感染性休克患者中心静脉血和混合静脉血氧饱和度缺乏一致性

目的感染性休克患者的中心静脉血氧饱和度(SCVO2)与混合静脉血氧饱和度(SVO2)的相关性分析。方法符合感染性休克诊断的25例患者分成重症肺炎组和腹腔感染组。所有患者均留置Swan-Ganz导管,从入科开始,每隔6小时不分顺序抽取中心静脉血和混合静脉血,进行血气分析,获取SCVO2和SVO2,对数据进行统计分析。结果所有患者及重症肺炎组、腹腔感染组的SCVO2和SVO2比较,差异均有统计学意义(t分别=4.90、4.29、7.21,P均<0.05),25例感染性休克患者SCVO2和SVO2的差异均值为(5.94±6.78)%,SCVO2比SVO2高,12例重症肺炎患者的SCVO2和SVO2的差异均值为(5.45±6.89)%,SCVO2比SVO2高,13例腹腔感染组患者的SCVO2和SVO2的差异均值为(7.90±6.22)%,SCVO2比SVO2高,重症肺炎组及腹腔感染组SCVO2和SVO2之间相关系数,差异有统计学意义(Δz=2.05,P<0.05)。结论感染性休克患者血流动力学不稳定时,尽量不用SCVO2替代SVO2。     

Use of central venous saturation monitoring in a patient with pediatric cardiac beriberi

The patient was a 1-year-and-4-mo-old boy. He had drunk about 1 L of an isotonic drink for infants daily since about 10 mo after birth. He was examined by a local doctor due to anorexia and vomiting, found to have cardiomegaly, and transported to our hospital with suspected myocarditis. After admission, the patient showed polypnea, a decreased level of consciousness, and marked metabolic acidosis and lapsed into circulatory insufficiency, requiring catecholamine administration, endotracheal intubation, and extracorporeal membrane oxygenation. Initially, low-output heart failure due to acute myocarditis was suspected, but the central venous oxygen saturation was high, at 82%. Considering high-output heart failure to be more likely, we evaluated its cause and noted, by urinary organic acid analysis, increases in lactate, pyruvate, 3-OH-butyrate, acetoacetate, metabolic products of branched-chain amino acids, 2-ketoglutarate, 2-OH-glutarate, 2-keto-adipate, and 2-OH-adipate. Since the vitamin B1 level was reduced to 12 ng/mL (normally 20-50 ng/mL), a diagnosis of cardiac beriberi due to vitamin B1 deficiency was made. When unexplained heart failure is observed in children, cardiac beriberi must be excluded as a differential diagnosis of myocarditis and cardiomyopathy. The measurement of the central venous oxygen saturation may be useful for the diagnosis.     

ScvO 2和Pcv-aCO 2在脓毒性休克早期目标指导治疗中的价值

目的探讨以中心静脉血氧饱和度（ScvO₂）和静脉-动脉血二氧化碳分压差（Pcv-aCO₂）为早期目标指导治疗（EGDT）靶点在脓毒性休克治疗中的价值。 方法采用前瞻性研究方法,选择2018年6月至2020年6月在首都医科大学附属北京世纪坛医院ICU住院治疗的脓毒性休克患者。所有患者入住ICU后立即按脓毒症治疗指南要求给予EGDT治疗。根据转入ICU后6 h的ScvO₂及Pcv-aCO₂水平将患者分为高Pcv-aCO₂组（ScvO₂≥0.7且Pcv-aCO₂≥6 mmHg,1 mmHg=0.133 kPa）;低Pcv-aCO₂组（ScvO₂ ≥0.7且Pcv-aCO₂＜6 mmHg）。观察2组患者血流动力学特点、病情严重程度及预后差异。 结果共入选74例脓毒性休克患者,其中高Pcv-aCO₂组28例,低Pcv-aCO₂组46例。EGDT后高Pcv-aCO₂组较低Pcv-aCO₂组心排血指数（CI）、每搏量指数（SVI）明显降低,血管外肺水指数（EVLWI）明显升高;转入ICU后6、24、48 h（T6、T24、T48）急性生理学与慢性健康状况（APACHEⅡ）评分、序贯器官衰竭（SOFA）评分、血乳酸均显著升高;ICU住院时间明显延长,ICU病死率显著增高,差异均有统计学意义（P＜0.05）。 结论脓毒性休克患者ScvO₂达标后,以Pcv-aCO₂＜6 mmHg为EGDT靶点可改善患者的组织灌注及病情严重程度,降低ICU脓毒性休克患者病死率;增加CI可能有助于降低Pcv-aCO₂。     

早期乳酸清除率和中心静脉血氧饱和度监测对重症肺炎患者预后的研究

目的：探讨重症肺炎患者早期动脉血乳酸清除率、中心静脉血氧饱和度（ScvO2）的监测价值。方法回顾性研究2012年1月—2013月12月56例重症肺炎患者,入科即刻和6 h时测定动脉血乳酸浓度和早期ScvO2,计算6 h乳酸清除率,并进行急性生理与慢性健康（APACHEⅡ）评分,根据APACHEⅡ评分将患者分为3组：10-＜20分组（A组）,20-＜30分组（B组）,≥30分组（C组）,比较不同组别早期乳酸清除率和ScvO2的差别,并分析其与预后的关系。结果①B组初始动脉血乳酸较A组高,C组初始动脉血乳酸较B组高,但组间差异均无统计学意义（均 P＞0．05）;②B组早期6 h乳酸清除率、ScvO2均较A组低,差异有统计学意义（ P＜0．05）,C组早期6 h乳酸清除率、ScvO2均低于B组,差异有统计学意义（ P＜0．05）。③B组病死率高于A组,C组病死率高于B组,差异均有统计学意义（均 P＜0．05）;④死亡组APACHE Ⅱ评分高于存活组,早期动脉血乳酸清除率和ScvO2水平低于存活组,差异均有统计学意义（均 P＜0．05）;⑤APACHEⅡ评分与早期乳酸清除率呈显著负相关（r＝0．661,P＜0．01）,与早期ScvO2水平呈显著负相关（r＝0．579,P＜0．01）。结论早期动脉血乳酸清除率及ScvO2水平是反映重症肺炎患者病情严重程度和预测患者转归的参考指标。     

中心静动脉血二氧化碳分压差联合早期乳酸清除率对感染性休克患者预后的判断价值

目的：探讨中心静动脉血二氧化碳分压差（ Pcv－aCO2）和早期乳酸清除率在评估感染性休克患者预后中的临床意义。方法选取2010－01～2013－10收住我院重症医学科的82例经早期目标导向治疗（ EGDT）达标的感染性休克患者进行前瞻性观察研究,记录入院6 h Pcv－aCO2及患者入院后第一个24 h急性生理学和慢性健康状况评分系统Ⅱ（ acute physiology and chronic health evaluationⅡ,APACHEⅡ）评分和全身性感染相关性器官衰竭（ SOFA）评分;并记录入院时、入院6 h、入院24 h动脉血乳酸,计算早期乳酸清除率;以入院6 h Pcv－aCO2高低分为两组：A组（ Pcv－aCO2＜6 mm Hg）和B组（ Pcv－aCO2≥6 mm Hg）,比较两组患者乳酸清除率、SOFA评分及病死率。以6 h乳酸清除率高低分为两组：C组（乳酸清除率≤10％）和D组（乳酸清除率＞10％）,比较两组患者的28天病死率。根据28天病程转归分为死亡组（32例）和存活组（50例）,比较两组患者不同时间动脉血乳酸浓度、APACHEⅡ评分。结果 B组较A组乳酸清除率低,SOFA评分及病死率高,入院6 h Pcv－aCO2与6 h乳酸清除率存在负相关（ r＝－0.324,P＝0.003）。 D组病死率低于C组（ P＜0.05）。存活组APACHEⅡ评分较死亡组高,而入院时、6 h、24 h动脉血乳酸浓度均低于死亡组（ P＜0.05）。结论6 h Pcv－aCO2和6 h乳酸清除率可作为判断感染性休克患者预后的指标。     

Comparison of two methods for enhanced continuous circulatory monitoring in patients with septic shock

Objective To compare a modified pulmonary artery catheter (PAC) and pulse-contour analysis by the PiCCO (Pulsion Medical Systems, Munich, Germany) system for continuous assessment of cardiac output in patients with septic shock. In addition, to assess the relationships between an index of global end-diastolic volume (GEDV) derived by the PiCCO system with traditional PAC-derived indicators of filling: central venous pressure; pulmonary artery occlusion pressure; and right ventricular end-diastolic volume (RVEDV). Design Prospective cohort study. Setting Surgical intensive care unit of a university hospital. Patients and participants 14 patients with septic shock. Interventions None. Measurements and results A significant correlation was found between continuous cardiac output by PAC (CCO_PAC) and by pulse-contour analysis (r ² = 0.714, p < 0.0001), accompanied by a bias of 0.1 l min⁻¹ and a precision of 2.7 l min⁻¹. The correlation between CCO_PAC and cardiac output measured by transcardiopulmonary thermodilution was also significant (r ² = 0.781, p < 0.0001). There was a bias for the two methods of 0.2 l min⁻¹, and a precision of 2.2 l min⁻¹. The GEDV showed no correlation with central venous pressure, pulmonary artery occlusion pressure, or RVEDV. Conclusion In patients with septic shock, the averaged bias in continuous measurement of cardiac output by both a modified pulmonary artery catheter and pulse-contour analysis was small, but variability was large. No correlation was found between GEDV and RVEDV. The clinical importance of different cardiac filling parameters needs further investigation. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Enhanced sympathetic nervous activity after intravenous propranolol in ischaemic heart disease: plasma noradrenaline splanchnic blood flow and mixed venous oxygen saturation at rest and during exercise

To study the mechanisms by which acute beta-adrenergic blockade may change the activity of the sympathetic nervous system we have measured haemodynamic responses including splanchnic blood flow in twenty-three patients with ischaemic heart disease at rest and during supine exercise before and after i.v. injection of 0.039 mmol (10 mg) dl-propranolol. After propranolol both at rest and on exercise blood pressure, cardiac output and heart rate decreased, while splanchnic vascular resistance increased; mixed venous oxygen saturation decreased whilst arterial oxygen saturation and oxygen uptake were unchanged. Plasma noradrenaline increased after propranolol, values correlating with mixed venous oxygen saturation and splanchnic vascular resistance, both at rest and during exercise before and after propranolol, only at rest was there any correlation with arterial blood pressure. The increase in sympathetic nervous activity after propranolol may be due to a reduction in cardiac output and thereby alteration of the metabolic state (oxygen or related factors) in tissues. Afferent neural signals from the tissues may play a significant role in the regulation of sympathetic nervous activity.     

A pilot study examining the role of regional cerebral oxygen saturation monitoring as a marker of return of spontaneous circulation in shockable (VF/VT) and non-shockable (PEA/Asystole) causes of cardiac arrest

Background

Non-invasive monitoring of cerebral perfusion and oxygen delivery during cardiac arrest is not routinely utilized during cardiac arrest resuscitation. The objective of this study was to investigate the feasibility of using cerebral oximetry during cardiac arrest and to determine the relationship between regional cerebral oxygen saturation (rSO2) with return of spontaneous circulation (ROSC) in shockable (VF/VT) and non-shockable (PEA/asystole) types of cardiac arrest.

Methods

Cerebral oximetry was applied to 50 in-hospital and out-of-hospital cardiac arrest patients.

Results

Overall, 52% (n = 26) achieved ROSC and 48% (n = 24) did not achieve ROSC. There was a significant difference in mean ± SD rSO2% in patients who achieved ROSC compared to those who did not (47.2 ± 10.7% vs. 31.7 ± 12.8%, p < 0.0001). This difference was observed during asystole (median rSO2 (IQR) ROSC versus no ROSC: 45.0% (35.1–48.8) vs. 24.9% (20.5–32.9), p < 0.002) and PEA (50.6% (46.7–57.5) vs. 31.6% (18.8–43.3), p = 0.02), but not in the VF/VT subgroup (43.7% (41.1–54.7) vs. 42.8% (34.9–45.0), p = 0.63). Furthermore, it was noted that no subjects with a mean rSO2 < 30% achieved ROSC.

Conclusions

Cerebral oximetry may have a role as a real-time, non-invasive predictor of ROSC during cardiac arrest. The main utility of rSO2 in determining ROSC appears to apply to asystole and PEA subgroups of cardiac arrest, rather than VF/VT. This observation may reflect the different physiological factors involved in recovery from PEA/asytole compared to VF/VT. Whereas in VF/VT, successful defibrillation is of prime importance, however in PEA and asytole achieving ROSC is more likely to be related to the quality of oxygen delivery. Furthermore, a persistently low rSO2 <30% in spite of optimal resuscitation methods may indicate futility of resuscitation efforts.