积指数（global enddiastolic volume index，GEDVI）和外周血管阻力指数（systemic vascular resistance index，SVRI）；血清白介素-6（interleukin-6，IL-6）和肿瘤坏死因子-α（tumor necrosis factor-α，TNF-α）含量；尿量、血肌酐（serum creatinine，Scr）、血胱抑素C（Cystatin-C，Cys-C）、2周进行持续肾脏替代治疗（continuous renal replacement therapy，CRRT）百分率和28 d病死率。结果：P组和PA组液体复苏6 h的MAP和SVRI差异没有统计学意义（P>0.05）；复苏6 h，PA组的中心静脉压（central venous pressure，CVP）和GEDVI明显低于P组（P<0.05）；液体复苏72 h后PA组血液中的IL-6和TNF-α的含量明显低于对照组（P<0.05）；复苏72 h时PA组尿量较P组增加更明显，差异有统计学意义（P<0.05）；复苏72 h时PA组Cys-C明显低于P组（P<0.05）。患者2周行CRRT治疗百分率和住院28 d患者死亡率，差异无统计学意义（P>0.05）。结论：PiCCO指导液体复苏联合前列地尔治疗脓毒性休克合并急性肾损伤，能更好地达到早期液体复苏目标，但不能降低肾脏替代治疗及死亡率。

Abstract:

Objective：To observe the clinical efficacy of pulse-induced contour cardiac output（PiCCO）-guided fluid resuscitation combined with alprostadil in the treatment of acute kidney injury in patients with septic shock and to discuss its mechanism of renal protection. Methods：Sixty-four patients with septic shock who were admitted to the Intensive Care Unit of the Second Affiliated Hospital of Chongqing Medical University or Chongqing Traditional Chinese Medicine Hospital from 2015 to 2018 were enrolled and randomly divided into PiCCO monitoring group（P group） and PiCCO monitoring + alprostadil group（PA group），with 32 patients in each group. After achieving target blood pressure levels，the PA group was slowly given intravenous injection of alprostadil 10 μg + normal saline 100 ml bid for five days；the P group was given normal saline in the same way and at the same dose and speed as the PA group. The two groups were compared in terms of mean arterial pressure（MAP），global end-diastolic volume index（GEDVI），and systemic vascular resistance index（SVRI） after 6-hour resuscitation；serum levels of interleukin-6（IL-6） and tumor necrosis factor-alpha（TNF-α）； urine output，serum levels of creatinine and cystatin C（Cys-C），percentage of patients adopting contin－uous renal replacement therapy（CRRT） over 2 weeks，and 28-day mortality. Results：After 6-hour fluid resuscitation，there was no significant difference in MAP or SVRI between the two groups（P>0.05），while the central venous pressure and GEDVI were significantly lower in the PA group than in the P group（P<0.05）；after 72-hour fluid resuscitation，the PA group had significantly reduced serum levels of IL-6，TNF-α，and Cys-C（all P<0.05），but had significantly increased urine output（P<0.05）. There was no significant difference between the two groups in the percentage of patients adopting CRRT over 2 weeks or 28-day mortality（P>0.05）. Conclusion：PiCCO-guided fluid resuscitation combined with alprostadil shows a better effect in achieving the goal of early fluid resuscitation，but cannot reduce the percentage of patients adopting CRRT or mortality in the treatment of acute kidney injury in patients with septic shock.