Zhou X Y, Li L, Gong S J, Yu Y H, Dai H W, Yan J
Intensive Care Unit, Zhejiang Hospital, Hangzhou 310013, China.
Zhonghua Nei Ke Za Zhi. 2016 Jun;55(6):435-9. doi: 10.3760/cma.j.issn.0578-1426.2016.06.007.
To investigate the influence of left ventricular-arterial coupling(VAC) on clinical prognosis of elderly patients with septic shock.
A total of 56 elderly septic shock patients were enrolled in this study, all of whom were admitted to Department of Intensive Care Unit in Zhejiang Hospital from August 2014 to October 2015.The patients were divided into two groups according to the status of left ventricular-arterial coupling when septic shock was diagnosed, which were left ventricular-arterial uncoupling group(UC group) and left ventricular-arterial coupling group(C group). Various parameters were recorded, including blood lactate level, central venous oxygen saturation(ScvO2), serum level of N-terminal pro-brain natriuretic peptide(NT-proBNP) and cardiac troponin Ⅰ(cTNⅠ), dose of vasoactive drugs, the total fluid volume and urine volume per hour within 24 hours. The 28-day survival rate was a key index of prognosis. Multivariate logistic regression was taken to analyze risk factors related to death within 28 day.
Compared with C group, UC group had lower values of left ventricular ejection fraction[(42.43±4.76)% vs (53.17±3.01)%; P<0.01] and cardiac index[(2.36±0.68) L·min(-1)·m(-2) vs (2.93±0.45)L·min(-1)·m(-2); P<0.01]. Yet serum levels of NT-proBNP[lg NT-proBNP 3.93±0.53 vs 3.40±0.63; P=0.004] and cTNⅠ [lg cTNⅠ-0.16±0.68 vs-1.03±0.69; P<0.001] in UC group were higher than those in C group. Moreover, the total fluid volume within 24 hours [(3 806.3±831.4) ml vs (3 142.0±770.0) ml; P=0.016], blood lactate level[(5.61±2.68) mmol/L vs (3.93±1.59) mmol/L; P=0.043] and dose of norepinephrine[(0.630±0.300)μg·kg(-1)·min(-1) vs (0.292±0.234)μg·kg(-1)·min(-1;) P=0.001] in UC group were greater than those in C group, while ScvO2[(60.75±2.91)% vs (64.42±2.19)%; P<0.001] and urine volume per hour[(0.518±0.358)ml vs (0.926±0.678)ml; P=0.007] were less than those in C group. Compared with C group, UC group had a lower 28-day survival rate[43.2%(19/44) vs 9/12; P=0.049]. Ea/Ees ratio was negatively correlated with LVEF, ScvO2(r=-0.686, P<0.001; r=-0.411, P=0.002), positively correlated with NT-proBNP, cTNⅠ(r=0.294, P=0.028; r=0.363, P=0.006), yet no obvious correlation was noticed with blood lactate level(r=0.170, P=0.21). Multiple logistic regression analysis showed that VAC(OR=11.187, 95%CI 2.489-50.285; P=0.002), lactate level (OR=1.727, 95%CI 1.164-2.563; P=0.007) and lg cTNⅠ(OR=0.247, 95%CI 0.079-0.779; P=0.017) were independent risk factors affecting 28-day mortality. Conclutions: In elderly patients with septic shock, left ventricular-arterial uncoupling indicates a lower 28-day survival rate, worse cardiac function and tissue perfusion. Ea/Ees ratio might sever as a predictive indicator of 28-day mortality.
探讨左心室 - 动脉耦联（VAC）对老年感染性休克患者临床预后的影响。
本研究共纳入56例老年感染性休克患者，均为2014年8月至2015年10月入住浙江医院重症监护病房的患者。根据诊断感染性休克时左心室 - 动脉耦联状态将患者分为两组，即左心室 - 动脉失耦联组（UC组）和左心室 - 动脉耦联组（C组）。记录各项参数，包括血乳酸水平、中心静脉血氧饱和度（ScvO2）血清N末端脑钠肽前体（NT - proBNP）和心肌肌钙蛋白Ⅰ（cTNⅠ）水平、血管活性药物剂量、24小时内总液体量及每小时尿量。28天生存率是预后的关键指标。采用多因素logistic回归分析28天内死亡的相关危险因素。
与C组相比，UC组左心室射血分数较低[（42.43±4.76）%对（53.17±3.01）%；P<0.01]，心脏指数较低[（2.36±0.68）L·min⁻¹·m⁻²对（2.93±0.45）L·min⁻¹·m⁻²；P<0.01]。然而，UC组血清NT - proBNP水平[lg NT - proBNP 3.93±0.53对3.40±0.63；P = 0.004]和cTNⅠ水平[lg cTNⅠ - 0.16±0.68对 - 1.03±0.69；P<0.001]高于C组。此外，UC组24小时内总液体量[（3806.3±831.4）ml对（3142.0±770.0）ml；P = 0.016]、血乳酸水平[（5.61±2.68）mmol/L对（3.93±1.59）mmol/L；P = 0.043]和去甲肾上腺素剂量[（0.630±0.300）μg·kg⁻¹·min⁻¹对（0.292±0.234）μg·kg⁻¹·min⁻¹；P = 0.001]大于C组，而ScvO2[（60.75±2.91）%对（64.42±2.xx）%；P<0.001]和每小时尿量[（0.518±0.358）ml对（0.926±0.678）ml；P = 0.007]小于C组。与C组相比，UC组28天生存率较低[43.2%（19/44）对9/12；P = 0.049]。Ea/Ees比值与LVEF、ScvO2呈负相关（r = - 0.686，P<0.001；r = - 0.411，P = 0.002），与NT - proBNP、cTNⅠ呈正相关（r = 0.294，P = 0.028；r = 0.363，P = 0.006），但与血乳酸水平无明显相关性（r = 0.170，P = 0.21）。多因素logistic回归分析显示，VAC（OR = 11.187，95%CI 2.489 - 50.285；P = 0.002）、乳酸水平（OR = 1.727，95%CI 1.164 - 2.563；P = 0.007）和lg cTNⅠ（OR = 0.247，95%CI 0.079 - 0.779；P = 0.017）是影响28天死亡率的独立危险因素。
在老年感染性休克患者中，左心室 - 动脉失耦联提示28天生存率较低、心功能及组织灌注较差。Ea/Ees比值可能作为28天死亡率的预测指标。
