ICU感染性休克患者不同平均动脉压维持水平与急性肾损伤的发生及预后的关系

目的 分析ICU感染性休克患者不同的平均动脉压维持水平与急性肾损伤的发生预后的关系.方法 回顾性分析2013年6月-2015年12月人住我院重症医学科有可信的平时血压记录的感染性休克患者79例,计算平时平均动脉压(MAPn).入住ICU后根据早期目标导向性治疗(earlygoal-directed therapy,EGDT)积极给予液体复苏并应用血管活性药物,按MAP实际维持水平(MAPk)将患者分为3组:A组(MAPk＜ 75％ MAPn)45例;B组(75％ MAPn≤MAPk＜ 90％ MAPn)23例;C组(90％MAPn≤MAPk＜MAPn)11例.应用PiCCO技术每6～8小时监测其心脏指数、系统性血管阻力指数及平均动脉压(MAP)、中心静脉压(CVP).比较3组患者房颤、室颤/心动过速、急性心肌梗死发生率,比较3组患者血乳酸浓度、乳酸清除率、尿量、血肌酐水平的差异,分析3组患者72 h内急性肾损伤(AKI)的发生率,并统计28 d病死率.结果 3组患者之间MAP、CI、SVRI无统计学差异.B组的CVP在6、24、48、72 h显著低于A组(P＜0.05).3组患者的氧输送和氧消耗无统计学差异,但是B组在12、24、48 h时的氧摄取率显著高于A组(P＜0.05).B、C组在6、12、24 h的血乳酸水平显著低于A组(P＜0.05),B、C组的6、12 h乳酸清除率显著高于A组(P＜0.05).B、C组在12、24、48 h的尿量显著高于A组(P＜0.05),血肌酐水平显著低于A组(P＜0.05).3组心血管不良事件无统计学差异.A、B、C3组72 h内分别发生AKI 27、6、5例,B组显著低于A组(P=0.011),其余各组间无统计学差异.A、B、C3组患者28 d存活率分别为63.95％、73.91％和63.64％.结论 对感染性休克患者平均动脉压维持在接近患者平时水平对预防急性肾损伤可能更为有利,且并未增加心血管不良事件的发生率.

Correlation of mean arterial pressure with incidence and prognosis of acute kidney injury in patients with septic shock in ICU

Objective To study the correlation between the mean arterial pressure (MAP) and incidence of acute kidney injury (AKI) as well as prognosis in the patients with septic shock in intensive care unit (ICU).Methods Retrospective clinical data review of 79 patients with septic shock (53 males and 26 females) at the age of 62.4 ± 10.1 years admitted to our ICU from June 2013 to December 2015 was performed.Normal MAP level of the patients (MAPn) was calculated by the normal blood pressure data.Following the early goal-directed therapy (EGDT) all patients were treated with adequate fluid resuscitation and given norepinephrine to maintain a MAP (MAPk).These patients were divided into 3 groups:group A (MAPk ＜75％ MAPn,n=45),group B (75％ MAPn≤MAPk ＜90％MAPn,n=23),and group C (90％MAPn ≤ MAPk ＜ MAPn,n =11).The cardiac index (CI),systemic vascular resistance index (SVRI),MAP,central venous pressure (CVP),oxygen metabolism [DO2,VO2 and oxygen extraction ratio (O2ER)],blood lactic acid,urinary output,and serum creatinine were compared among the groups before treatment and at 6,12,24,48 and 72 h after treatment.The lactic acid clearance (6 and 12 h),occurrence of serious cardiac events (arterial fibrillation,ventricular fibrillation/tachycardia and acute myocardial infarction),incidence of AKI,and 28-day survival rate were also observed.Results During the treatment,the MAP,CI and SVRI of 3 groups have no significant differences.After 6,24,48,72 hours' treatment,the CVP in group B were significantly lower than group A (P ＜ 0.05).There was no significant difference in DO2 or VO2 among the 3 groups.The O2 ER values at 12,24,48 h after treatment were higher in group B than group A (P ＜0.05).In comparison of groups B and C to group A,blood lactic acid after 6,12,24 hours' treatment and serum creatinine were significantly lower,whereas lactate clearance rate after 6 and 12 hours' treatment and urinary output after 12,24 and 48 hours' treatment were significantly higher (P ＜ 0.05).Additionally,the occurrence of serious cardiac events did not differ significantly among the groups.Within 72 h 27,6 and 5 cases of AKI were occurred in group A,B and C respectively.The incidence rate was lower in group B (6/23) than group A (27/45) though without statistical significance (P =0.011).The 28-day survival rates for group A,B and C were 63.95％,73.91％ and 63.64％ respectively,which were not significant different (P ＞ 0.05).Conclusion It is very likely that maintenance of MAP nearly to normal level is beneficial to prevent the occurrence of AKI and serious cardiac events in patients with septic shock in ICU.