全心舒张末期容积指数对心功能不全并脓毒性休克患者液体复苏的应用价值

目的探讨全心舒张末期容积指数（GEDI）指导心功能不全并脓毒性休克患者液体复苏的临床价值。 方法选择2016年1月至2018年1月收住杭州师范大学附属医院重症医学科的心功能不全并脓毒性休克患者共41例，分为中心静脉压组（CVP组）和GEDI组，其中CVP组21例，GEDI组20例。CVP组按照脓毒症指南进行常规早期目标导向治疗；GEDI组进行脉搏指示连续心输出量监测，根据GEDI指导液体复苏，使GEDI达到680 ~ 800 mL / m²，余复苏目标（平均动脉压、中心静脉血氧饱和度、尿量）同常规EGDT方案。观察两组患者达到复苏目标所需液体总量、24 h血管外肺水指数（EVLWI）、6 h及24 h脑尿钠肽、乳酸清除率、去甲肾上腺素用量。 结果GEDI组达到复苏目标时所需液体总量少于CVP组（2 572 ± 1 108）mL vs.（3 327 ± 925）mL，t = 2.375，P = 0.023）]。GEDI组24 h EVLWI7.3（5.5，8.8）mL / kg vs. 9.6（8.9，9.8）mL / kg]、6 h脑尿钠肽889.0（340.3，1 270.0）ng / L vs. 1 746.0（634.0，2 160.0）ng / L]与24 h脑尿钠肽684.5（192.5，749.9）ng / L vs. 1 120.0（400.5，2 480.0）ng / L]均低于CVP组（Z = 86.500、120.000、124.000，P = 0.001、0.020、0.026）。GEDI组6 h乳酸清除率34.21（15.64，45.87）% vs. 20.00（0.00，33.19）%，Z = 129.5，P = 0.037]优于CVP组，且能减少去甲肾上腺素用量（0.9 ± 0.6）mg / kg vs. （1.9 ± 1.5）mg / kg，t’ = 2.817，P = 0.009]。 结论心功能不全患者合并脓毒性休克时以GEDI指导的液体复苏能达到更有效的早期液体复苏目标，所需复苏液体总量及血管活性药物相对较少，肺水增加较轻且不明显加重心功能损害。

Clinical value of global end-diastolic volume index for fluid resuscitation in cardiac dysfunction patients with septic shock

ObjectiveTo explore the value of global end-diastolic volume index (GEDI) for fluid resuscitation in cardiac dysfunction patients with septic shock. MethodsA total of 41 cardiac dysfunction patients with septic shock hospitalized in the Department of Intensive Care Unit of Affiliated Hospital of Hangzhou Normal University from January 2016 to January 2018 were randomly divided into the central venous pressure (CVP) group (n = 21) and GEDI group (n = 20). Patients in the CVP group were treated with standard early goal-directed therapy recommended in sepsis guidelines. Patients in the GEDI group were monitored by pulse-indicated continuous cardiac output and performed fluid resuscitation directed by GEDI to ensure GEDI should reach 680 ~ 800 mL / m²; other goals of treatment, including mean arterial pressure, central venous oxygen saturation and urine volume, were equal to standard EGDT. The fluid volume when achieved resuscitation goals, 24 h extravascular lung water index (EVLWI), 6 h and 24 h brain natriuretic peptide, blood lactate clearance rate, and norepinephrine dosage were recorded. ResultsThe liquid volume was less in the GEDI group than in CVP group (2 572 ± 1108) mL vs. (3 327 ± 925) mL, t = 2.375, P = 0.023]. Compared to the CVP group, 24 h EVLWI 7.3 (5.5, 8.8) mL / kg vs. 9.6 (8.9, 9.8) mL / kg], 6 h brain natriuretic peptide 889.0 (340.3, 1 270.0) ng / L vs. 1 746.0 (634.0, 2 160.0) ng / L] and 24 h brain natriuretic peptide 684.5 (192.5, 749.9) ng / L vs. 1 120.0 (400.5, 2 480.0) ng / L] were lower in the GEDI group (Z = 86.500, 120.000, 124.000; P = 0.001, 0.020, 0.026). Blood lactate clearance rate in 6 h 34.21 (15.64, 45.87)% vs. 20.00 (0.00, 33.19)%] was higher, and the norepinephrine dosage (0.9 ± 0.6) mg / kg vs. (1.9 ± 1.5) mg / kg] was less in the GEDI group than in the CVP group (Z = 129.500, t' = 2.817; P = 0.037, 0.009). ConclusionGEDI-directed EGDT can achieve liquid resuscitation targets more effectively in cardiac dysfunction patients with septic shock, with less fluid volume, vasoactive agent, extravascular lung water and cardiac function impairment.