Monitoring the circulatory responses of shocked patients during fluid resuscitation in the emergency department

Objectives: To assess the feasibility of constructing left ventricular response curves non-invasively during the fluid resuscitation of critically ill patients in the emergency department (ED) using a portable suprasternal Doppler ultrasound (PSSDU) device.¶Design: Prospective case series.¶Setting: Emergency department, Catholic University of Leuven, Belgium. Patients: Shocked patients in the ED were diagnosed by predefined criteria. Only those thought to require standardised intravenous colloid challenges were observed i. e., sequential boluses of 3.5 ml/kg/10 min titrated against changes in stroke distance (Doppler surrogate for left ventricular stroke volume).¶Results: A total of 50 shocked patients were studied. Stroke distance was measurable in 45 patients. 35 patients were fluid responders in terms of stroke distance. Group mean stroke distance increased during resuscitation (8.6 ± 4.1 cm to 19.5 ± 4.6 cm, P < 0.001) and then reached a plateau value (19.6 ± 4.6 cm, P = 0.488). No response to fluid was seen in nine patients of which eight had severe sepsis. Alternative therapeutic approaches increased stroke distance for all of these patients. Evidence for right ventricular dysfunction was found as a cause for fluid non-response in the majority of patients with sepsis.¶Conclusions: Previous experimental work has shown that changes in central blood flow can be derived using the PSSDU device. This clinical feasibility study suggests that the PSSDU can help tailor haemodynamic therapy for an individual patient and give an early indication of treatment failure in the ED.     

脓毒性休克早期液体复苏的临床研究

目的:探讨早期液体复苏容量对脓毒性休克的治疗意义。方法:定义正平衡即液体入量大于液体出量,负平衡即液体入量小于液体出量。回顾性分析80例脓毒性休克患者入院后24h和入院后72h液体复苏正平衡组及负平衡组的资料,分析两组间患者的预后。结果:入院后24h内负平衡组,负平衡液体量-218±21.4ml,死亡率显著低于正平衡组,正平衡液体量3206±57.9ml(P<0.01)。入院后72h内负平衡组,负平衡液体量-278±25.9ml,死亡率显著低于正平衡组,正平衡液体量5265±98.7ml(P<0.01)。结论:脓毒性休克患者早期液体复苏容量负平衡可以降低病死率。     

国内限制性液体复苏在创伤失血性休克中的应用研究进展

综述了限制性液体复苏对创伤性休克病人影响的临床研究及实验研究,介绍了限制性液体复苏时机、适当的液体种类及效果的判断。     

不同液体复苏量与休克患者预后及并发症的相关性研究

目的探讨不同液体复苏量对休克患者临床预后及并发症的影响。方法收集2018年1月1日至2019年4月30日在安徽医科大学附属安徽省立医院ICU住院的休克患者116例,将患者根据1周液体入量分为3组(1组:<2500 mL,17例;2组:2500~3500 mL,66例;3组:>3500 mL,33例);根据液体平衡量分为4组(A组:<-500 mL,22例;B组:-500~<0 mL,27例;C组:0~500 mL,36例;D组>500 mL,31例)。比较不同液体入量组患者的年龄、性别、APACHEⅡ评分、SOFA评分、氧和指数、BNP、Cr、BUN、LAC、总胆红素水平、ICU死亡率、28 d死亡率、心力衰竭发生率、ICU住院天数、机械通气时间、利尿剂1周内总量;比较不同液体平衡量组患者的ICU死亡率、28 d死亡率;采用韦恩图分析两种分组方法下患者的28 d死亡情况。结果液体复苏后,3组与1、2组患者1周前、后的APACHEⅡ评分、SOFA评分、BNP、BUN、总胆红素水平差值比较,差异有统计学意义(P<0.05);1组与2、3组患者1周前、后的氧合指数差值比较,差异有统计学意义(P<0.05);1、2、3组患者的Cr、LAC水平差值比较,差异无统计学意义(P>0.05)。3组患者的ICU死亡率、心力衰竭发生率高于1、2组(P<0.05);1组的28 d死亡率低于2、3组,机械通气时间短于2、3组(P<0.05);3组患者的利尿剂1周内总量大于2组(P<0.05)。D组患者的ICU死亡率及28 d死亡率均高于A、B、C组,差异具有统计学意义(P<0.05)。根据韦恩图可知,28 d死亡总人数为46例,D组与3组的死亡人数交集为14例,分别占D组死亡人数的60.87%,占3组死亡人数的73.68%,占死亡总数的30.43%。结论休克患者液体复苏成功后,当患者液体入量>3500 mL,且液体平衡量>500 mL时,患者临床预后差,死亡率高。临床医师应加强液体管理,减少液体输注,从而改善患者预后,提高患者存活率。     

限制性液体复苏在治疗晚期血吸虫病上消化道大出血中的临床应用研究

目的：探讨不同的液体复苏对晚期血吸虫病上消化道大出血低血容量性休克的应用效果。方法：将313例晚期血吸虫病上消化道大出血低血容量性休克患者,随机分成充分液体复苏组（153例）和限制液体复苏组（160例）,比较其凝血功能,并发症发生率、病死率已及住院天数。结果：2h内充分液体复苏组病死率37.9%,限制液体复苏组病死率25%,两组2h病死率和住院天数比较差异有统计学意义（P〈0.01）,充分液体复苏组血浆凝血酶原时间延长,血小板呈进行性下降,存活患者并发症的发生率显著高于限制性液体复苏组（P〈0.01）。限制液体复苏组存活患者住院天数明显缩短（P〈0.01）。结论：限制性液体复苏能降低晚期血吸虫病上消化道大出血低血容量性休克患者病死率,提高生存率,同时降低并发症的发生率,减少住院天数,改善预后。     

不同液体早期复苏在感染性休克患者的临床研究

目的:评价不同液体早期复苏对感染性休克患者EGDT达标、血乳酸清除率、APACHEⅡ评分和28d病死率的影响。方法:选取2005-10-2010-10收住ICU的感染性休克患者作为研究对象,随机分为高渗氯化钠羟乙基淀粉40溶液组(霍姆组)、3%高渗氯化钠组(高钠组)、羟乙基淀粉130/0.4氯化钠溶液组(万汶组)、生理盐水组(NS组)。分别经中心静脉通路输入相应的复苏液体,配合林格液对患者进行包括6h早期液体复苏在内的早期目标指导性治疗(EGDT)。分别记录各组患者在液体复苏前及复苏0、1、3和6h的心率(HR)、MAP、CVP、24h血乳酸值,并计算24h血乳酸清除率。观察EGDT达标情况、升压药物使用情况、复苏前及复苏72h的APACHEⅡ评分变化以及28d病死率。结果:①共收集符合条件标准的病例51例:霍姆组12例、高钠组10例、万汶组14例、NS组15例。各组患者的性别、年龄、MAP、CVP、HR、APACHEⅡ评分、血乳酸值比较,差异无统计学意义(均P>0.05);②研究液体用量在各组间比较,霍姆组与高钠组比较,差异无统计学意义;NS组、万汶组各自与其他3组比较,差异均有统计学意义(均P<0.05);复苏液体总量在各组间比较,NS组与其他3组比较,万汶组与霍姆组比较,差异均有统计学意义(均P<0.05);高钠组与霍姆组、高钠组和万汶组比较,差异均无统计学意义;林格液量在各组间比较,差异均无统计学意义;③随复苏时间延长,MAP逐渐升高,HR逐渐减慢,MAP、HR在不同时间点各组间比较,差异均无统计学意义(均P>0.05)。随复苏时间延长,CVP逐渐升高,在复苏1h、3h和6h时,霍姆组CVP均高于NS组,差异有统计学意义(均P<0.05);且在复苏1h时,霍姆组CVP高于万汶组,差异有统计学意义(P<0.01),高钠组CVP显著高于NS组(P<0.05);④复苏24h血乳酸值及其清除率在各组间比较,以及复苏后72hAPACHEⅡ评分在各组间比较,差异无统计学意义(均P>0.05);⑤各组患者使用升压药例数、使用升压药>3d例数及EGDT达标例数比较,差异均无统计学意义(均P>0.05)。感染性休克患者的整体病死率为45.10%(23/51),28d病死率在各组间比较,差异无统计学意义。结论:在感染性休克的早期液体复苏中,应用霍姆有利于提高CVP,但对需要应用升压药时间、EGDT达标、乳酸清除率、APACHEⅡ评分以及28d病死率并无无显著影响;对某些需限制性液体管理的患者,使用高渗氯化钠羟乙基淀粉40注射液或高渗盐水可以减少补液总量。     

脉搏指示连续心输出量监测在感染性休克患者早期液体复苏中的临床价值

目的探讨根据脉搏指示连续心输出量(PICCO)监测中的容量指标对感染性休克患者的早期液体复苏,以及治疗效果和预后的影响。方法将该院急诊科重症监护病房收治的80例感染性休克患者随机分为根据中心静脉压(CVP)指导液体复苏治疗的对照组,和依据血管外肺水指数(EVWL)和全心舒张末期容积(GEDV)指导液体复苏治疗的实验组,每组各40例,2组患者经液体复苏治疗后的疗效与预后进行对比分析。结果实验组患者乳酸水平明显低于对照组,中心静脉血氧饱和度、氧合指数、尿量均明显高于对照组,差异均有统计学意义(P0.05);实验组患者ICU时间、机械通气时间、使用血管活性药物时间均明显少于对照组,差异均有统计学意义(P0.05);治疗后1h与6h,2组患者EVLWI、GEDVI、平均动脉压(MAP)、心率(HR)、CVP等指标比较,差异无统计学意义(P0.05)。结论依据EVWL和GEDV指导感染性休克患者早期液体复苏治疗,能够改善患者的预后、降低病死率,具有临床意义。     

限制与积极液体复苏法救治创伤失血性休克的疗效比较

目的比较限制液体复苏与积极液体复苏救治创伤失血性休克的临床效果,以提高治愈率。方法将符合创伤失血性休克患者随机分为限制液体复苏组和积极液体复苏组,对其临床资料和实验室指标进行统计学分析。结果限制性液体复苏组与积极液体复苏组比较,收缩压差异无显著性(院前51±19 mmHg vs 50±21 mmHg,术前74±27 mmHg vs 82±28 mmHg,P>0.05),输液量显著降低(院前232±215 mL vs 830±542 mL,术前328±309 mL vs 1905±1340 mL,P<0.01),死亡率降低(13.3%vs 27.8%,P<0.05),术前血红蛋白升高(94±21 g/L vs 85±23 g/L,P<0.05),术前凝血指标好转〔血小板计数(268±94)×109/L vs(233±91)×109/L,P<0.05;凝血酶原时间12.3±1.7 s vs 14.5±1.9 s,P<0.01;部分凝血酶原时间36.5±14.1 s vs 41.8±18.5 s,P<0.05〕。结论救治创伤失血性休克限制液体复苏法可能优于积极液体复苏法。     

脉搏指示连续心排血量监测在脓毒性休克患者早期液体复苏及治疗中的应用

目的探讨脉搏指示连续心排血量监测(PiCCO)在脓毒性休克患者早期液体复苏及治疗中的临床应用价值。方法选取2013年7月至2015年5月本院收治的符合入选标准的50例脓毒性休克患者,按随机数字表法分为研究组和对照组各25例。研究组患者于PiCCO指导下进行液体复苏及治疗,对照组患者利用中心静脉压(CVP)指导液体复苏及治疗。观察两组患者治疗前后的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ评分)、血乳酸清除率、复苏液体量、CVP、尿量、平均动脉压、呼吸机使用例数、肺水肿及心衰发生例数。结果经过液体复苏及治疗后两组患者的APACHEⅡ评分均逐步下降,72h时研究组明显低于对照组,差异有统计学意义(P0.05);6、24h时研究组液体使用量明显多于对照组,而72h时液体总量明显少于对照组,差异均有统计学意义(P0.05);治疗6、24h后研究组乳酸清除率、尿量、CVP、平均动脉压均优于对照组,差异均有统计学意义(P0.05);72h时研究组发生心衰及肺水肿的例数明显少于对照组,差异均有统计学意义(P0.05)。72h后两组患者使用呼吸机例数比较差异无统计学意义(P0.05)。结论 PiCCO监测可较为准确地评估脓毒性休克患者的容量状态,精准地指导液体复苏及治疗,减少并发症,对脓毒性休克患者早期液体复苏及治疗具有较好的指导意义。     

延迟复苏治疗活动性失血性休克临床探讨

目的：探讨延迟复苏策略治疗重症活动性失血性休克在临床的应用实践。方法：延迟复苏组（A组）,限制输晶体液和胶体液量,扩容更多地依赖输血及血浆,控制目标血压以收缩压80~90 mm Hg（1 mm Hg=0.133 kPa）为允许性低血压;传统复苏组（B组）,不限制输晶体液和胶体液量,快速进行液体复苏。输液以晶体液和胶体液为主,输血及血浆为辅助,不有意控制血压上限。结果：A组抢救成活率显著高于B组。结论：在重症加强护理病房（ICU）临床上认识重症活动性失血性休克特殊性以及治疗的特殊性。应用延迟复苏方法,有望提高该类危重患者的治愈率。     

An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: An evaluation for medical student training

Objective

Widespread application of early goal-directed therapy (EGDT) and the severe sepsis resuscitation bundle is limited by clinician knowledge, skills and experience. This study evaluated use of simulation-based teaching during medical training to increase future clinician knowledge in the above therapies for severe sepsis and septic shock.

Methods

A prospective cohort study was performed with medical students at all levels of training. A 5-h course including didactic lectures, skill workshops, and a simulated case scenario of septic shock were administered to the participants. A checklist including 21 tasks was completed during the patient simulation. An 18-question pre-test, post-test and 2-week post-test were given. The participants completed a survey at the end of the course.

Results

Sixty-three students were enrolled. There was statistical difference between the pre-test and each of the post-test scores: 57.5 ± 13.0, 85.6 ± 8.8, and 80.9 ± 10.9%, respectively. 20.6% of participants thought the pre-test was too difficult, whereas all participants thought the post-test was either appropriate or too easy. The task performance during the simulated septic shock patient was 94.1 ± 6.0%. The participants noted improvements in their confidence levels at managing severe sepsis and septic shock, and agreed that the course should be a requirement during medical school training.

Conclusions

Medical simulation is an effective method of educating EGDT and the severe sepsis resuscitation bundle to medical students with limited experience in patient care. The results suggest that our course may be of further benefit at increasing clinical experience with this intensive protocol for the management of severe sepsis and septic shock.     

创伤失血性休克早期液体复苏策略及氧代谢监测的临床观察

目的:观察创伤失血性休克限制性液体复苏及充分液体复苏的临床疗效及对氧代谢的影响。方法:将218例创伤失血性休克患者随机分为治疗组(n=110)及对照组(n=108),分别进行限制性液体复苏及充分液体复苏。比较两组输液量、病死率及并发症(ARDS、MODS、脓毒血症)发生率,复苏2 h后氧输送(DO-2)、氧消耗(VO2)、混合静脉血氧饱和度(SVO2)情况及24 h乳酸恢复情况。结果:治疗组输液量显著少于对照组(P0.01),治疗组死亡率、并发症发生率明显低于对照组(P0.05);治疗组DO_2、VO_2、SVO_2及24 h乳酸恢复正常例数均明显高于对照组(P0.05)。结论:与充分液体复苏比较,对创伤失血性休克进行限制性液体复苏能减少输液量,降低病死率及并发症发生率,且在组织供氧及纠正乳酸酸中毒方面有明显优势。     

未控制失血性休克早期复苏的研究进展

综述未控制失血性休克复苏补液的量、速度、时机、液体的种类和早期温度复苏以及新的复苏终点标准。     

Intensive care nurse-led point of care ultrasound in the assessment and management of the critically ill COVID-19 patient: A single centre case series

Focused ultrasound can be used to rapidly diagnose COVID-19 disease, assess disease severity, and inform management of COVID-19 and associated pathologies, reducing radiation exposure from other imaging modalities and minimizing spread of infection. Ultrasound examinations performed by trained nurses in the intensive care unit (ICU) enable more patients to receive these assessments. This case series evaluates the use of nurse-led focused cardiac and lung ultrasound for clinical management of ICU patients with COVID-19. We describe common pathophysiological findings and how findings were used to inform clinical decision-making. An ultrasound trained ICU nurse performed Focused Ultrasound in Intensive Care (FUSIC) cardiac and lung scans enabling calculation of a lung severity score on adult ICU patients with a confirmed COVID-19 diagnosis in a single-centre setting. Fifteen scans were performed on 15 patients. Thirteen (87%) patients had normal left ventricular function; 12 (80%) normal right ventricular function. All 15 (100%) scans identified abnormal lung findings including irregular thickened pleura, B-lines, sub-pleural consolidation and hepatization. Worse lung severity scores were correlated with higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores (r = 0.70; p = .003). Of the 15 scans, 10 (67%) identified abnormal pathology contributing to a change in clinical management. This included targeted fluid removal (4, 27%), change in respiratory management (3, 20%) and need for formal echocardiographic assessment (3, 20%). Findings from five (33%) scans required no intervention. This case series demonstrates nurse-led ultrasound could be a useful adjunct in the management of the COVID-19 patient.     

脓毒性休克患者血浆胱抑素C的改变及早期液体复苏对其影响

目的通过检测血浆胱抑素C（CystatinC）,早期评价肾功能损伤程度,并探讨早期液体复苏对脓毒性休克患者肾功能的影响。方法河北医科大学第四医院ICU自2008年3月1日~2008年11月30日收治的脓毒性休克患者48例为实验组,健康志愿者20例为正常对照组。参照2004年国际脓毒症治疗指南的早期目标导向治疗（EGDT）对脓毒性休克患者进行液体复苏。分别于0、6、24、48h4个时间点,用ELISA法测定血浆CystatinC的浓度,同时记录患者体温、心率、呼吸、平均动脉压及小时尿量和24h尿量、CVP、APACHEII评分,根据预后再分为死亡组和存活组。结果液体复苏前脓毒性休克患者血浆CystatinC水平显著高于对照组,P〈0．05;24h血浆CystatinC水平较液体复苏前显著下降,P〈0．05;死亡组血浆Cys．tatlnC水平较存活组显著升高,P〈0．05。结论脓毒性休克患者血浆CystatinC水平明显升高,提示存在急性肾损伤;早期充分的液体复苏可以明显改善脓毒性休克患者的肾功能状态;血浆CystatinC水平与r水平有很好的相关性,能反应患者早期的肾损害,与肾损害程度正相关。     

不同的血压控制在早期失血性休克限制性液体复苏中的治疗效果

目的 探讨限制性液体复苏时维持不同的血压水平对创伤失血性休克早期的治疗效果.方法 回顾性分析维持两种不同的血压水平对患者的死亡率、存活患者并发症发生率、血乳酸、凝血酶原时间、血红蛋白、血小板计数及血细胞比容等指标在早期失血性休克限制性液体复苏中的影响.结果 p40组死亡率15.69%,存活患者并发症发生率16.28%;p60组死亡率28.57%,存活患者并发症发生率35.00%.两组死亡率及存活患者并发症发生率比较差异均有统计学意义(P<0.05).两组血乳酸、凝血酶原时间、血红蛋白、血小板计数、血细胞比容及血红蛋白比较差异均有统计学意义(P<0.05).结论 早期失血性休克患者限制性液体复苏过程中平均动脉压(MAP)维持在40～60 mm Hg之间,可以降低患者死亡率,提高存活率,降低存活患者并发症的发生率,改善预后.     

Effects of Delaying Fluid Resuscitation on an Injury to the Systemic Arterial Vasculature

OBJECTIVES: To determine the effects of delaying fluid on the rate of hemorrhage and hemodynamic parameters in an injury involving the arterial system. METHODS: Twenty-one adult, anesthetized sheep underwent left anterior thoracotomy and transection of the left internal mammary artery. A chest tube was inserted into the thoracic cavity to provide a continuous measurement of blood loss. The animals were randomly assigned to one of three resuscitation protocols: 1) no fluid resuscitation (NR), 2) standard fluid resuscitation (SR) begun 15 minutes after injury, or 3) delayed fluid resuscitation (DR) begun 30 minutes after injury. All of the animals in the two resuscitation groups received 60 mL/kg of lactated Ringer's solution over 30 minutes. Blood loss and hemodynamic parameters were measured throughout the experiment. RESULTS: Total hemorrhage volume (mean +/- SD) at the end of the experiment was significantly lower (p = 0.006) in the NR group (1,499 +/- 311 mL) than in the SR group (3,435 +/- 721 mL) or the DR group (2,839 +/- 1549 mL). Rate of hemorrhage followed changes in mean arterial pressure in all groups. Hemorrhage spontaneously ceased significantly sooner (p = 0.007) in the NR group (21 +/- 14 minutes) and the DR group (20 +/- 15 minutes) than in the SR group (54 +/- 4 minutes). In the DR group, after initial cessation of hemorrhage, hemorrhage recurred in five of six animals (83%) with initiation of fluid resuscitation. Maximum oxygen (O2) delivery in each group after injury was as follows: 101 +/- 34 mL O2/kg/min at 45 minutes in the DR group, 51 +/- 20 mL O2/kg/min at 30 minutes in the SR group, and 35 +/- 8 mL O2/kg/min at 60 minutes in the NR group. CONCLUSIONS: Rates of hemorrhage from an arterial injury are related to changes in mean arterial pressure. In this animal model, early aggressive fluid resuscitation in penetrating thoracic trauma exacerbates total hemorrhage volume. Despite resumption of hemorrhage from the site of injury, delaying fluid resuscitation results in the best hemodynamic parameters.