应用“目标与目的”方案进行脓毒症患者的复苏：来自一个中国三级甲等医院ICU的回顾性研究

doi:10.24920/11816

摘要/Abstract

摘要：

目的探讨“目标与目的”方案进行脓毒症复苏的效果。方法回顾性研究北京协和医院以脓毒症收入且应用去甲肾上腺素维持血压的患者545例。记录患者的一般资料,入室时、入室6及24 h动脉血乳酸水平,平均动脉压（MAP）、中心静脉压（CVP）、中心静脉血氧饱和度（ScvO2）以及乳酸清除率、住院死亡率等。结果患者的6h乳酸清除率为21.6%（四分位距,8.6%-39.0%）,住院死亡率为9.4%。入室时低CVP（<8 mm Hg,1 mm Hg=0.133 kPa）患者,6h后CVP显著上升（5.4 ± 1.6 mm Hg 比7.7 ± 2.6 mm Hg,P<0.001）。入室时低MAP（< 75 mm Hg）患者,6h后MAP显著升高（64.2 ± 7.1 mm Hg比82.2 ± 13.1 mm Hg,P<0.001）。入室时低ScvO2 （< 70%）患者,6h后ScvO2显著升高（61.9% ± 7.0%比71.9% ± 7.8%,P<0.001）。各参数于6h和24h无明显变化。入室时高CVP （≥8 mm Hg）患者,6h后CVP 显著下降（11.3 ± 4.0 mm Hg比10.3 ± 2.9 mm Hg,P<0.001）。入室时高MAP（≥ 75 mm Hg）患者,6h后MAP显著下降（94.2 ± 13.9 mm Hg比89.4 ± 11.4 mm Hg,P<0.001）。入室时高ScvO2（≥ 70%）患者,6h后ScvO2显著下降（76.8% ± 4.2%比72.9% ± 7.3%,P<0.001）。各参数于6h和24h无明显变化。结论在对脓毒症患者进行复苏时,早期目标指导治疗提出的“目标正常值”并非适合于所有患者。“目标与目的”复苏方案能使治疗目标个体化,值得进一步研究。

关键词: 脓毒症, 感染性休克, 乳酸, 中心静脉压

Abstract:

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 (ScvO₂) 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 ScvO₂ value (<70%) at admission, the ScvO₂value 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 ScvO₂ value (≥70%) at admission, the ScvO₂ 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.

Key words: sepsis, septic shock, lactate, central venous pressure

Zhang Hongmin, Wang Xiaoting, Zhang Qing, Liu Dawei. Resuscitation of Septic Patients with Target-and-endpoint Protocol: A Retrospective Study from a Chinese Tertiary Hospital ICU[J].Chinese Medical Sciences Journal, 2018, 33(3): 135-142.

图/表 4

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Groups	n	SOFA (score)	APACHE Ⅱ(score)	0-hour lactate level (mmol/L)	In-hospital mortality (%)
Low-CVP group (CVP<8 mm Hg)	187	11	20	1.8	11.3
High-CVP group (CVP≥8 mm Hg)	358	12	23	1.9	9.5
P value		<0.001	<0.001	0.110	0.627
Low-MAP group (MAP<75 mm Hg)	148	11	24	1.7	8.8
High-MAP group (MAP≥75 mm Hg)	397	11	22	1.9	9.5
P value		0.455	0.019	0.111	0.807
Low-ScvO₂ group (ScvO₂<70%)	185	12	23	1.8	11.4
High-ScvO₂ group (ScvO₂≥70%)	360	11	22	1.9	8.3
P value		0.614	0.227	0.628	0.250

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