感染性休克复苏期间的缺氧相关参数：病理生理决定因素及潜在临床意义
Hypoxia-related parameters during septic shock resuscitation: Pathophysiological determinants and potential clinical implications.
作者信息
Pavez Nicolás, Kattan Eduardo, Vera Magdalena, Ferri Giorgio, Valenzuela Emilio Daniel, Alegría Leyla, Bravo Sebastian, Pairumani Ronald, Santis César, Oviedo Vanessa, Soto Dagoberto, Ospina-Tascón Gustavo, Bakker Jan, Hernández Glenn, Castro Ricardo
机构信息
Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile.
Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
出版信息
Ann Transl Med. 2020 Jun;8(12):784. doi: 10.21037/atm-20-2048.
BACKGROUND
Assessment of tissue hypoxia at the bedside has yet to be translated into daily clinical practice in septic shock patients. Perfusion markers are surrogates of deeper physiological phenomena. Lactate-to-pyruvate ratio (LPR) and the ratio between veno-arterial PCO difference and Ca-vO (ΔPCO/Ca-vO) have been proposed as markers of tissue hypoxia, but they have not been compared in the clinical scenario. We studied acute septic shock patients under resuscitation. We wanted to evaluate the relationship of these hypoxia markers with clinical and biochemical markers of hypoperfusion during septic shock resuscitation.
METHODS
Secondary analysis of a randomized controlled trial. Septic shock patients were randomized to fluid resuscitation directed to normalization of capillary refill time (CRT) versus normalization or significant lowering of lactate. Multimodal assessment of perfusion was performed at 0, 2, 6 and 24 hours, and included macrohemodynamic and metabolic perfusion variables, CRT, regional flow and hypoxia markers. Patients who attained their pre-specified endpoint at 2-hours were compared to those who did not.
RESULTS
Forty-two patients were recruited, median APACHE-II score was 23 [15-31] and 28-day mortality 23%. LPR and ΔPCO/Ca-vO ratio did not correlate during early resuscitation (0-2 h) and the whole study period (24-hours). ΔPCO/Ca-vO ratio derangements were more prevalent than LPR ones, either in the whole cohort (52% 23%), and in association with other perfusion abnormalities. In patients who reached their resuscitation endpoints, the proportion of patients with altered ΔPCO/Ca-vO ratio decreased significantly (66% to 33%, P=0.045), while LPR did not (14% 25%, P=0.34).
CONCLUSIONS
Hypoxia markers did not exhibit correlation during resuscitation in septic shock patients. They probably interrogate different pathophysiological processes and mechanisms of dysoxia during early septic shock. Future studies should better elucidate the interaction and clinical role of hypoxia markers during septic shock resuscitation.
背景
在脓毒性休克患者中，床旁组织缺氧评估尚未转化为日常临床实践。灌注标志物是更深层次生理现象的替代指标。乳酸与丙酮酸比值（LPR）以及静脉 - 动脉二氧化碳分压差与动静脉血氧含量差的比值（ΔPCO₂/Ca-vO₂）已被提议作为组织缺氧的标志物，但它们在临床场景中尚未得到比较。我们研究了复苏中的急性脓毒性休克患者。我们想评估这些缺氧标志物与脓毒性休克复苏期间低灌注的临床和生化标志物之间的关系。
方法
一项随机对照试验的二次分析。脓毒性休克患者被随机分为两组，一组进行旨在使毛细血管再充盈时间（CRT）正常化的液体复苏，另一组进行旨在使乳酸正常化或显著降低乳酸的液体复苏。在0、2、6和24小时进行多模式灌注评估，包括宏观血流动力学和代谢灌注变量、CRT、区域血流和缺氧标志物。将在2小时达到预定终点的患者与未达到的患者进行比较。
结果
招募了42名患者，APACHE-II评分中位数为23[15 - 31]，28天死亡率为23%。在早期复苏（0 - 2小时）和整个研究期间（24小时），LPR与ΔPCO₂/Ca-vO₂比值不相关。无论是在整个队列中（52%对23%），还是与其他灌注异常相关时，ΔPCO₂/Ca-vO₂比值紊乱都比LPR更普遍。在达到复苏终点的患者中，ΔPCO₂/Ca-vO₂比值改变的患者比例显著下降（66%至33%，P = 0.045），而LPR没有（14%对25%，P = 0.34）。
结论
脓毒性休克患者复苏期间缺氧标志物未表现出相关性。它们可能探究了早期脓毒性休克期间不同的病理生理过程和缺氧机制。未来的研究应更好地阐明脓毒性休克复苏期间缺氧标志物的相互作用和临床作用。
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