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目的探讨脉搏灌注指数变异(PVI)指导下液体复苏对感染性休克患者预后的影响。方法选择河北省人民医院重症医学科收治的感染性休克患者38例;随机分为二组,PVI组(A组)(n=20)根据患者机械通气时的潮气量的大小确定PVI的阈值,潮气量在8ml/kg左右,如PVI≥13%进行充分的液体复苏;潮气量在10ml/kg左右,如PVI≥15%时进行充分的容量复苏,复苏目标:使中心静脉压(CVP)达12~15mmHg,平均动脉压≥65mmHg,尿量≥0.5ml/(kg·h),ScvO2≥70%,不能维持者首先应用去甲肾上腺素,必要时加用多巴酚丁胺维持。常规液体输入组(B组)(n=18)根据CVP、HR等指标综合判断进行容量复苏,使中心静脉压(CVP)达12~15mmHg,平均动脉压≥65mmHg,尿量≥0.5ml/(kg·h),ScvO2≥70%,不能维持者应用去甲肾上腺素,必要时加用多巴酚丁胺维持。观察指标观察二组患者达到复苏目标的时间、ICU住院时间、应用呼吸机时间、血管活性药物(去甲肾上腺素及多巴酚丁胺)使用时间;6h中心静脉氧饱和度、乳酸值、血管活性药物的剂量;二组患者3d液体平衡情况、MODS例数、病死率。结果二组在复苏后6h相比乳酸与去甲肾上腺素的剂量A组低于B组,差异有统计学意义;呼吸机使用时间相比A组低于B组,差异有统计学意义;二组患者3d液体正平衡液体量A组低于B组,差异有统计学意义,MODS例数及病死率差异无统计学意义。结论 PVI指导下对感染性休克患者实施液体复苏与常规液体复苏相比能降低血乳酸水平,能较快改善感染性休克患者微循环状态,且能减少使用呼吸机的时间,并能减少液体正平衡,在改善血流动力学的同时能减少液体的入量,对于减轻肺水肿有重要意义,但MODS发生率及病死率影响不大,需要大样本进一步研究证实。
Objective To investigate the effect of fluid resuscitation under the guidance of pulse perfusion index (PVI) on the prognosis of patients with septic shock. Methods Thirty-eight septic shock patients admitted to the Department of Critical Care Medicine of Hebei Provincial People’s Hospital were randomly divided into two groups. The PVI group (group A) (n = 20) was used to determine the threshold of PVI according to the tidal volume of patients with mechanical ventilation, Tidal volume of about 8ml / kg, such as PVI ≥ 13% for adequate liquid resuscitation; tidal volume of 10ml / kg or so, such as PVI ≥ 15% of the full capacity recovery, recovery goals: the central venous pressure (CVP) 12 ~ 15mmHg, mean arterial pressure ≥ 65mmHg, urine output ≥ 0.5ml / (kg · h), ScvO2 ≥ 70%, can not maintain the first use of norepinephrine, if necessary, with dobutamine maintenance. Conventional fluid infusion group (group B) (n = 18) performed volume resuscitation based on CVP, HR and other indicators to make central venous pressure (CVP) 12-15 mmHg, mean arterial pressure 65 mmHg, urine output 0.5 ml / kg · h), ScvO2 ≥ 70%, can not maintain those who apply norepinephrine, if necessary, plus dobutamine maintenance. Observed indicators observed two groups of patients to achieve the goal of recovery time, ICU length of stay, application of ventilator time, vasoactive drugs (norepinephrine and dobutamine) use time; 6h central venous oxygen saturation, lactic acid value, blood vessels Dose of active drug; 3d liquid balance of two groups of patients, MODS cases, case fatality rate. Results The dose of lactic acid and norepinephrine in group A at 6h after resuscitation was lower than that at group B, the difference was statistically significant. The duration of ventilator was lower than that of group A, but the difference was statistically significant. Group 3d fluid positive balance of liquid volume in group A was lower than in group B, the difference was statistically significant, MODS cases and mortality no significant difference. Conclusion Under the guidance of PVI, fluid resuscitation in patients with septic shock can reduce blood lactate level compared with conventional liquid resuscitation, and can quickly improve the microcirculation state of patients with septic shock and reduce the time of using respirator, Balance, while improving hemodynamics can reduce the amount of fluid, for the reduction of pulmonary edema is important, but the incidence of MODS and mortality little effect, requiring large sample further study confirmed.