主动脉流速时间积分变异度对重症脓毒症患者液体复苏的指导

目的 利用容量负荷试验引导主动脉流速时间积分变异度(△VTI)指导重症脓毒症患者的液体复苏,评价其在重症脓毒症患者液体复苏中的应用价值。方法 本试验为前瞻性、随机对照、干预性研究,纳入2015年3月至2016年1月收治于河北医科大学第四医院重症医学科(ICU)的重症脓毒症患者,按照随机对照原则将其分为超声指导组和常规治疗组。2组的复苏目标按照早期目标导向治疗(EGDT)(除外中心静脉压指标)。超声指导组在液体复苏前,行容量负荷试验(5 min之内输注300 ml复方氯化钠注射液),并利用超声检测△VTI;若△VTI≥15%,提示患者存在容量反应性,可继续给予复方氯化钠注射液500 ml,30 min左右输注体内,反复重复此过程,直到完成EGDT;若△VTI <15%,提示患者无容量反应性,不积极行液体复苏,由临床医师评价后自行决定后续治疗。常规治疗组由临床医师决定治疗。观察2组患者治疗前后各时间点重要生理及实验室指标、各时间段液体出入量及平衡、EGDT达标率、住院时间、住ICU时间、机械通气时间、血管活性药物应用量及使用时间、7 d病死率及28 d病死率。结果 本试验共纳入了70例重症脓毒症患者,按照随机对照原则分为超声指导组(37例)和常规治疗组(33例)2组,最终完成超声指导组和常规治疗组分别有34例、29例。0~6 h时间段内,超声指导组复苏液体入量及正平衡量明显高于常规治疗组;0~7 d时间段内,超声指导组液体平衡明显低于常规治疗组,差异均有统计学意义(P均<0.05)。而在0~12 h、0~24 h、0~72 h、0~5 d,2组的液体出入量及平衡量比较,差异均无统计学意义(P均>0.05)。2组患者EGDT达标率比较,超声指导组达标率高于常规治疗组,但差异无统计学意义(76.5%vs. 58.6%,P=0.129)。2组患者住院时间比较,差异无统计学意义(P> 0.05);超声指导组机械通气时间及住ICU时间较常规治疗组明显缩短,差异有统计学意义(P <0.05)。血管活性药物应用量显著少于常规治疗组,使用时间显著较常规治疗组缩短,差异有统计学意义(P <0.05)。2组患者7 d病死率及28 d病死率比较,差异均无统计学意义(P均> 0.05)。结论 利用容量负荷试验引导△VTI评价重症脓毒症患者的容量反应性,从而指导液体复苏,比常规治疗在液体管理方面更加精确,降低血管活性药物的用量、缩短使用时间及机械通气时间。

Implementation of fluid resuscitation according to aortic velocity time integral variability in severe septic patients

ObjectiveTo evaluate the role of aortic velocity time integral variability (△VTI) in severe septic patients for fluid resuscitation. MethodsThis is a prospective, randomized controlled, intreventional study. Severe septic patients in the intensive care unit of the Fourth Hospital of Hebei Medical University from March 2015 to January 2016 were enrolled and randomly divided into two groups according to the randomized controlled principles: ultrasound-guided group and routine care group. For the patients in the ultrasound-guided group, we used ultrasound to detect aortic velocity time integral variability after fluid challenge (within 5 minutes of the infusion of 300 ml compound sodium chloride) and then determined whether to start fluid resuscitation; if △VTI≥15%, it meant these patients had fluid responsiveness, then they would be intravenously infused with 500 ml compound sodium chloride injection within 30 minutes. This pattern of ultrasound-guided resuscitation would be repeated until the accomplishment of EGDT. If △VTI <15%, it meant patients hadn′t fluid responsiveness, they would not be given fluid resuscitation. For the patients in the routine care group, the clinicians determined their therapeutic regimen. The physiological and laboratory variables, amount of fluid resuscitation, achievement rate of EGDT, length of hospital stay, length of ICU stay, length of mechanical ventilation, length of vasopressor requirement, amount of vasopressor, 7-days mortality and 28-days mortality were collected. ResultWe enrolled 70 patients and randomly divided them into two groups according to the randomized controlled principles: ultrasound-guided group (n=37) and routine care group (n=33). We finally completed the ultrasound guide group (n=34) and routine care group (n=29). The amount of fluid intake and fluid positive balance within 0-6 h in the ultrasound guide group increased significantly compared with the routine care group (P<0.05). The amount of fluid balance within 0-7 days in the ultrasound guide group was significantly less than that of usual care group (P<0.05). There were no significant differences between the two groups in fluid intake, fluid discharge and fluid balance in 0-6 h, 0-12 h, 0-24, 0-72 h, 0-5 days. There were no significant differences between the two groups (P=0.129), but the ultrasound-guided group had higher achievement rate of EGDT(except CVP) than the usual care group (76.5 vs. 58.6%) .There were no significant differences between the two groups in length of hospital stay. Length of mechanical ventilation and ICU stay was significantly reduced in the ultrasound-guided group compared with the routine care group (P<0.05). The amount of vasopressor in the ultrasound-guided group was significantly less than that of routine care group, and the length of vasopressor requirement was significantly reduced in the ultrasound-guided group compared with the routine care group (P<0.05). There were no significant differences between the two groups in the 7-day mortality and the 28-day mortality. ConclusionThe aortic velocity time integral variability can be used to evaluate the volume responsiveness in severe sepsis patients and guide fluid resuscitation. It is more precise in terms of fluid management than the routine care, and it can reduce the amount of vasopressor, shorten length of vasopressor requirement and mechanical ventilation.