Zhang Hong-Min, Wang Xiao-Ting, Zhang Qing, Liu Da-Wei
Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
Chin Med Sci J. 2018 Sep 20;33(3):135-142. doi: 10.24920/11816.
Objective To investigate the effect of target-and-endpoint protocol on the resuscitation of septic patients.Methods This is a retrospective study performed at the Peking Union Medical College Hospital Intensive Care Unit. We enrolled 545 septic patients who needed vasopressors on at least the first day of ICU admission. The general characteristics, blood lactate level, mean arterial pressure (MAP), central venous pressure (CVP) and saturation of central venous oxygen (ScvO) at admission and 6, 24 hours after admission were collected. The parameters at different time points were compared. Lactate clearance rate and in-hospital mortality were analyzed.Results The 6-hour lactate clearance rate was 21.6% (IQR, 8.6%-39.0%), and in-hospital mortality was 9.4%. For patients with low CVP values (<8 mm Hg, 1 mm Hg=0.133 kPa) at admission, CVP increased significantly at 6 hours after admission (5.4±1.6 mm Hg vs. 7.7±2.6 mm Hg, P<0.001). For patients with low MAP (<75 mm Hg) at admission, the MAP values increased significantly at 6 hours (64.2±7.1 mm Hg vs. 82.2±13.1 mm Hg, P<0.001). For patients with low ScvO value (<70%) at admission, the ScvO value increased significantly at 6 hours (61.9%±7.0% vs. 71.9%±7.8%, P<0.001). No difference was found between the values at 6 hours and the corresponding values at 24 hours after admission. For patients with high CVP values (≥8 mm Hg) at admission, CVP decreased significantly at 6 hours (11.3±4.0 mm Hg vs. 10.3±2.9 mm Hg, P<0.001). For patients with high MAP (≥75 mm Hg) at admission, the MAP values decreased significantly at 6 hours (94.2±13.9 mm Hg vs. 89.4±11.4 mm Hg, P<0.001). For patients with high ScvO value (≥70%) at admission, the ScvO values decreased significantly at 6 hours (76.8%±4.2% vs. 72.9%±7.3%, P<0.001). No difference was found between the values at 6 hours and the corresponding values at 24 hours.Conclusions This study suggested that in the resuscitation of sepsis and septic shock patients in the ICU, the target values did not need to be within the "normal range" recommended by early-goal directed therapy. The "target-and-endpoint" protocol, which aimed for personalized goals, deserves more consideration.
目的 探讨目标导向与终点导向方案对脓毒症患者复苏的影响。方法 这是一项在北京协和医院重症监护病房进行的回顾性研究。我们纳入了545例在入住重症监护病房（ICU）首日至少需要使用血管升压药的脓毒症患者。收集患者的一般特征、入院时以及入院后6小时、24小时的血乳酸水平、平均动脉压（MAP）、中心静脉压（CVP）和中心静脉血氧饱和度（ScvO₂）。比较不同时间点的参数。分析乳酸清除率和院内死亡率。结果 6小时乳酸清除率为21.6%（四分位数间距，8.6% - 39.0%），院内死亡率为9.4%。入院时中心静脉压值低（<8 mmHg，1 mmHg = 0.133 kPa）的患者，入院后6小时中心静脉压显著升高（5.4±1.6 mmHg比7.7±2.6 mmHg，P<0.001）。入院时平均动脉压低（<75 mmHg）的患者，6小时时平均动脉压值显著升高（64.2±7.1 mmHg比82.2±13.1 mmHg，P<0.001）。入院时中心静脉血氧饱和度值低（<70%）的患者，6小时时中心静脉血氧饱和度值显著升高（61.9%±7.0%比71.9%±7.8%，P<0.001）。入院后6小时的值与入院后24小时的相应值之间未发现差异。入院时中心静脉压值高（≥8 mmHg）的患者，6小时时中心静脉压显著降低（11.3±4.0 mmHg比10.3±2.9 mmHg，P<0.001）。入院时平均动脉压高（≥75 mmHg）的患者，6小时时平均动脉压值显著降低（94.2±13.9 mmHg比89.4±11.4 mmHg，P<0.001）。入院时中心静脉血氧饱和度值高（≥70%）的患者，6小时时中心静脉血氧饱和度值显著降低（76.8%±4.2%比72.9%±7.3%，P<0.001）。6小时的值与24小时的相应值之间未发现差异。结论 本研究表明，在ICU中对脓毒症和脓毒症休克患者进行复苏时，目标值无需处于早期目标导向治疗推荐的“正常范围”内。旨在实现个性化目标的“目标导向与终点导向”方案值得更多考虑。
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