Objective To investigate the value of pulse indicator continuous cardiac output ( PiCCO) monitoring in the treatment of septic shock.Methods Patients with septic shock were selected in intensive care unit ( ICU) . After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index ( ITBVI) , cardiac index ( CI) , extravascular lung water index ( EVLWI) . Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after 0h ( before) , 8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHEⅡ score, central venous pressure ( CVP) , CI, ITBVI, mean arterial pressure ( MAP) , systemic vascular resistance index ( SVRI) and EVLWI after 0h and 24h were substituted into the regression equation by the multiple linear regression, to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP( 73.6 ±13.4 and 75.1 ±10.2 mm Hg) , ITBVI ( 843.5 ±168.9 and 891.5 ±232.9 mL/m2 ) and CI ( 3.2 ±1.1 and 3.9 ±0. 4 L· min-1 · m-2 ) on 8h and 24h were significantly higher than that at 0h ( 69.1 ±21.4 mm Hg, 781.2±146.7 mL/m2 and 2.7 ±1.5 L·min-1·m-2 ) , and Lac( 2.0 ±1.4 and 1.1 ±1.0 mmol /L) and SVRI ( 1 624. 2 ±301. 7 and 1 543.6 ±435.4 d·s·m2·cm-5 ) were declined than that at 0h( 3.1 ±2.4 mmol /L and 1 796.2 ±399.1 d·s·m2 ·cm-5 ) ( Plt;0.05) . The rate of implementing resuscitation goals at 8h ( 64.7% ) and 24h ( 66.9% ) were significantly higher than that at 0h ( 55.7% ) ( Plt;0.05) , but there was no significant difference between 8h and 24h ( Pgt;0.05) . All of the patients were divided into a survival group ( n=54) and a death group ( n=26) . The rate of implementing resuscitation goals at 0h and 24h in the survival group ( 57.1% and 71.3% ) were significantly higher than that of the death group( 28.6% and 39.3% ) . By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference ( F=55.03, Plt;0.05) . By the layer-wise screening, equation was fitted, both the CI ( R=0.431) and ITBVI ( R=0.627) at beginning and EVLWI ( R= 0.305) at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goaldirectors for the prognosis evaluation in critical ill patients.
目的通过漂浮导管（Swan-Ganz导管）监测外周血管阻力指数（SVRI）作为优化的心功能不全状态下感染性休克早期目标导向治疗（EGDT）的临床意义。 方法2012年1月至2014年1月第四军医大学附属西京医院心血管外科ICU收治体外循环心脏术后感染性休克患者8例，其中男7例、女1例，年龄（50.9±11.1）岁。以中心静脉压（CVP）为复苏目标行经验性容量复苏治疗，循环未见改善，则实施漂浮（Swan-Ganz）导管监测血流动力学指标，以外周血管阻力指数（SVRI）为优化目标复苏，观察Swan-Ganz导管复苏前及复苏6 h、24 h后的血流动力学及氧代谢指标，分析复苏达标所需时间。 结果8例患者平均住ICU时间（16.87±3.35）d，发生肺部并发症8例，急性肾功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好转存活，死亡2例。8例感染性休克患者经Swan-Ganz导管目标导向治疗6 h和24 h后平均动脉压（MAP）分别为（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心静脉压（CVP）分别为（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指数（CI）分别为（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指数（SVRI）分别为（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各项指标均较治疗前升高；治疗6 h和24 h后动脉血乳酸分别为（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，较治疗前[（14.98±0.45）mmol/L]下降。 结论采用Swan-Ganz导管监测SVRI作为优化目标导向治疗心功能不全状态下感染性休克可以提高6 h复苏成功率，改善患者预后。
Objective To investigate the value of extravascular lung water index ( EVLWI) and intrathoracic blood volume index ( ITBVI) monitoring in fluid management of severe pneumonia patients with sepsis shock.Methods A prospective controlled study was conducted in106 patients who were diagnosed as severe pneumonia with sepsis shock in intensive care unit fromJanuary 2010 to February 2013. 54 patients who received pulse indicator continuous output ( PiCCO) monitoring were enrolled into the EVLWI + ITBVI group, and EVLWI and ITBVI were used as indicator of fluid management. 52 patients who received central venous pressure ( CVP) as indicator of traditional fluid managementwere enrolled into the control group. The time and the rate to achieve early goal-directed therapy ( EGDT) target were compared between two groups. Acute physiology and chronic health evaluation Ⅱ ( APACHE Ⅱ ) , sepsis related organ failure assessment ( SOFA) , noradrenaline dosage, serumlactic acid, serum creatinine were compared between 1 day and 3 days after treatment. The characteristics of fluid management were recorded and compared within 72 hours. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-day mortality were compared between two groups. Results The ratio of achieving EGDT target in 6 hours was significantly higher in the EVLWI + ITBVI group than that in the control group ( 75.9% vs. 55.7% , Plt;0.05) , whereas the time and the ratio to achieve EGDT target in 24 hours were not statistically different. APACHE Ⅱ, SOFA, norepinephrine dosage, serum lactate were significantly decreased 3 days after treatment in the EVLWI + ITBVI group, but did not change significantly in the control group. On3 days after treatment, serumcreatinine was increased in the control group, and did not change significantly in the EVLWI + ITBVI group. The fluid intake and fluid balance volume during 0-6 hours period were significantly higher in the EVLWI + ITBVI group than those in the control group ( Plt;0.05) , but showed no difference ( Pgt;0.05) in other periods. Mechanical ventilation ratio, duration of mechanical ventilation, ICU stay and 28-days mortality were significantly lower in the EVLWI + ITBVI group compared with the control group ( Plt;0.05) . Conclusion Compared with CVP, ITBVI and EVLWI can more accurately assess and guide fluid management in severe pneumonia patients with septic shock with less duration of mechanical ventilation, ICU stay and mortality.
Objective To evaluate the effects of intensive care unit (ICU)-acquired hypernatremia (IAH) on the outcome of septic shock patients. Methods This retrospective study analyzed 116 septic shock patients admitted to the ICU of the First Affiliated Hospital of Soochow University from August 2018 to December 2022. Patients were divided into two groups: IAH group and normonatremia group. χ2 test, t test and the Mann-Whitney U test of the non-parametric test were used to compare the differences in clinical data between the two groups. Independent risk factors for IAH were identified by unconditioned Logistic regression analysis, and receiver operating characteristic (ROC) curves were constructed to determine their role in predicting IAH. The Kaplan-Meier curve was used to evaluate the effects of IAH and its duration on 28-day survival. Results Renal insufficiency, K+ concentration, body temperature max, mechanical ventilation, chronic critical illness, rapid recovery, sepsis-associated encephalopathy, persistent inflammation, immunosuppression and catabolism syndrome, and the length of stay in ICU had significant differences (P<0.05). Multivariate logistic regression analysis showed: total urine volume in the previous 3 days [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.01 - 1.16, P=0.019] and sodium content in enteral nutrition preparations (670 mg) (OR 6.00, 95%CI 1.61 - 22.42, P=0.006) were independent risk factors for IAH. In addition, the area under the ROC curve of total urine output in the first 3 days was 0.800 (95%CI 0.678 - 0.922, P=0.001). Finally, the duration of IAH was significantly correlated with 28-day survival rate (P=0.020). Conclusions IAH is a common and serious complication in septic shock, and is the main cause of poor prognosis. Sodium status may act as an ideal screening tool for patients with septic shock.
目的 探讨早期碱剩余对感染性休克患者病情严重程度的预测价值。 方法 对2009年2月－2011年2月资料完整入院的感染性休克患者60例进行回顾性分析，按死亡及存活进行分组，对最初24 h的碱剩余值差异及血乳酸清除率情况进行对照研究。 结果 死亡组碱剩余值变化及乳酸清除率低于存活组（P＜0.05）。治疗后碱剩余≤−6 mmol/L较碱剩余＞−6 mmol/L的患者病死率明显增加，尤其是治疗后24 h 碱剩余仍≤−6 mmol/L病死率高达92.23%。 结论 早期碱剩余有助于感染性休克预后评估和指导临床治疗。
【摘要】 目的 探讨微创经皮肾镜碎石术后并发感染性休克的原因和防治措施。 方法 回顾性分析2005年1月-2010年12月5例经皮肾镜术300例，其中术后并发感染性休克5例的临床资料。男1例，女4例，均表现为术后2~8 h内出现寒战、高热、烦燥不安，血压降至80/50 mm Hg（1 mm Hg=0.133 kPa）以下，心率超过120次/min。所有患者均行抗感染和抗休克治疗。 结果 所有患者均在72 h内停用升压药，1周内体温及血常规恢复正常，术后15 d治愈出院。 结论 感染性休克是微创经皮肾镜碎石术严重的并发症之一，术前有效抗感染、术中低压灌注、术后加强生命体征的监测、早期发现并合理处理，可有效防治感染性休克的发生。【Abstract】 Objective To explore the etiology and treatment of septic shock after percutaneous nephrolithotomy. Methods From Janurary 2005 to December 2010, the clinical data of five patients with septic shock after percutaneous nephrolithotomy in our hospital were retrospectively analyzed. The patients, including one male and four females, had chillness and high temperature after the nephrolithotomy. The blood pressure decreased to under 80/50 mm Hg （1 mm Hg=0.133 kPa）, and the heart rate was more than 120 per minute. All patients underwent anti-shock and anti-infection therapies rapidly. Results Five patients were cured in the end, their temperature and blood routine tests returned to normal within one week. Conclusions Septic shock is one of the serious complications after percutaneous nephrolithotomy. Effective preoperative preparation, low pressure irrigation during operation, early diagnosis and treatment postoperatively are the effective ways to prevent the septic shock.