[脓毒性休克患者早期目标导向治疗期间中心静脉-动脉血二氧化碳分压差的评估]

[Assessment of central venous-to-arterial CO(2) difference during early goal-directed therapy in patients with septic shock].

作者信息

Liu Ling, Zhao Hong-jie, Huang Ying-zi, Liu Song-qiao, Yang Cong-shan, Guo Feng-mei, Qiu Hai-bo, Yang Yi

机构信息

Department of Critical Medicine , Southeast University, Nanjing, China.

出版信息

Zhonghua Wai Ke Za Zhi. 2012 Oct;50(10):918-22.

PMID:23302464

Abstract

OBJECTIVE

To detect the changes of central venous-to-arterial carbon dioxide difference (P(cv-a)CO(2)) during early goal-directed therapy (EGDT) in patients with septic shock and evaluate its' value in predicting adequate resuscitation and prognosis.

METHODS

From April 2009 to October 2010, 26 septic shock patients were enrolled in the study. EGDT was performed in all the patients immediately after enrollment. According to the whether they achieved early goal with in the 6 hour or not, patients were separated to EGDT achievement and un-achievement groups. At the onset and after the 6 hours EGDT, mean arterial pressure (MAP), cardiac index (CI), central venous oxygen saturation (ScvO(2)), oxygen delivery (DO(2)), oxygen consumption (VO(2)), oxygen extraction ratio (O(2) ext), lactate, P(cv-a)CO(2) were recorded. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and 28 day mortality were compared between 2 groups.

RESULTS

There were no significant difference of age and sex between the 15 patients who achieved early goals and 11 patients who did not. EGDT un-achievement patients had higher APACHE II score (21 ± 5) and 28 day mortality (9/11) when compared with EGDT achievement patients (t = 2.985, χ(2) = 4.547, P < 0.05). In EGDT un-achievement group, MAP, CI, DO(2), VO(2), O(2)ext, ScvO(2), Lac, P(cv-a)CO(2) were comparable between the onset and 6 hours after EGDT. However, in EGDT achievement group, MAP ((90 ± 9) mmHg (1 mmHg = 0.133 kPa)), CI ((4.0 ± 1.8) L×min(-1)×m(-2)), DO(2) ((596 ± 274) ml×min(-1)×m(-2)), ScvO(2) (76.9% ± 4.1%) increased, and P(cv-a)CO(2) ((4.2 ± 2.7) mmHg) decreased significantly after 6 hours of EGDT (t values were -3.393, -2.985, -2.103 and -3.195 respectively, all P < 0.05). The changes of P(cv-a)CO(2) between the onset and 6 hours after EGDT, demonstrated high value for predictability of outcome, according to the area under the ROC curve (AUC) was 0.839 (P = 0.004). As a predictor for death, increasing of P(cv-a)CO(2) after 6 hours of EGDT has a sensibility of 100% and specificity of 60%.

CONCLUSIONS

Increasing of P(cv-a)CO(2) after EGDT purports inadequate tissue perfusion in patients with septic shock. Changes of P(cv-a)CO(2) during EGDT demonstrated a useful tool to evaluate adequate resuscitation and prognosis.

摘要

目的

检测感染性休克患者早期目标导向治疗（EGDT）期间中心静脉-动脉血二氧化碳分压差（P（cv-a）CO₂）的变化，并评估其在预测充分复苏及预后方面的价值。

方法

2009年4月至2010年10月，26例感染性休克患者纳入本研究。所有患者在入组后立即进行EGDT。根据患者在6小时内是否达到早期目标，将患者分为EGDT达标组和未达标组。在EGDT开始时及6小时后，记录平均动脉压（MAP）、心脏指数（CI）、中心静脉血氧饱和度（ScvO₂）、氧输送（DO₂）、氧消耗（VO₂）、氧摄取率（O₂ext）、乳酸、P（cv-a）CO₂。比较两组的急性生理与慢性健康状况评分系统II（APACHE II）评分及28天死亡率。

结果

15例达到早期目标的患者与11例未达到早期目标的患者在年龄和性别上无显著差异。与EGDT达标患者相比，EGDT未达标患者的APACHE II评分（21±5）及28天死亡率（9/11）更高（t = 2.985，χ² = 4.547，P < 0.05）。在EGDT未达标组，EGDT开始时及6小时后的MAP、CI、DO₂、VO₂、O₂ext、ScvO₂、Lac、P（cv-a）CO₂无明显变化。然而，在EGDT达标组，EGDT 6小时后MAP（（90±9）mmHg（1 mmHg = 0.133 kPa））、CI（（4.0±1.8）L·min⁻¹·m⁻²）、DO₂（（596±274）ml·min⁻¹·m⁻²）、ScvO₂（76.9%±4.1%）升高且P（cv-a）CO₂（（4.2±2.7）mmHg）显著降低（t值分别为-3.393、-2.985、-2.103和-3.195，均P < 0.05）。根据ROC曲线下面积（AUC）为0.839（P = 0.004），EGDT开始时及6小时后的P（cv-a）CO₂变化对结局具有较高的预测价值。作为死亡预测指标，EGDT 6小时后P（cv-a）CO₂升高的敏感度为100%，特异度为60%。