摘要
目的探讨感染性休克患者微循环障碍分型及其与预后的相关性。方法选2019年3-12月中南大学湘雅医院重症医学科收治的资料完整的感染性休克患者,收集患者平均动脉压、中心静脉压、中心静脉血氧饱和度、中心静脉-动脉二氧化碳分压差、血细胞比容及动脉血乳酸水平。采用旁流暗场成像设备监测患者舌下微循环,测总血管密度、灌注血管密度、灌注血管比例、微血管流动指数、异质性指数。记录患者30 d生存情况。采用Cox回归模型分析影响感染性休克患者30 d病死率的危险因素。结果64例感染性休克患者舌下微循环障碍中淤滞型18例,稀释型11例,异质型18例,高动力型17例,各型间的平均动脉压[淤滞型为(77±9)mmHg(1 mmHg=0.133 kPa),稀释型为(80±11)mmHg,异质型为(78±12)mmHg,高动力型为(88±12)mmHg]、总血管密度[淤滞型为(10.84±3.01)mm/mm^(2),稀释型为(9.64±1.72)mm/mm^(2),异质型为(11.39±2.18)mm/mm^(2),高动力型为(11.87±2.67)mm/mm^(2)]、灌注血管密度[淤滞型为(5.93±1.94)mm/mm^(2),稀释型为(6.86±1.48)mm/mm^(2),异质型为(8.31±1.78)mm/mm^(2),高动力型为(9.68±2.46)mm/mm^(2)]、灌注血管比例[淤滞型为52.45(46.25,63.33)%,稀释型为73.70(61.50,75.20)%,异质型为71.25(67.95,77.00)%,高动力型为80.70(77.25,86.45)%]、微血管流动指数(淤滞型为1.34±0.45,稀释型为1.70±0.38,异质型为1.82±0.28,高动力型为2.25±0.33)、异质性指数[淤滞型为0.68(0.51,1.87),稀释型为0.57(0.49,0.64),异质型为0.70(0.59,0.91),高动力型为0.40(0.37,0.52)]差异有统计学意义(P值<0.05)。30 d累计生存率淤滞型为7/18,稀释型为4/11,异质型为10/18,高动力型为14/17。多因素Cox回归分析显示,患者舌下微循环障碍类型(淤滞型:RR=4.551,95%CI 1.228~16.864,P=0.023;稀释型:RR=4.086,95%CI 1.011~16.503,P=0.048)、急性生理与慢性健康状况评分Ⅱ(RR=1.077,95%CI 1.006~1.153,P=0.032)是感染性休克患者30 d病死率的独立危险因素。结论感染性休克患者的微循环障碍普遍存在,且无法通过大循环参数预知微循环障碍类型。感染性休克患者预后与其微循环障碍类型相关,提示常规监测微循环可能有助于指导血流动力学治疗。
Objective To explore the correlation between different types of microcirculation alterations and the prognosis in patients with septic shock.Methods This research employed a prospective observational study methodology for selecting subjects with septic shock.Side-stream dark field(SDF)was used to monitor the sublingual microcirculation to determine the total vascular density(TVD),perfused vessel density(PVD),the proportion of perfused vessels(PPV),and the microvascular flow index(MFI),heterogeneity index(HI)indicators.At the bedside,patients with microcirculation disorders were divided into four types:stasis,dilution,heterogeneity,and hyperdynamic.The 30-day survival status after enrollment and hemodynamics parameters were recorded.Results A total of 64 patients with septic shock were selected in the study,including 18 cases of stasis type,11 of dilution type,18 of heterogeneous type,and 17 of hyperdynamic type.There were statistical differences in the mean arterial pressure(MAP)[stasis:(77±9)mmHg(1 mmHg=0.133 kPa),dilution:(80±11)mmHg,heterogeneity:(78±12)mmHg,hyperdynamic:(88±12)mmHg],TVD[stasis:(10.84±3.01)mm/mm^(2),dilution:(9.64±1.72)mm/mm^(2),heterogeneity:(11.39±2.18)mm/mm^(2),hyperdynamic:(11.87±2.67)mm/mm^(2)],PVD[stasis:(5.93±1.94)mm/mm^(2),dilution:(6.86±1.48)mm/mm^(2),heterogeneity:(8.31±1.78)mm/mm^(2),hyperdynamic:(9.68±2.46)mm/mm^(2)],PPV[stasis:52.45(46.25,63.33)%,dilution:73.70(61.50,75.20)%,heterogeneity:71.25(67.95,77.00)%,hyperdynamic:80.70(77.25,86.45)%],MFI(stasis:1.34±0.45,dilution:1.70±0.38,heterogeneity:1.82±0.28,hyperdynamic:2.25±0.33),and HI[stasis:0.68(0.51,1.87),dilution:0.57(0.49,0.64),heterogeneity:0.70(0.59,0.91),hyperdynamic:0.40(0.37,0.52)]of the four types of microcirculation alterations.The cumulative survival rates in stasis,dilution,heterogeneity and hyperdynamic types at 30 day were 7/18,4/11,10/18 and 14/17,respectively,which in stasis and dilution types was significantly lower than that of hyperdynamic type(χ²=7.221,P=0.007;χ^(2)=6.764,P=0.009).Multivariate Cox regression analysis showed the type of microcirculation alterations(stasis:RR=4.551,95%CI 1.228-16.864,P=0.023;dilution:RR=4.086,95%CI 1.011-16.503,P=0.048),acute physiology and chronic health evaluationⅡ(RR=1.077,95%CI 1.006-1.153,P=0.032)were independent prognostic risk factors.Conclusions Microcirculation alterations are common in patients with septic shock,and it is hard to predict the types of microcirculation alterations with hemodynamics parameters.The prognosis of patients with septic shock is related to the types of microcirculation alterations,suggesting that routine monitoring of microcirculation might be helpful to guide hemodynamic therapy.
作者
张晓蕾
李莉
彭倩宜
艾美林
张海松
艾宇航
张丽娜
Zhang Xiaolei;Li Li;Peng Qianyi;Ai Meilin;Zhang Haisong;Ai Yuhang;Zhang Lina(Department of Critical Care Medicine,Xiangya Hospital,Central South University,National Clinical Research Center for Geriatric Disorders,Hunan Provincial Clinical Research Center for Critical Care Medicine,Changsha 410008,China)
出处
《中华内科杂志》
CAS
CSCD
北大核心
2021年第10期898-903,共6页
Chinese Journal of Internal Medicine
关键词
脓毒症
感染性休克
微循环
预后
Sepsis
Septic shock
Microcirculation
Prognosis
作者简介
通信作者:张丽娜,Email:zln7095@163.com。
