P（v-a）CO 2/C（a-v）O 2 ratio在休克复苏中的临床应用进展

静脉-动脉二氧化碳分压差/动脉-静脉氧含量差[P（v-a）CO₂/C（a-v）O₂ ratio]通过计算氧的消耗量和二氧化碳的生成量的比率获得,其本质是反映机体呼吸商。在无氧代谢时只有CO₂的产生,却无O₂的消耗,此时呼吸商趋向无限大。因此,当机体存在无氧代谢时,可出现P（v-a）CO₂/C（a-v）O₂ ratio增高。近来,应用P（v-a）CO₂/C（a-v）O₂ ratio作为识别机体是否存在无氧代谢的指标在休克复苏中受到广泛关注。     

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。     

中心静脉血与动脉血二氧化碳分压差、中心静脉血氧饱和度、乳酸清除率对感染性休克预后不良的预测

目的 探讨中心静脉血与动脉血二氧化碳分压差(Pcv-aCO2)、中心静脉血氧饱和度(ScvO2)、乳酸清除率(LCR)联合对感染性休克患者预后不良的预测价值.方法 回顾性分析2015年3月至2020年5月收治的70例感染性休克患者的临床资料,均在入院后6、24 h检测Pcv-aCO2、ScvO2,且均计算入院6、24 ...     

P(v-a)CO2/C(a-v)O2对急性有机磷中毒患者预后的预测价值研究

目的:探讨动静脉二氧化碳分压差/动静脉氧含量差[P(v-a)CO_(2)/C(a-v)O_(2)]对急性有机磷中毒患者预后的预测价值。方法:选取我院111例有机磷农药中毒患者,按P(v-a)CO_(2)/C(a-v)O_(2)治疗后变化分为下降组(n=54)和上升组(n=57)。比较两组的一般资料、并发症、氧代谢相关指标以及预后,分析氧代谢指标对预后的价值。结果:与下降组相比,上升组休克、重要器官损伤以及中间综合征发生率明显升高,同时胆碱酯酶恢复正常、意识恢复及机械通气时间延长,阿托品用量明显升高,病死率亦升高。两组乳酸在治疗前后比较差异均有统计学意义(P<0.05)。两组的P(v-a)CO_(2)/C(a-v)O_(2)治疗前比较差异无统计学意义,治疗后上升组P(v-a)CO_(2)/C(a-v)O_(2)明显高于下降组。Logistic回归分析显示,乳酸是治疗前患者的死亡危险因素(P<0.05),P(v-a)CO_(2)/C(a-v)O_(2)和乳酸是急性有机磷中毒治疗后的死亡危险因素。进一步ROC曲线发现,治疗前后均是P(v-a)CO_(2)/C(a-v)O_(2)对急性有机磷中毒患者死亡预测价值最高,曲线下面积及最佳诊断界值为分别为0.840、2.45以及0.861、2.55。结论:氧代谢相关指标与急性有机磷中毒患者预后密切相关,其中P(v-a)CO_(2)/C(a-v)O_(2)是评估预后不良的较好指标。     

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。     

Pv-aCO2在非体外循环冠状动脉旁路移植术后低血容量患者液体复苏中的应用价值

目的 探讨混合静脉-动脉血二氧化碳分压差(Pv-aCO₂)在非体外循环冠状动脉旁路移植(OPCABG)术后低血容量患者液体复苏中的应用价值。方法 选择北部战区总医院2019年5月至2020年8月择期行 OPCABG 后低血容量冠心病患者120例为研究对象。入ICU 后立即给予早期目标导向治疗(EGDT),并2小时记录1次 PvaCO₂,根据术后12小时 Pv-aCO₂均值分为 Pv-aCO₂≥ 6mmHg(高 Pv-aCO₂ 组,n= 52)和 Pv-aCO₂<6mmHg(低Pv-aCO₂ 组,n=68)两组。比较两组患者入ICU 后0h(T0)、6h(T6)及12h(T12)三个时间点的中心静脉压(CVP)、平均动脉压(MAP)、心脏指数(CI)、乳酸(Lac)和术后机械通气辅助时间、ICU 停留时间及并发症。分析 Pv-aCO₂与CI、Lac的相关性。结果 两组患者 OPCABG术后 T6、T12时CV...     

目标乳酸清除和 CVP水平在感染性休克患者液体复苏中的指导作用

目的评价以目标乳酸水平和中心静脉压（CVP）指导液体复苏对感染性休克患者脏器功能及预后的影响。方法采用前瞻性研究方法,将符合感染性休克患者随机分为中心静脉压（CVP）组和乳酸组,前6h,两组均按感染性休克的EGDT给予集束化治疗,之后中心静脉压组以CVP为指导进行液体复苏。结果乳酸组患者与CVP组患者在CVP、呼吸机使用时间、氧合指数、血管活性药物用量、B型利钠肽（BNP）及72h液体总量、病死率等方面比较差异有统计学意义。结论感染性休克患者以CVP指导的液体复苏优于目标乳酸指导的液体复苏,一定程度上可降低患者病死率。     

羟乙基淀粉注射液在脓毒性休克早期容量复苏中的应用价值研究

目的:评估羟乙基淀粉注射液在脓毒性休克早期容量复苏中的应用价值.方法:回顾性分析我院2005年1月至2010年12月收住院的43例脓毒性休克患者的临床资料;根据确诊脓毒性休克后是否应用羟乙基淀粉注射液(HES)进行液体复苏分为HES组和对照组,记录、检测复苏前后血流动力学指标的变化,比较两组血流动力学指标复苏前后的改善情况.结果:两组间性别、年龄、入组时的APACHEⅡ评分等一般指标均无统计学差异(P＞0.05);对照组与HES组容量复苏后血流动力学指标均有所好转;然而HES组改善幅度明显优于对照组,差异有统计学意义(P＜0.05),其中平均动脉压升高幅度及6小时乳酸清除率差异尤其显著(P＜0.01).结论:在脓毒性休克早期应用羟乙基淀粉(HES)进行容量复苏在改善血流动力学方面要优于单纯应用晶体液.     

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。     

中心静脉-动脉二氧化碳分压差在反映感染性休克患者全身组织灌注的价值北大核心CSCD

目的评价中心静脉-动脉二氧化碳分压差[P（CV—a）CO2]在反映感染性休克患者全身组织灌注方面的价值。方法对2009—06～2011—06收住ICU的126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,测定入组时（T0）的P（cv—a）CO2值,以6mmHg作为其界限,将患者分为低P（CV—a）CO2组（n=68）和高P（CV—a）CO2组（n=58）。测定T0,入组后6、12h（T6、T12）的平均动脉压（MAP）、心率（HR）、心指数（CI）、经皮血氧饱和度（SaO2）、中心静脉氧饱和度（ScvO2）、氧摄取率[ERO2=（SaO2-ScvO2）／SaO2]、P（CV—a）CO2及动脉血乳酸（Lac）。结果在T0低P（CV—a）CO2组的CI明显高于高P（CV—a）CO2组[（4．35±0．90）L／（min·m2）vs（3．14±0．65）L／（min·m2）,P〈0．0001）,但ScvO2值两组比较差异无统计学意义[（76±4）％vs（75±4）％,P=0．18]。T0～T12,低P（cv—a）CO2组乳酸清除率明显高于高P（CV—a）CO2组[（33±28）％vs（24±24）％,P〈0．05],在T24两组感染相关器官功能衰竭评分系统（SOFA）评分比较差异有统计学意义[（11．1±3．2）分vs（12．4±4．0）分,P〈0．05]。两组28d病死率分别为38．2％、56．9％,差异有统计学意义（P〈0．05）。在入组后各时间点,CI和P（CV—a）CO2均存在负相关。结论感染性休克患者按EGDT进行复苏治疗时,仅以ScvO2作为目标来指导复苏治疗是不够的,当ScvO2已经达到70％时,可将P（CV—a）CO2≥6mmHg作为另一个判断患者存在复苏不充分的指标。     

细胞因子、经皮氧分压/吸入氧浓度联合危重评分对脓毒症患者进展为脓毒性休克及预后的预测价值

目的探讨细胞因子、经皮氧分压(TcPO₂)/吸入氧浓度(FiO₂)及危重评分等对脓毒症患者短期进展为脓毒性休克及其28 d预后的预测价值。方法前瞻性选择2018年7月至2018年12月复旦大学附属中山医院急诊科收治的96例脓毒症患者,患者入院时均未休克。记录入院当天首次测定的TcPO₂/FiO₂、细胞因子、炎症标志物、肾功能、血乳酸等炎症及灌注相关指标;记录患者入院时急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和序贯性器官功能衰竭评估(SOFA)评分。根据入院后7 d内是否进展为脓毒性休克分为休克组(n=14)和非休克组(n=82)。根据入院后28 d内是否死亡分为生存组(n=63)和死亡组(n=33)。采用logistic回归分析筛查脓毒症患者短期内进展为脓毒性休克和28 d内预后的危险因素,并采用受试者工作特征(ROC)曲线分析相关指标对脓毒症患者进展为脓毒性休克及28 d预后的预测价值。结果脓毒性休克组患者血白细胞计数、白介素(IL)-6、IL-8、IL-10、乳酸、血肌酐、TcP...     

Effect of early goal directed therapy on tissue perfusion in patients with septic shock

BACKGROUND:

This study aimed to observe the effect of early goal directed therapy (EGDT) on tissue perfusion, microcirculation and tissue oxygenation in patients with septic shock.

METHODS:

Patients with early septic shock (<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled (research time: 12 months), and they didn’t meet the criteria of EGDT. Patients who had one of the following were excluded: stroke, brain injury, other types of shock, severe heart failure, acute myocardial infarction, age below 18 years, pregnancy, end-stage disease, cardiac arrest, extensive burns, oral bleeding, difficulty in opening the mouth, and the onset of septic shock beyond 24 hours. Patients treated with the standard protocol of EGDT were included. Transcutaneous pressure of oxygen and carbon dioxide (PtcO₂, PtcCO₂) were monitored and hemodynamic measurements were obtained. Side-stream dark field (SDF) imaging device was applied to obtain sublingual microcirculation. Hemodynamics, tissue oxygen, and sublingual microcirculation were compared before and after EGDT. If the variable meets the normal distribution, Student''s t test was applied. Otherwise, Wilcoxon''s rank-sum test was used. Correlation between variables was analyzed with Pearson''s product-moment correlation coefficient method.

RESULTS:

Twenty patients were involved, but one patient wasn’t analyzed because he didn’t meet the EGDT criteria. PtcO₂ and PtcCO₂ were monitored in 19 patients, of whom sublingual microcirculation was obtained. After EGDT, PtcO₂ increased from 62.7±24.0 mmHg to 78.0±30.9 mmHg (P<0.05) and tissue oxygenation index (PtcO₂/FiO₂) was 110.7±60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT (P<0.05). The difference between PtcCO₂ and PCO₂ decreased significantly after EGDT (P<0.05). The density of perfused small vessels (PPV) and microcirculatory flow index of small vessels (MFI) tended to increase, but there were no significant differences between them (P>0.05). PtcO₂, PtcO₂/FiO₂, and PtcCO₂ were not linearly related to central venous saturation, lactate, oxygen delivery, and oxygen consumption (P>0.05).

CONCLUSION:

Peripheral perfusion was improved after EGDT in patients with septic shock, and it was not exactly reflected by the index of systemic perfusion.KEY WORDS: Transcutaneous pressure of oxygen, Transcutaneous pressure of carbon dioxide, Microcirculation, Septic shock, EGDT, Tissue perfusion, Tissue oxygenation, Sidestream dark field imaging     

早期目标导向治疗对感染性休克组织灌注和氧代谢的影响

目的 探讨早期目标导向治疗(EGDT)对感染性休克患者组织灌注、微循环和氧代谢的影响.方法 前瞻性观察性研究,选取2009年9月至2011年5月东南大学附属中大医院ICU收治的早期感染性休克(＜24 h)患者,并且EGDT未达标(四项指标中至少一项未达标),排除脑血管意外、颅脑外伤、合并其他类型休克、重度心衰、急性心梗、未成年人、妊娠、疾病终末期、心搏呼吸骤停、大面积烧伤、口腔毁损或出血、张口极度困难、感染性休克发病时间大于24h等患者,按照EGDT流程对患者进行治疗,监测血流动力学、经皮氧分压(PtcO2)和二氧化碳分压(PtcCO2),用旁流暗视野成像仪(SDF)监测舌下微循环,观察同一患者EGDT达标前后血流动力学、组织氧和舌下微循环变化.符合正态性分布者自身比较用配对t检验,不符合者用Wilcoxon符号秩和检验,变量相关性采用Pearson相关分析.结果 20例患者进入本研究,1例患者EGDT未达标,未纳入分析,最终共有19例患者EGDT达标并监测了组织氧,其中4例患者同时监测了患者舌下微循环.(1)与治疗前相比,EGDT达标后PtcO2[(8.0±30.9) mm Hgvs.(62.7±24.0)mm Hg,P＜0.05,1 mm Hg =0.133 kPa],组织氧合指数(PtcO2/FiO2)[(141.6±78.2) mmHgvs.(110.7 ±60.4) mm Hg,P＜0.05]显著增加,PtcCO2和经皮-动脉二氧化碳分压差(PCO2 gap) (P ＜0.05)显著降低.(2) EGDT达标后灌注血管比例(PPV) (P =0.051)、微循环血流量指数(MFI) (P =0.074)均较治疗前有增加趋势.(3) PtcO2、组织氧合指数、PtcCO2与中心静脉血氧饱和度、乳酸、氧输送、氧耗差异均无统计学意义(P＞0.05).结论 EGDT能改善感染性休克患者局部组织灌注和微循环,感染性休克EGDT达标前后全身组织灌注的指标可能不能反映局部组织灌注.     

Cerebral metabolic rate of oxygen (CMRO2) in pig brain determined by PET after resuscitation from cardiac arrest

Aim

To assess the regional vulnerability to ischemic damage and perfusion/metabolism mismatch of reperfused brain following restoration of spontaneous circulation (ROSC) after cardiac arrest.

Method

We used positron emission tomography (PET) to map cerebral metabolic rate of oxygen (CMRO₂), cerebral blood flow (CBF) and oxygen extraction fraction (OEF) in brain of young pigs at intervals after resuscitation from cardiac arrest. After obtaining baseline PET recordings, ventricular fibrillation of 10 min duration was induced, followed by mechanical closed-chest cardiopulmonary resuscitation (CPR) in conjunction with i.v. administration of 0.4 U/kg of vasopressin. After CPR, external defibrillatory shocks were applied to achieve restoration of spontaneous circulation (ROSC). CBF and CMRO₂ were mapped and voxelwise maps of OEF were calculated at times of 60, 180, and 300 min after ROSC.

Results

There was hypoperfusion throughout the telencephalon at 60 min, with a return towards baseline values at 300 min. In contrast, there was progressively increasing CBF in cerebellum throughout the observation period. The magnitude of CMRO₂ decreased globally after ROSC, especially in cerebral cortex. The magnitude of OEF in cerebral cortex was 60% at baseline, tended to increase at 60 min after ROSC, and declined to 50% thereafter, thus suggesting transition to an ischemic state.

Conclusion

The cortical regions tended most vulnerable to the ischemic insult with an oligaemic pattern and a low CMRO₂ whereas the cerebellum instead showed a pattern of luxury perfusion.     

A Sudden Increase in Partial Pressure End-Tidal Carbon Dioxide (PETCO2) at the Moment of Return of Spontaneous Circulation

Background: Previous studies established that a level of partial pressure end-tidal carbon dioxide (P_ETCO₂) of 10 mm Hg divided patients undergoing advanced life support (ALS) into those likely to be resuscitated (values > 10 mm Hg) and those likely to die during ALS (values < 10 mm Hg). Objective: The study tested the significance of a sudden increase in the P_ETCO₂ in signaling the return of spontaneous circulation (ROSC) during ALS. Material and Methods: P_ETCO₂ values were continuously recorded during ALS in out-of-hospital patients with cardiac arrest. Constant ventilation was maintained by an automatic device. There were 108 patients, representing two extreme outcomes of ALS, who were subdivided into two groups. The first group included 59 patients with a single ROSC followed by a stable spontaneous circulation. The second group included 49 patients with no signs of ROSC. Results: ROSC was associated with a sudden increase in P_ETCO₂ that remained significantly higher than before ROSC. P_ETCO₂ did not rise during the entire ALS in the second group of patients without ROSC and was lower than in the first group of patients. Conclusions: In constantly ventilated patients, P_ETCO₂ is significantly higher (about 10 mm Hg) after ROSC than before ROSC. A sudden increase in P_ETCO₂ exceeding 10 mm Hg may indicate ROSC. Consequently, the rule of 10 mm Hg may be extended to include a sudden increase in continuously recorded P_ETCO₂ by more than 10 mm Hg as an indicator of the possibility of ROSC.     

Release of protein S100B in haemorrhagic shock: effects of small volume resuscitation combined with arginine vasopressin

BACKGROUND: The present study was designed to evaluate the effect of conventional fluid resuscitation and small volume resuscitation alone and combined with arginine vasopressin (AVP) on cerebral perfusion pressure (CPP) and protein S100B during experimental haemorrhagic shock. MATERIAL AND METHODS: Thirty anaesthetised pigs underwent a penetrating liver trauma. Following haemodynamic decompensation, pigs received either (1) a combination of crystalloid (40 mL kg(-1)) and colloid (20 mL kg(-1)) solutions (fluid, n=10), (2) hypertonic-hyperoncotic solution (HHS; 4 mL kg(-1)) combined with normal saline (HHS+NS; n=10) or (3) HHS combined with AVP (0.2 U kg(-1) followed by an infusion of 2 U kg(-1)h(-1); HHS+AVP; n=10). RESULTS: Compared to baseline, CPP decreased and S100B levels increased significantly at haemodynamic decompensation (S100B: fluid, 0.52+/-0.23 microg L(-1) vs. 0.85+/-0.37 microg L(-1), p<0.05; HHS+NS, 0.47+/-0.18 microg L(-1) vs. 0.90+/-0.33 microg L(-1), p<0.05; HHS+AVP, 0.53+/-0.18 microg L(-1) vs. 0.90+/-0.39 microg L(-1), p<0.01). During the initial 10 min of therapy, CPP of HHS+NS was significantly higher compared to the fluid group, increased more rapidly in the HHS+AVP group, but was not significantly different thereafter. S100B levels decreased close to baseline values (p<0.001), and did not differ between groups. CONCLUSION: HHS+AVP resulted in higher CPP compared to fluid and HHS+NS in the initial phase of therapy, but did not differ thereafter. Haemorrhage-induced hypotension yielded increased S100B levels that were comparable in groups throughout the study period.