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目的探讨肺动脉导管在感染性休克中的应用价值。方法回顾性分析2001-2006年间北京协和医院加强医疗科收治的经初步复苏后放置肺动脉导管(PAC)的70例感染性休克患者的临床资料,记录放置 PAC 初始与24h 后血流动力学参数、乳酸、APACHEⅡ评分及28d 住院生存状况。结果 70例患者中存活28例,死亡42例,28d 总住院病死率为60%。初始血流动力学参数中,心率、血乳酸水平、APACHEⅡ评分死亡者显著高于存活者;24h 血流动力学参数中,平均动脉压(MAP)死亡者显著低于存活者,肺动脉嵌压(PAWP)、血乳酸水平、APACHEⅡ评分死亡者显著高于存活者,其他指标存活者与死亡者比较差异无统计学意义。死亡者中有15例患者接受了超剂量的去甲肾上腺素治疗,7例接受了超剂量的多巴胺治疗。初始和24h 是否达到超常氧输送、早期目标指导性血流动力学支持治疗(EGDT)目标,病死率差异无统计学意义。多重线性回归分析显示,24hMAP、24h PAWP 为独立预后指标。结论感染性休克患者经初步复苏后采用 PAC 监测未显示出存活者与死亡者初始血流动力学特征存在差异,24h 后死亡者的 PAWP 高于存活者。存活者与死亡者间是否存在全身血流动力学特征差异,不是应用 PAC 的基础,其监测价值应在于平衡高动力循环需求与心功能抑制间的关系。
Objective To investigate the value of pulmonary artery catheter in septic shock. Methods The clinical data of 70 patients with septic shock who were placed in pulmonary artery catheter (PAC) after primary resuscitation admitted to Peking Union Medical College Hospital during 2001-2006 were retrospectively analyzed. The hemodynamic parameters of initial and 24 h after PAC placement were recorded, Lactic acid, APACHE Ⅱ score and 28d hospitalization status. Results Of the 70 patients, 28 survived and 42 died. The 28-day total hospital mortality rate was 60%. Initial hemodynamic parameters, heart rate, blood lactate levels, APACHE Ⅱ score were significantly higher than survivors; 24h hemodynamic parameters, mean arterial pressure (MAP) were significantly lower than those survived, pulmonary embolism PAWP), blood lactate levels, APACHE Ⅱ score were significantly higher than survivors, the other indicators of survival and death were no significant difference. Fifteen patients who died had received an overdose of norepinephrine and seven received overdose of dopamine. Initial and 24h whether to achieve the supernatural oxygen delivery, early goal-directed hemodynamic supportive therapy (EGDT) goals, mortality was no significant difference. Multiple linear regression analysis showed that 24hMAP and 24h PAWP were independent prognostic factors. Conclusion The initial hemodynamic characteristics of patients with septic shock who were monitored by PAC after initial resuscitation did not show any difference between survivors and those with death. The PAWP of survivors after 24 hours of resuscitation was higher than that of survivors. Whether there is a difference in systemic hemodynamic characteristics between survivors and deaths is not the basis for the application of PAC, and the value of monitoring should lie in balancing the relationship between hyperdynamic circulation requirements and cardiac function inhibition.