目的 探讨早期碱剩余对感染性休克患者病情严重程度的预测价值。 方法 对2009年2月－2011年2月资料完整入院的感染性休克患者60例进行回顾性分析，按死亡及存活进行分组，对最初24 h的碱剩余值差异及血乳酸清除率情况进行对照研究。 结果 死亡组碱剩余值变化及乳酸清除率低于存活组（P＜0.05）。治疗后碱剩余≤−6 mmol/L较碱剩余＞−6 mmol/L的患者病死率明显增加，尤其是治疗后24 h 碱剩余仍≤−6 mmol/L病死率高达92.23%。 结论 早期碱剩余有助于感染性休克预后评估和指导临床治疗。
ObjectiveTo evaluate the value of stroke volume variation (SVV) and intrathoracic blood volume index (ITBVI) to predict fluid responsiveness in mechanically ventilated septic shock patients with spontaneous breathing. MethodsA prospective observational study was conducted in the Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University. Fluid resuscitation data was collected in septic shock patients who received PiCCO monitoring from June 2013 to June 2014. Transpulmonary thermodilution data were collected before and after fluid resuscitation, including cardiac index (CI), SVV, ITBVI, and central venous pressure (CVP). Seventeen patients were defined as responders by an observed increase of≥15% in the cardiac index (CI) after fluid resuscitation, 12 patients were defined as non-responders. Pearson correlation between changes of CI (ΔCI) and SVV, ITBVI, CVP was established. Area under the receiver operating characteristic (ROC) curve of SVV, ITBVI and CVP was calculated for predicting fluid responsiveness. ResultsBaseline CI and ITBVI were significantly lower in the responders (P < 0.05).There was no significant difference in baseline SVV between the responders and the non-responders (P > 0.05). A significant correlation was found between baseline ITBVI andΔCI (r=-0.593, P < 0.001), but no significant correlation between SVV andΔCI (r=0.037, P=0.847) or CVP andΔCI (r=0.198, P=0.302). The area under ROC curve of SVV, ITBVI and SVV for predicting fluid responsiveness was 0.640 (P=0.207), 0.865 (P=0.001), and 0.463 (P=0.565), respectively. The cut-off value of ITBVI for predicting fluid responsiveness was 784 mL/m2 with a sensitivity of 100.0% and a specificity of 70.6%. ConclusionIn mechanically ventilated septic shock patients with spontaneous breathing, ITBVI may be a valuable indicator in predicting fluid responsiveness compared with SVV.
This article reports the management of thirty elderly patients of septic shock during anesthesia. Twenty-four of them received continious epidural anesthesia, five of them were under intravenous general anesthesia with endotracheal intubation, and onr patients recerived intravenous ketamine anesthesia. The effects of these patients on enesthesia wer satisfactory. Twenty-four patients recouverd after roperation. Six patients died. The authors atresses the high risk of anesthetic management in these patients. Experiences are introduced in per-anesthetic preparation and medication selection and maintenance of anesthesia, monitoring and treatment during anesthesia and postoperative care of septic shock of the elderly.
目的 探讨孤立肾肾结石经皮肾镜取石（PCNL）术并发感染性休克的护理。 方法 回顾性分析2010年3月－2012年10月5例孤立肾肾结石患者行PCNL术后并发感染性休克的临床资料，对患者术后出现的休克及时补足血容量，使用有效的抗生素，早期足量应用激素、血管活性药物，同时加强心理疏导、健康教育等护理措施。 结果 5例患者体温均在3 d内降至正常；血管活性药物平均使用时间为1.8 d （2～4 d）；1例因血氧饱和度＜80%，血压＜85/50 mm Hg（1 mm Hg=0.133 kPa）转往重症监护病房行呼吸机辅助呼吸2 d后呼吸循环功能改善；另1例同时出现少尿无尿，及时行血液透析，第4天尿量逐渐恢复；5例患者均痊愈出院。 结论 感染性休克是PCNL术后最危险的并发症之一，对其采取积极预防、及早发现、及时有效的治疗和护理等措施，可有效促进患者康复。
目的通过漂浮导管（Swan-Ganz导管）监测外周血管阻力指数（SVRI）作为优化的心功能不全状态下感染性休克早期目标导向治疗（EGDT）的临床意义。 方法2012年1月至2014年1月第四军医大学附属西京医院心血管外科ICU收治体外循环心脏术后感染性休克患者8例，其中男7例、女1例，年龄（50.9±11.1）岁。以中心静脉压（CVP）为复苏目标行经验性容量复苏治疗，循环未见改善，则实施漂浮（Swan-Ganz）导管监测血流动力学指标，以外周血管阻力指数（SVRI）为优化目标复苏，观察Swan-Ganz导管复苏前及复苏6 h、24 h后的血流动力学及氧代谢指标，分析复苏达标所需时间。 结果8例患者平均住ICU时间（16.87±3.35）d，发生肺部并发症8例，急性肾功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好转存活，死亡2例。8例感染性休克患者经Swan-Ganz导管目标导向治疗6 h和24 h后平均动脉压（MAP）分别为（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心静脉压（CVP）分别为（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指数（CI）分别为（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指数（SVRI）分别为（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各项指标均较治疗前升高；治疗6 h和24 h后动脉血乳酸分别为（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，较治疗前[（14.98±0.45）mmol/L]下降。 结论采用Swan-Ganz导管监测SVRI作为优化目标导向治疗心功能不全状态下感染性休克可以提高6 h复苏成功率，改善患者预后。
ObjectiveTo investigate the influence of norepinephrine on pulmonary vessel pressure in animal model of septic shock. MethodsTwelve health mongrel dogs were randomly divided into a control group (n=5, intravenously injected with normal saline 1 mL/kg) and an endotoxin group(n=7, intravenously injected with lipopolysaccharide 1 mg/kg). When the systemic blood pressure decreased by more than 40% of baseline before administration, the dogs in two groups were intravenously injected with NE 0.5, 1.0, 2.0, 5.0μg·kg-1·min-1. The interval of each dose was more than 10 minutes. The changes of the pulmonary arterial pressure (PAP), pulmonary venous pressure (PVP), and systemic arterial rressure (SAP) were recorded and compared between two groups. ResultsIn the control group, PAP didn't change significantly after administration (P < 0.05), however, PVP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.01). In the endotoxin group, PAP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), while PVP didn't change significantly (P > 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). There were significant differences in SAP (P < 0.05), not in PAP and PVP (P > 0.05), between two groups after NE administration at dose of 1.0, 2.0 and 5.0μg·kg-1·min-1. The PVP/SAP and PAP/SAP values didn't change significantly after administration in the control group (P > 0.05). In the endotoxin group, the PVP/SAP and PAP/SAP values increased significantly after LPS administration, and decreased slightly after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). ConclusionsNE administration in septic shock can not increase the angiotasis of the pulmonary vein. NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 can cause the increase of PAP and SAP, but the increase of PAP is lower than the increase of SAP.
Objective To investigate the value of extravascular lung water index ( EVLWI) and intrathoracic blood volume index ( ITBVI) monitoring in fluid management of severe pneumonia patients with sepsis shock.Methods A prospective controlled study was conducted in106 patients who were diagnosed as severe pneumonia with sepsis shock in intensive care unit fromJanuary 2010 to February 2013. 54 patients who received pulse indicator continuous output ( PiCCO) monitoring were enrolled into the EVLWI + ITBVI group, and EVLWI and ITBVI were used as indicator of fluid management. 52 patients who received central venous pressure ( CVP) as indicator of traditional fluid managementwere enrolled into the control group. The time and the rate to achieve early goal-directed therapy ( EGDT) target were compared between two groups. Acute physiology and chronic health evaluation Ⅱ ( APACHE Ⅱ ) , sepsis related organ failure assessment ( SOFA) , noradrenaline dosage, serumlactic acid, serum creatinine were compared between 1 day and 3 days after treatment. The characteristics of fluid management were recorded and compared within 72 hours. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-day mortality were compared between two groups. Results The ratio of achieving EGDT target in 6 hours was significantly higher in the EVLWI + ITBVI group than that in the control group ( 75.9% vs. 55.7% , Plt;0.05) , whereas the time and the ratio to achieve EGDT target in 24 hours were not statistically different. APACHE Ⅱ, SOFA, norepinephrine dosage, serum lactate were significantly decreased 3 days after treatment in the EVLWI + ITBVI group, but did not change significantly in the control group. On3 days after treatment, serumcreatinine was increased in the control group, and did not change significantly in the EVLWI + ITBVI group. The fluid intake and fluid balance volume during 0-6 hours period were significantly higher in the EVLWI + ITBVI group than those in the control group ( Plt;0.05) , but showed no difference ( Pgt;0.05) in other periods. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-days mortality were significantly lower in the EVLWI + ITBVI group compared with the control group ( Plt;0.05) . Conclusion Compared with CVP, ITBVI and EVLWI can more accurately assess and guide fluid management in severe pneumonia patients with septic shock with less duration of mechanical ventilation, ICU stay and mortality.
Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.