Value of dynamic arterial elasticity as a guide of the use of norepinephrine in patients with severe pneumonia shock
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摘要:
目的探索动态动脉弹性（Eadyn）对重症肺炎休克患者去甲肾上腺素使用时机及剂量的指导效果。 方法采用前瞻性观察性队列研究方法，选取2018年6月~2019年6月在佛山市第二人民医院重症医学科收治的68例行机械通气且计划使用去甲肾上腺素的重症肺炎患者，其中男性38例，女性30例，年龄27~77岁（58.60±8.72岁）。根据是否使用Eadyn监测技术，将患者分为监测组（n=32）和对照组（n=36）。监测组患者使用脉搏指示连续心排血量技术持续监测，据检测的血流动力学指标计算Eadyn，随时调整使用去甲肾上腺素；对照组患者予有创血压监测，以平衡盐溶液进行早期液体复苏目标导向性治疗。对比两组患者治疗后效果。 结果两组患者开始复苏升压治疗12 h后，监测组病情评分低于对照组（P<0.05）；24 h后，呼吸、循环功能相关指标，监测组优于对照组；监测组各时间段的CVP、BNP低于对照组（P<0.05）。96 h胸部CT影像比较，对照组肺部渗出明显增加，差异具有统计学意义（P<0.05）。监测组患者机械通气时间为9.47±2.7 d，对照组为14.42±2.9 d；监测组ICU住院时间11.31±3.2 d，对照组为20±2.9 d；从28 d统计来看，监测组死亡4例，病死率12.5%；对照组死亡8例，病死率22.22%，差异具有统计学意义（P<0.05）。监测组预后优于对照组。 结论实时Eadyn可以指导重症肺炎休克患者加用去加甲上腺素的时机和剂量，根据动态血流动力学监测数据指导升压方案更加个体化，能够减轻脏器负荷，改善预后。 Abstract:ObjectiveTo explore the effect of Eadyn on norepinephrine application. MethodsThe study was a prospective and observative cohort study. A total of 68 patients with severe pneumonia admitted to intensive care unit (ICU) of Foshan Second People's Hospital were enrolled from June 2018 to June 2019, including 38 males and 30 females with the age from 27 to 77 years old (average 58.60±8.72). All the patients were treated by mechanical ventilation and planned to use noradrenaline. Based on whether Eadyn was used as as an indicator for the use of norepinephrine, the patients were divided into the monitoring group (32 cases) and the control group (36 cases). The patients in the monitoring group were monitored continuously by pulse indicating continuous cardiac output (PiCCO). According to the real-time eadyn which calculated by the hemodynamic indexes, norepinephrine was adjusted at any time.Patients in the control group were monitored for invasive blood pressure.The ealy goal directed therapy(EGDT) was carried out with the balanced salt solution. The indexes were compared after treatment. ResultsAfter 12 hours of resuscitating and vasopressor treatment, the severity scores were significantly lower in the monitoring group than in the control group (P<0.05). At the beginning of 24 hours, the indexes of respiratory and circulatory function in the monitoring group were better than those in the control group. The CVP and BNP in the monitoring group were lower than those in the control group (P<0.05). Compared with the lung CT images after 96 hours, the exudation in the control group increased significantly(P<0.05). The time of mechanical ventilation in the monitoring group were 9.47±2.7 days, and that in the control group were 14.42±2.9 days. The length of stay in ICU in the monitoring group were 11.31±3.2 days, and that in the control group were 20±2.9 days. From the statistics of 28 days, 4 cases died in the monitoring group with a mortality rate of 12.5%, and 8 cases died in the control group with a mortality rate of 22.22%. The difference was significant (P<0.05). The prognosis of the monitoring group was better than that of the control group. ConclusionUsing Eadyn as an indicator for norepinephrine application is beneficial to severe pneumonia shock patients. -
Key words:
- dynamic arterial elasticity /
- severe pneumonia /
- shock /
- norepinephrine
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图 1 治疗前后肺部影像
A，B：治疗前监测组患者，半数以上患者单个及双肺叶受累，部分患者3个及3个以上肺叶受累，主要表现为渗出，支气管充气征，胸腔积液等；C，D：治疗96 h后监测组患者，局部病灶有所吸收；E，F：治疗前对照组患者，情况同监测组；G，H：治疗96 h后对照组患者，肺部渗出明显增加.
Figure 1. Lung Imaging before and after treatment
表 1 监测组和对照组间一般资料比较（Mean±SD）
Table 1. Comparison of general information between monitoring and control groups
项目 监测组（n=32） 对照组（n=36） t/U/χ2 P 性别（女/男） 13/19 17/19 0.299 0.585 年龄（岁） 57.34±8.59 57.33±7.70 0.003 0.997 BMI 25.85±10.75 24.6±11.83 1.101 0.275 APACHE Ⅱ评分（分） 34.68±5.47 33.54±4.54 462 0.163 SOFA评分（分） 14.75±3.35 13.9±4.41 461.5 0.161 MAP（mmHg） 89.56±11.56 86.96±9.87 499 0.350 PaO2/FiO2（mmHg） 164.2±15.85 166.7±14.78 514 0.452 CVP（cmH2O） 8.16±3.45 8.05±5.49 564.5 0.891 BNP（pg/mL） 151.4±30.38 142.6±38.26 498 0.343 CI [L/（m2•min）] 3.24±1.08 3.11±2.09 497.5 0.302 EF（%） 53.74±7.10 55.07±5.83 505.5 0.391 乳酸（mmol/L） 4.69±3.41 5.211±4.12 0.95 0.346 单个及双个肺叶[n（%）] 21（65.62） 23（63.89） 0.397 0.639 3个及3个以上肺叶[n（%）] 11（34.38） 13（36.11） 0.474 0.427 BMI：体质量指数；APACHE：急性生理和慢性健康评价；SOFA：全身性感染相关性器官功能衰竭评分；MAP：平均动脉压；PaO2/FiO2：氧合指数；CVP：中心静脉压；BNP：脑利钠肽；CI：心排指数；EF：左室射血分数. 
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表 2 监测组和对照组间病情评分资料比较（Mean±SD，分）
Table 2. Comparison of disease scores between monitoring and control groups
组别 APECHEII评分 SOFA评分 T0 T6 T12 T24 T48 T0 T6 T12 T24 T48 监测组（n=32） 34.68±5.47 32.79±3.25 21.90±3.19 14.63±3.14 13.44±2.56 14.75±3.35 12.26±2.17 7.53±3.64 4.18±2.34 3.04±2.64 对照组（n=36） 33.54±4.54 32.06±4.41 25.84±2.67 23.52±1.89 19.29±1.34 13.9±4.41 11.77.±3.10 8.99±4.45 7.58±4.17 5.38±3.85 t/U 462 434 7.023 14.16 0 461.5 1.691 3.605 18.5 47.5 P 0.163 0.082 <0.001 <0.001 <0.001 0.161 0.097 0.001 <0.001 <0.001
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表 3 监测组和对照组间循环和氧合指标比较（Mean±SD，mmHg）
Table 3. Comparison of circulating and oxygenation indicators between monitoring groups and control groups
组别 MAP PaO2/FiO2 T0 T6 T12 T24 T48 T0 T6 T12 T24 T48 监测组（n=32） 89.56±1.56 95.0±10.52 100.1±10.26 119.4±12.27 132.4±9.17 164.2±21.87 184.5±15.17 199.9±26.63 268.3±33.01 310.7±25.79 对照组（n=36） 86.96±9.87 93.08±12.43 98.47±11.53 107.6±9.02 120.4±10.82 166.7±11.96 188.6±11.45 197.3±28.78 241.3±21.28 254.5±33.72 U 499 520 526.5 267 242 514 483 550 298 116 P 0.350 0.498 0.548 <0.001 <0.001 0.452 0.257 0.756 <0.001 <0.001
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表 4 监测组和对照组心脏负荷指标比较（Mean±SD）
Table 4. Comparison of cardiac load index in monitoring group and control group
组别 CVP（cmH2O） BNP（pg/mL） T0 T6 T12 T24 T48 T0 T6 T12 T24 T48 监测组（n=32） 8.16±3.45 10.96±2.62 9.96±1.69 8.94±2.1 8.79±2.15 151.4±36.12 147.2±14.01 144.8±36.16 103.6±22.11 100.3±16.05 对照组（n=36） 8.05±5.49 15.00±2.27 15.80±1.02 17.98±1.4 17.78±2.01 142.6±35.71 178.8±26.24 194.4±36.33 257.7±49.41 325.0±71.47 t/U 564.5 73 17.94 0 18 498 181 116 0 0 P 0.891 <0.01 <0.001 <0.001 <0.001 0.343 <0.001 <0.001 <0.001 <0.001
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表 5 监测组和对照组间心功能比较（Mean±SD）
Table 5. Comparison of cardiac function between monitoring and control groups
组别 CI [L/（m2•min）] EF（%） T0 T6 T12 T24 T48 T0 T6 T12 T24 T48 监测组（n=32） 3.24±1.08 2.93±1.72 3.12±1.34 3.13±1.25 3.01±1.44 53.74±6.27 55.19±7.13 48.33±7.78 59.68±6.32 62.64±3.41 对照组（n=36） 3.11±2.09 2.85±2.09 2.85±1.89 2.41±1.43 2.30±2.13 55.07±5.03 56.84±7.48 47.72±10.09 44.76±8.06 49.63±9.08 t/U 497.5 0.482 476 6.10 174.5 505.5 491 0.278 8.47 107 P 0.339 0.632 0.223 <0.001 <0.001 0.391 0.301 0.782 <0.001 <0.001
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表 6 监测组和对照组96 h影像学比较[n（%）]
Table 6. Comparison of 96 h imaging between monitoring and control groups
分组 渗出增加 渗出不变 渗出减少 监测组（n=32） 8（25.00） 12（37.50） 12（37.50） 对照组（n=36） 25（69.44） 3（8.33） 8（22.22） χ2 14.77 P 0.001
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表 7 监测组和对照组间乳酸水平比较（Mean±SD）
Table 7. Comparison of lactate levels between monitoring and control groups
组别 乳酸（mmol/L） T0 T6 T12 T24 T48 监测组（n=32） 4.69±3.41 3.22±2.65 3.08±1.86 2.74±1.23 2.19±1.19 对照组（n=36） 5.21±4.12 5.13±3.12 5.53±2.35 6.11±1.26 6.44±1.35 t/U 0.95 13.5 99.5 23 4 P 0.346 <0.001 <0.001 <0.001 <0.001
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表 8 观察组和对照组间预后比较
Table 8. Comparison of prognosis between observation and control groups
项目 监测组（n=32） 对照组（n=36） t/U/χ2 P 机械通气时间（d，Mean±SD） 9.47±2.7 14.42±2.9 7.237 <0.001 ICU住院时间（d，Mean±SD） 11.31±3.2 20±2.9 21 <0.001 28 d病死率[n（%）] 4（12.5%） 8（22.22%） 5.775 <0.001
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