院前脉搏压与移动重症监护单元救治的脓毒性休克患者的死亡率。

Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit.

机构信息

Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles De Gaulle, Boulogne-Billancourt, 92100, France.

Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France.

出版信息

BMC Emerg Med. 2023 Aug 25;23(1):97. doi: 10.1186/s12873-023-00864-0.

DOI:10.1186/s12873-023-00864-0

PMID:37626302

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10464421/

Abstract

BACKGROUND

Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU).

METHODS

From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality.

RESULTS

Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88].

CONCLUSION

The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.

摘要

背景

脓毒性休克的治疗依赖于一整套治疗方案，包括抗生素治疗和血流动力学优化。血流动力学优化包括液体扩张和去甲肾上腺素的应用，目的是优化心输出量，使平均动脉压达到 65mmHg。在院前环境中，由于缺乏有创和无创设备，直接心输出量评估较为困难。本研究旨在评估院前移动重症监护单元（MICU）治疗的脓毒性休克患者 30 天死亡率与（i）初始脉压（iPP）和（ii）院前阶段的脉压变异（dPP）之间的关系。

方法

从 2016 年 5 月 9 日至 2021 年 12 月 2 日，回顾性分析了需要 MICU 干预的脓毒性休克患者。iPP 计算为患者与 MICU 团队首次接触时的收缩压（SBP）与舒张压（DBP）之间的差异，在任何治疗之前，并且，dPP 计算为最终 PP（院前阶段结束时的 SBP 与 DBP 之间的差异）与 iPP 之间的差异除以院前持续时间。为了考虑混杂因素，使用倾向评分法评估（i）iPP<40mmHg、（ii）阳性 dPP 与 30 天死亡率之间的关系。

结果

在分析的 530 名患者中，怀疑患有肺部、消化系统和泌尿系统感染的患者分别占 43%、25%和 17%。30 天总体死亡率达到 31%。Cox 回归分析显示，30 天死亡率与（i）iPP<40mmHg 之间存在关联；aHR 为 1.61[1.03-2.51]，和（ii）阳性 dPP；aHR 为 0.56[0.36-0.88]。