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目的探讨去甲肾上腺素对脓毒性休克患者被动抬腿试验(PLR)预测液体反应性的影响。方法采用前瞻性观察研究的方法,收集2012年9月至2012年11月南京大学医学院附属鼓楼医院重症医学科收治的46例脓毒性休克患者的临床资料,其中36例PLR阳性患者纳入研究,以PLR实施1 min后每博输出量指数(SVI)增加(ΔSVI=SVI变化值/基础SVI)≥10%,定义为PLR阳性,提示有液体反应性。纳入研究后患者均先行第1次PLR(PLR1),然后体位改为平卧并稳定}后,给予去甲肾上腺素静脉泵入或增加去甲肾上腺素治疗剂量维持MAP≥65 mm Hg,稳定20 min后,行第2次PLR(PLR2)。采用脉搏轮廓连续心排出量监测(PiCCO)法监测患者心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心排指数(CI)、每搏输出量指数(SVI)、外周血管阻力指数(SVRI)、全心舒张末期容积指数(GEDVI)、心功能指数(CFI)等血流动力学指标。观察患者去甲肾上腺素治疗后PLR及其他血流动力学监测指标的变化。结果实施PLR1时SVI增加,ΔSVI为(20.54±9.63)%,CI增加(20.57±9.89)%,MAP升高(7.64±5.77)%,CVP亦升高(25.83±23.39)%。给予去甲肾上腺素静脉泵入或增加去甲肾上腺素治疗剂量后SVI增加,ΔSVI(16.97±9.06)%,CI增加(16.78±8.39)%,GEDVI增加(9.08±4.47)%MAP升高(28.07±12.48)%,CVP增加(7.86±8.52)%。实施PLR2时SVI增加,ΔSVI(13.74±8.79)%,CI增加(13.79±9.08)%,MAP升高(2.93±5.06)%,CVP升高(13.36±4.74)%,与PLR1比较,去甲肾上腺素治疗后及PLR2时ΔSVI均显著降低(P均<0.05)。实施PLR2时6例患者SVI增加<10%,即无液体反应性。结论去甲肾上腺素增加PLR阳性脓毒性休克患者的心脏前负荷,增加心排出量,影响液体反应性。
Objective To investigate the effect of norepinephrine on the prediction of fluid reactivity by passive leg-raising test (PLR) in patients with septic shock. Methods A prospective observational study was conducted to collect the clinical data of 46 patients with septic shock admitted to the Department of Critical Care Medicine, Drum Tower Hospital, Nanjing University Medical College from September 2012 to November 2012. Of these, 36 patients with positive PLR were included in the study, Per 1 hour after PLR administration, the Peri-Bo index of output (SVI) increased (ΔSVI = SVI change / basal SVI) ≥10% and was defined as positive for PLR, indicating a reactivity of the fluid. Patients enrolled in the study were given PLR1 (PLR1) first and then changed their position to supine and stable. After norepinephrine infusion or norepinephrine treatment, the dose was maintained at MAP ≥65 mm Hg and stable at 20 min, run the second PLR (PLR2). The heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), cardiac output index (CI), stroke volume index (SVI), peripheral Vascular resistance index (SVRI), global end-diastolic volume index (GEDVI), cardiac function index (CFI) and other hemodynamic parameters. To observe the changes of PLR and other hemodynamic parameters after norepinephrine treatment. Results When PLR1 was administered, SVI increased (20.54 ± 9.63)%, CI increased (20.57 ± 9.89)%, MAP increased (7.64 ± 5.77)% and CVP increased by 25.83 ± 23.39%. SVI increased (16.97 ± 9.06)%, CI increased (16.78 ± 8.39)%, GEDVI increased (9.08 ± 4.47)% MAP increased (28.07 ± 4.47) after intravenous injection of norepinephrine or increased norepinephrine treatment ± 12.48)%, CVP increased (7.86 ± 8.52)%. Compared with PLR1, norepinephrine increased compared with that of PLR1 (P <0.05). Compared with PLR1, norepinephrine increased (P <0.01) ΔSVI after treatment and at PLR2 were significantly lower (all P <0.05). 6 patients with PLR2 increased SVI <10%, ie, no fluid reactivity. Conclusion Norepinephrine increases cardiac preload, increases cardiac output, and affects fluid responsiveness in patients with PLR-positive septic shock.