脓毒症休克目标治疗后左心室特征及其相关因素分析

目的探讨脓毒症休克目标治疗后左心室特征及其相关因素。方法 25例胆囊、小肠、结肠与直肠穿孔并发脓毒症休克患者,行早期目标性指导治疗(EGDT)与急诊手术后由急诊重症监护室(EICU)医生做液体管理,记录24小时内急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、72小时内超声心动图及部分治疗措施,根据28天生存状况分成存活组(9例)和死亡组(16例),并对所得数据进行统计学分析。结果死亡组初始APACHEⅡ、72小时内左心室舒张功能障碍发生率及分级高于存活组,左心室舒张末期内径(LVEDD)低于存活组,差异有统计学意义(P<0.05)。存活组LVEDD与日累积液体正平衡、心率呈负相关(r分别为-0.73、-0.81,均P<0.05);死亡组LVEDD与日累积液体平衡、心率均无显著性关联。组合功能障碍死亡患者日累积液体正平衡高于单纯舒张性心功能障碍死亡患者,差异有统计学意义(P<0.05),但近期肾损伤发生率低于单纯舒张性心功能障碍患者,差异有统计学意义(P<0.05)。结论脓毒症休克目标治疗后,普遍存在左心室舒张功能减低;左心室舒张末期内径不增大、左心舒张功能障碍与EGDT达标后预后不良关系密切。

The characteristics of left ventricle after goal-directed therapy for patients with septic shock and analysis of relative factors

Objective To investigate the clinical characteristics of left ventricle and its impact on septic shock patients after resuscitation. Methods Twenty-five consecutive patients with intestinal perforation were treated with damage control surgery after early goal-directed therapy （EGDT） in the emergency intensive care unit （EICU） of Sichuan Province People＇s Hospital from October 2009 to August 2011. After that, the patients were treated with fluid management. The scores of acute physiology and chronic health evaluation Ⅱ （ APACHE Ⅱ ） within 24 hours, eehoeardiography within 72 hours and therapeutic measures were recorded. The patients were divid- ed into survival （n = 9 ） and death （n = 16 ） groups according to clinic outcome after 28 days treatment, and the data collected were sta- tistically analyzed. Results There were significant differences in APACHE Ⅱ scores,left ventricular end-diastolic diameter （LVEDD） within 72 hours,and the ratio of diastolic dysfunction to its grade between survival group and death group （P〈 0.05 ）. In survival group, LVEDD was negatively correlated with fluid balance and heart rate （ r = -0.73 and -0.81, respectively ; P〈 0.05 ） while no cor- relation between LVEDD and fluid balance or heart rate in death group. The fluid balance was higher in patients with both systolic and diastolic dysfunctions than that in patients only with Left ventricular diastolic dysfunction （ P〈 0.05 ）. However, the rate of acute kidney injury was lower in patients with both？ systolic and diastolic dysfunctions than that in patients only with Left ventricular diastolic dys- function （P〈 0.05 ）. Conclusion Most septic patients show impairment in left ventrieular relaxation and LVEDD enlargement after early goal-directed therapy. Both characters were correlated with fluid balance.