重症超声与PiCCO监测指导急性心力衰竭容量管理的临床研究

Clinical study of critical ultrasound and pulse-indicated continuous cardiac output monitoring to guide capaciyu management of acute heart failure

摘要:

目的：探讨重症超声与脉搏指示持续心排血量（pulse-indicated continuous cardiac output，PiCCO）对急性心力衰竭（acute heart failure，AHF）患者的容量管理，对比2种方式早期治疗效果，在治疗及时性方面为患者提供一定的科学依据。方法：选择2017年1月至2018年9月重庆市大足区人民医院重症监护室（intensive care unit，ICU）收治的符合入选标准的AHF患者，随机分为试验组（n=30）和对照组（n=28）。试验组采用重症超声监测指导，对照组采用 PiCCO 监测指导，对比2组患者72 h内的N末端B型利钠肽前体（N-terminal pro-brain natriuretic peptide，NT-proBNP）、中心静脉压（central venous pressure，CVP）、平均动脉压（mean arterial pressure，MAP）、乳酸清除率、中心静脉血氧饱和度（central venous oxygen saturation，ScvO2）的情况；统计肺部感染发生率、机械通气时间、ICU入住时间、28 d死亡率、生存曲线、6 h复苏达标情况及3 h内能进行容量监测的例数；2种监测方法在治疗前后的心功能，血容量指标比较情况。结果：72 h 2组NT-proBNP、CVP、MAP、乳酸清除率、ScvO2差异均无统计学意义（P＞0.025）。2组患者肺部感染发生率对照组大于试验组，差异有统计学意义（P＜0.025 ）。3 h内能进行容量监测的例数，试验组明显多于对照组，差异有统计学意义（P＜0.05）。2组6 h容量达标人数差异无统计学意义（P>0.05）。2组患者在机械通气时间、ICU入住时间、28 d死亡率、生存时间方面差异均无统计学意义（P>0.05）。治疗前后心功能指标对比：试验组治疗前心输出量（cardiac output，CO）、左心射血分数（left ventricular ejection fraction，LVEF）指标小于治疗后，差异均有统计学意义（P＜0.05）；对照组治疗前心脏指数（cardiac index，CI）、全心射血分数（global ejection fraction，GEF）指标小于治疗后，差异有统计学意义（P＜0.05）。治疗前后血容量指标对比：试验组治疗后下腔静脉呼吸异变率、左心室舒张末期容积（left ventricular end diastolic volume，LVEDV）、每搏量（stroke volume，SV）高于治疗前，下腔静脉（inferior vena cava，IVC）低于治疗前，差异有统计学意义（P＜0.05）；对照组治疗后每搏量指数（stroke volume index，SVI）高于治疗前，全心舒张末期容积指数（global end diastolic volume，ＧＥＤＩ）低于治疗前，差异有统计学意义（P＜0.05）。结论：通过重症超声与PiCCO对AHF患者的容量管理临床研究，两者均能准确地评估容量和预测容量反应性。但比较PiCCO，重症超声明显缩短了治疗过程的延迟时间，在血流动力学变化的情况下也能及时操作监测，且其属于无创操作，在治疗中可反复进行检查，实时进行容量的管理，可以减少一定的操作和治疗风险，比如导管相关性感染、肺部感染等问题，提高AHF患者的早期救治能力。但是，PiCCO和重症超声对患者不能降低其死亡率，故需进一步研究其他综合性治疗方案减少患者的死亡风险，提高AHF患者的存活率。

Abstract:

Objective：To explore the capacity management of critical ultrasound and pulse-indicated continuous cardiac output（PiCCO） in patients with acute heart failure（AHF） and to compare the early therapeutic effect of those two methods，so as to provide a scientific basis for timely treating patients. Methods：AHF patients who met the admission criteria were selected from January 2017 to September 2018 in the intensive care unit（ICU） of Dazu District People’s Hospital and were randomly divided into the experimental group（n=30） and the control group（n=28）. The experimental group was guided by critical ultrasound monitor－ing，while the control group was guided by PiCCO monitoring. The N-terminal pro-brain natriuretic peptide（NT-proBNP），central venous pressure（CVP），mean arterial pressure（MAP），lac－tate clearance rate and central venous oxygen saturation（ScvO2） within 72 hours were compared among patients in two groups. The in－cidence of pulmonary infection，mechanical ventilation time，ICU occupancy time，28-day mortality rate，survival curve，6-hour re－covery and the number of cases that can be monitored within 3 hours were statistically recorded. Pre-and-post-treatment cardiac function and blood volume indexes of the two monitoring methods were compared. Results：NT-proBNP，CVP，MAP，lactate clearance and ScvO2 at the 72nd hour in two groups had no statistically significant difference（P>0.025）. The incidence of pulmonary infection in the experimental group was higher than that in the control group，with statistically significant difference（P<0.025）. The number of cases of capacity management that could be monitored within 3 hours in the experimental group was significantly higher than that in the control group，with statistically significant difference（P<0.05）. The number of cases of capacity management that could be moni－tored within 6 hours in two groups had no statistically significant difference（P>0.05）. Mechanical ventilation time，ICU stay time，28-day mortality and survival time in two groups had no statistically significant difference（P>0.05）. Comparison of cardiac function indexes before and after treatment：in the experimental group，the indexes of CO and LVEF before treatment were lower than those after treatment，with statistically significant difference（P<0.05）；in the control group，the indexes of CI and GEF before treatment were lower than that after treatment，with statistically significant difference（P<0.05）. Comparison of blood volume indexes before and after treatment：in the experimental group，the respiratory rate of inferior vena cava，LVEDV and SV after treatment were higher than those before treatment，and IVC after treatment was lower than that before treatment，with statistically significant difference（P<0.05）；in the control group，SVI after treatment was higher than that before treatment，and GEDI after treatment was lower than that before treatment，with statistically significant difference（P<0.05）. Conclusion：According to the clinical study of capacity management on critical ultrasound and PiCCO in patients with AHF，we find that both methods can accurately assess capacity and predict volume responsiveness. However，compared with PiCCO，critical ultrasound can significantly shorten the delay time in the course of treatment，can also be operated and monitored in time under the condition of hemodynamic changes，and belongs to non-invasive operation which can be repeatedly checked in the treatment. Real-time capacity management can reduce certain operational and therapeutic risks，such as the catheter-related infection and pulmonary infection，improving the early treatment ability for AHF patients. The short－comings of PiCCO and critical ultrasound can’t reduce the mortality，so it is necessary to further study other comprehensive treatment schemes to reduce the risk of death and improve the survival rate of patients with AHF.