本文選題：休克 + 血管活性藥�。� 參考：《武漢大學(xué)》2015年博士論文

【摘要】：背景重癥醫(yī)學(xué)中,休克極為常見(jiàn),ICU中的1/3病人存在休克。血管活性藥物是休克治療中的重要循環(huán)支持手段。休克時(shí)血管活性藥物的選擇和應(yīng)用一直以來(lái)都是討論的熱點(diǎn)。國(guó)外已有的血管活性藥臨床觀察性研究結(jié)果顯示,不同的ICU醫(yī)生血管活性藥物的應(yīng)用存在較大的差異,甚至在歐洲和北美發(fā)達(dá)國(guó)家的ICU醫(yī)生之間,這樣的差異也較明顯。這種差異存在的原因之一是在休克治療中,很難確切地認(rèn)為某一種血管活性藥物在維持血流動(dòng)力學(xué)穩(wěn)定和生存率方面優(yōu)于另一種血管活性藥物,其應(yīng)用策略也沒(méi)有統(tǒng)一的方案。休克治療指南(綜合了目前最新的研究證據(jù))可以一定程度上協(xié)助ICU醫(yī)生做出決策,目前的休克指南發(fā)展最完善的是感染性休克指南。然而,一個(gè)前瞻性的隊(duì)列研究結(jié)果顯示,ICU醫(yī)生對(duì)感染性休克指南依從性并不高,包括血管活性藥物的應(yīng)用；另外,不同國(guó)家和地區(qū)的ICU的依從性存在較大的差異。而這種不同ICU醫(yī)生血管活性藥物應(yīng)用的差異會(huì)對(duì)病人造成傷害。我國(guó)各地ICU醫(yī)生血管活性藥物應(yīng)用現(xiàn)狀及是否存在較大的差異還未知,目前國(guó)內(nèi)還沒(méi)有這方面的臨床研究報(bào)道。目的本研究主要目的是調(diào)查我國(guó)ICU醫(yī)生血管活性藥物應(yīng)用的現(xiàn)狀,探討不同ICU醫(yī)生血管活性藥物應(yīng)用的差異,分析可能的原因以及規(guī)范合理使用血管活性藥物的對(duì)策。方法采用問(wèn)卷調(diào)查的方法,用立意抽樣(purposed sampling)選取樣本。(1)調(diào)查對(duì)象： 研究者從中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì)委員中選取來(lái)自全國(guó)不同地區(qū)的負(fù)責(zé)人。由各地區(qū)負(fù)責(zé)人確定他們所在地區(qū)接受問(wèn)卷調(diào)查的ICU醫(yī)生。原則是選取的樣本盡量具有代表性,需要考慮到醫(yī)院等級(jí)、是否是教學(xué)醫(yī)院、ICU類型、ICU醫(yī)生職稱。本抽樣樣本代表性在一定程度上依賴各地區(qū)負(fù)責(zé)人可聯(lián)系到的ICU醫(yī)生及問(wèn)卷回復(fù)情況。(2)調(diào)查工具： 自行編制"ICU血管活性藥物的應(yīng)用情況調(diào)查問(wèn)卷”,該調(diào)查問(wèn)卷是在參考國(guó)內(nèi)外文獻(xiàn)、訪談ICU醫(yī)生及反復(fù)修訂后確定。在正式調(diào)查前進(jìn)行了一次預(yù)調(diào)查,并根據(jù)預(yù)調(diào)查的結(jié)果對(duì)問(wèn)卷進(jìn)行了進(jìn)一步修訂。正式調(diào)查問(wèn)卷包括血管活性藥物應(yīng)用概況、休克治療中血管活性藥的選擇、血管活性藥應(yīng)用的管理(包括應(yīng)用縮血管藥的MAP目標(biāo)值、正性肌力藥的應(yīng)用指征和療效判斷依據(jù)和低劑量多巴胺的應(yīng)用)及血管活性藥物應(yīng)用過(guò)程中的監(jiān)測(cè)策略4個(gè)方面共26問(wèn)題。(3)調(diào)查方法： 正式調(diào)查問(wèn)卷通過(guò)電子郵件的方式發(fā)送和回收,先由研究者將問(wèn)卷發(fā)送給各地區(qū)負(fù)責(zé)人,各地區(qū)負(fù)責(zé)人再發(fā)送給其選取的ICU醫(yī)生,各地區(qū)負(fù)責(zé)人收集好問(wèn)卷后再發(fā)送給研究者。為了提高回收率,其間有兩次向各地區(qū)負(fù)責(zé)人電子郵件提醒。本問(wèn)卷調(diào)查自2012年5月開(kāi)始發(fā)放,2012年9月結(jié)束回收。結(jié)果(1)一般資料本調(diào)查發(fā)放問(wèn)卷900份,回收有效問(wèn)卷586份,有效回收率65.1%�；貜�(fù)者主要來(lái)自三級(jí)醫(yī)院,占77.8%；教學(xué)醫(yī)院的回復(fù)者395人,占67.4%,非教學(xué)醫(yī)院的回復(fù)者191人,占32.6%；回復(fù)問(wèn)卷的醫(yī)生中,初中級(jí)職稱者338名,占57.7%,高級(jí)職稱者有248人,占42.3%。地區(qū)分布為我國(guó)31省市中的29個(gè)省市,沒(méi)有收到來(lái)自西藏和甘肅省的問(wèn)卷。(2)血管活性藥的選擇對(duì)于感染性休克,70.8%(415/586)的回復(fù)者首選縮血管藥是去甲腎上腺素,其次是多巴胺(27.6%,162/586)。然而,對(duì)于低血容量性休克和心源性休克,分別有73.4%(430/586)和68.3%(400/586)的回復(fù)者首選的縮血管藥是多巴胺,其次是去甲腎上腺素(低血容量性休克22.7%,33/586;心源性休克18.9%,111/586)。對(duì)不同ICU醫(yī)生首選縮血管藥物進(jìn)行比較,結(jié)果發(fā)現(xiàn)三種類型休克中教學(xué)醫(yī)院回復(fù)者首選去甲腎上腺素的比例均比非教學(xué)醫(yī)院回復(fù)者的比例高,而非教學(xué)醫(yī)院回復(fù)者首選多巴胺的比例均比教學(xué)醫(yī)院回復(fù)者的比例高,差異有統(tǒng)計(jì)學(xué)意義。而不同職稱回復(fù)者首選縮血管藥物無(wú)統(tǒng)計(jì)學(xué)差異。由于低血容量性休克使用正性肌力藥物的幾率較小,586位回復(fù)者中只有321位會(huì)考慮低血容量性休克中使用正性肌力藥。對(duì)于感染性休克,84.1%(493/586)的回復(fù)者首選正性肌力藥是多巴酚丁胺,其次是洋地黃類藥物(11.9%,70/586)。對(duì)于低血容量性休克和心源性休克,分別有64.5%(207/321)和60.6%(355/586)的回復(fù)者首選多巴酚丁胺,其次是洋地黃類藥物(低血容量性休克27.7%,89/321；心源性休克29.7%,174/586)。對(duì)不同ICU醫(yī)生首選正性肌力藥物進(jìn)行比較,結(jié)果發(fā)現(xiàn)三種類型休克中教學(xué)醫(yī)院回復(fù)者首選多巴酚丁胺的比例均較非教學(xué)醫(yī)院回復(fù)者的比例高,而非教學(xué)醫(yī)院回復(fù)者選擇洋地黃類約物的比例均較教學(xué)醫(yī)院回復(fù)者的比例高,差異具有統(tǒng)計(jì)學(xué)意義。而不同職稱回復(fù)者首選縮血管藥物無(wú)統(tǒng)計(jì)學(xué)差異。當(dāng)問(wèn)及休克病人是否會(huì)使用擴(kuò)血管藥,回復(fù)使用頻率為“不用”的回復(fù)者占13.1%(77/586),“偶爾用”占74.6%(437/586),“常用”占12.3%(72/586),沒(méi)有回復(fù)者報(bào)告“全部用”。根據(jù)休克類型的不同可能用到擴(kuò)血管藥的頻率依次為心源性休克67.1%(393/586)、感染性休克32.3%(189/586)、低血容量性休克6.5%p8/586)。最常用到的擴(kuò)血管藥排在前三位依次是硝酸甘油(71.2%,417/586)、硝普鈉(45.6%267/586)、酚妥拉明(32.9%,193/586)。非教學(xué)醫(yī)院回復(fù)者管理休克時(shí),有更高比例醫(yī)生傾向應(yīng)用擴(kuò)血管藥,中初級(jí)職稱回復(fù)者管理休克時(shí),有更高比例醫(yī)生傾向應(yīng)用擴(kuò)血管藥,差異具有統(tǒng)計(jì)學(xué)意義。(3)應(yīng)用縮血管藥的MAP目標(biāo)值接近半數(shù)回復(fù)者認(rèn)為不同類型休克應(yīng)用縮血管藥的MAP目標(biāo)值均相同,這種觀點(diǎn)在非教學(xué)醫(yī)院回復(fù)者中的比例更高。對(duì)于感染性休克,應(yīng)用縮血管藥的MAP目標(biāo)值為64.3±7.5mmHg；教學(xué)醫(yī)院回復(fù)者應(yīng)用縮血管藥的MAP目標(biāo)值較非教學(xué)醫(yī)院回復(fù)者高,差異具有統(tǒng)計(jì)學(xué)差異。而不同職稱回復(fù)者應(yīng)用縮血管藥的MAP目標(biāo)值比較無(wú)統(tǒng)計(jì)學(xué)差異。(4)正性肌力藥的應(yīng)用指征和療效判斷指標(biāo)正性肌力藥物的應(yīng)用指征排在前四位的依次是低血壓(80.2%,470/586)、低心輸出量(66.4%,389/586)、末稍低灌注(37.0%,217/586)和少尿(30.9%,181/586)。正性肌力藥物的療效判斷指標(biāo)排在前4位的依次是血壓(86.7%,508/586)、尿量(58.9%,345/586)、心輸出量(50.2%,294/586)和血乳酸濃度(40.8%,239/586)。教學(xué)醫(yī)院回復(fù)者更傾向選擇心輸出量作為正性肌力藥的應(yīng)用指征。而非教學(xué)醫(yī)院回復(fù)者更傾向選擇少尿?yàn)檎约×λ幍膽?yīng)用指征。對(duì)于正性肌力藥應(yīng)用的療效判斷指標(biāo),僅尿量的選擇在教學(xué)醫(yī)院和非教學(xué)醫(yī)院回復(fù)者之間存在統(tǒng)計(jì)學(xué)差異。高級(jí)職稱和初中級(jí)職稱回復(fù)者在正性肌力藥的應(yīng)用指征和療效判斷指標(biāo)的選擇,差異均無(wú)統(tǒng)計(jì)學(xué)差異。(5)低劑量多馬胺的應(yīng)用為了改善腎臟灌注保護(hù)腎功能,有28.3%的回復(fù)者(166/586)選擇應(yīng)用低劑量多巴胺。與教學(xué)醫(yī)院回復(fù)者(24.8%)相比較,非教學(xué)醫(yī)院回復(fù)者(35.6%)更傾向使用低價(jià)量多巴胺改善腎臟灌注,差異具有統(tǒng)計(jì)學(xué)意義。與高級(jí)職稱回復(fù)者(25.8%)比較,初中級(jí)職稱回復(fù)者(30.2%)更傾向使用低劑量多巴胺改善腎臟灌注,但差異不具有統(tǒng)計(jì)學(xué)差異。(6)血管活性藥使用過(guò)程中的監(jiān)測(cè)全部回復(fù)者報(bào)告常規(guī)監(jiān)測(cè)的項(xiàng)目有心率、袖帶血壓、脈搏血氧飽和度。其它常規(guī)監(jiān)測(cè)的項(xiàng)目依次為血?dú)?98.5%,577/586)、血乳酸測(cè)定(84.6%,496/586)、中心靜脈壓(87.9%,515/586),而有創(chuàng)動(dòng)脈血壓常規(guī)監(jiān)測(cè)的僅為44.2%(259/586)。教學(xué)醫(yī)院回復(fù)者常規(guī)監(jiān)測(cè)血乳酸和常規(guī)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)的比例較非教學(xué)醫(yī)院回復(fù)者高,差異具有統(tǒng)計(jì)學(xué)意義。對(duì)不同職稱回復(fù)者常規(guī)監(jiān)測(cè)方法的選用均不具有統(tǒng)計(jì)學(xué)意義。血管活性藥物使用過(guò)程中,特殊監(jiān)測(cè)及其應(yīng)用頻率情況如表28所示�；貜�(fù)特殊監(jiān)測(cè)方法使用頻率為“常用”的依次為脈搏指示連續(xù)心排血量(21.8%,128/586)、肺動(dòng)脈導(dǎo)管(3.6%,21/586)、經(jīng)胸廓超聲心動(dòng)圖(1.0%,6/586)和經(jīng)食道超聲心動(dòng)圖(0.3%,2/586)。微循環(huán)監(jiān)測(cè)使用情況極少,分別僅有3個(gè)回復(fù)者常用胃黏膜CO2張力監(jiān)測(cè)和舌下微循環(huán)監(jiān)測(cè)。各監(jiān)測(cè)方法“偶爾”用到的比例也并不高。教學(xué)醫(yī)院回復(fù)者在選擇脈搏指示連續(xù)心排血量監(jiān)測(cè)、肺動(dòng)脈導(dǎo)管監(jiān)測(cè)和經(jīng)胸廓超聲心動(dòng)圖監(jiān)測(cè)方面比例較高,有統(tǒng)計(jì)學(xué)差異。不同職稱回復(fù)者特殊監(jiān)測(cè)方法選用方面差異均不具有統(tǒng)計(jì)學(xué)意義。結(jié)論中國(guó)ICU醫(yī)生在血管活性藥物的選擇、縮血管藥物的血壓目標(biāo)值、正性肌力藥應(yīng)用指征和療效判斷指標(biāo)、低劑量多巴胺應(yīng)用和監(jiān)測(cè)策略各方面均存在較大的差異。(1)部分ICU醫(yī)生對(duì)血管活性藥物的應(yīng)用沒(méi)有很好地遵循最新的研究證據(jù)和新近指南的推薦意見(jiàn),仍延續(xù)以往的經(jīng)驗(yàn)。(2)ICU醫(yī)生在感染性休克血管活性藥物的應(yīng)用中能較好地遵從最新的循證證據(jù),而在低血容量性休克和心源性休克中較差。(3)與非教學(xué)醫(yī)院ICU醫(yī)生相比,教學(xué)醫(yī)院的ICU醫(yī)生在血管活性藥物的應(yīng)用方面相對(duì)較規(guī)范。本研究結(jié)果提示,感染性休克管理指南的推廣和學(xué)術(shù)交流對(duì)臨床具有很大的指導(dǎo)性意義,系統(tǒng)的培訓(xùn)教育能夠顯著改進(jìn)臨床醫(yī)生的行為。為了規(guī)范ICU血管活性藥物的應(yīng)用,應(yīng)該加強(qiáng)血管活性藥物應(yīng)用及休克管理的規(guī)范化培訓(xùn),不斷進(jìn)行知識(shí)更新,從而提高臨床救治休克病人的水平。
[Abstract]:In the background of intensive medicine , shock is very common in ICU , and 1 / 3 of patients in ICU have shock . Vascular active drugs are important circulatory support methods in shock therapy . One of the reasons for this difference is that in shock therapy , it is difficult to accurately think that one of the vascular active drugs is superior to the other vascular active agents in the maintenance of haemodynamic stability and survival rate . The present shock guide has developed the most perfect guide for septic shock . However , a prospective cohort study suggests that the ICU doctors are not highly dependent on the guidelines on septic shock , including the use of vascular active agents ;
In order to improve the recovery rate , the questionnaire was sent to the person in charge of ICU .
In the teaching hospital , 395 persons , accounting for 67.4 % , were 191 in non - teaching hospitals , accounting for 36.6 % ;
Among the doctors who responded to the questionnaire , 338 ( 57.7 % ) were junior middle - grade titles , 248 were senior titles , accounting for 42.3 % . ( 2 ) There were 29 provinces and cities in 31 provinces and cities of China . No questionnaires from Tibet and Gansu were received . ( 2 ) Selection of blood vessel active agents was for septic shock , 70.8 % ( 415 / 586 ) of the respondents preferred vasomotor to norepinephrine , followed by dopamine ( 27 . 6 % , 162 / 586 ) . However , for low blood volume shock and cardiac shock , 73.4 % ( 430 / 586 ) and 68.3 % ( 400 / 586 ) of the respondents preferred the preferred vasomotor as dopamine , followed by norepinephrine ( low blood volume shock 22 . 7 % , 33 / 586 ; cardiac shock 18.9 % , 111 / 586 ) . Compared with non - teaching hospital , the rate of choice of norepinephrine is higher than that of non - teaching hospital , and the proportion of patients with non - teaching hospital is higher than that of non - teaching hospital , and the difference is statistically significant . For hypovolaemia shock and cardiac shock , there were 64.5 % ( 207 / 321 ) and 60.6 % ( 355 / 586 ) of the patients who had the choice of dopa , followed by digitalis ( 27 . 7 % , 89 / 321 ) .
Cardiogenic shock ( 29 . 7 % , 174 / 586 ) . The results showed that the rate of choice of polyphentermine in patients with shock was higher than that of non - teaching hospital , and that of non - teaching hospital respondents were higher than those of non - teaching hospitals , and the difference was statistically significant . The frequency of the patients with shock type was 67.6 % ( 77 / 586 ) , " common " was 12.3 % ( 72 / 586 ) , and the incidence of septic shock was 67.1 % ( 393 / 586 ) , septic shock was 36.3 % ( 189 / 586 ) , hypocalcemia shock was 6.5 % p8 / 586 . The most commonly used vasodilators were nitrate ( 71.2 % , 417 / 586 ) , sodium nitrate ( 45.6 % 267 / 586 ) , phentolamine ( 32.9 % , 193 / 586 ) in the first three orders . ( 3 ) The MAP target value of vasomotor was 64.3 鹵 7.5 mmHg for septic shock .
There was no statistical difference between the MAP target value and the MAP target value of non - teaching hospital in the patients who responded to teaching hospital . ( 4 ) The application of positive muscle medicine indicated that the first four digits were hypotension ( 80.2 % , 470 / 586 ) , low cardiac output ( 66.4 % , 389 / 586 ) , low cardiac output ( 37.0 % , 217 / 586 ) and oliguria ( 30.9 % , 181 / 586 ) . The efficacy of positive muscle drugs in the first four were blood pressure ( 86.7 % , 508 / 586 ) , urinary volume ( 58.9 % , 345 / 586 ) , cardiac output ( 50.2 % , 294 / 586 ) , and blood lactic acid concentration ( 40.8 % , 239 / 586 ) . In order to improve the renal function of patients with positive muscle strength , the rate of blood pressure and pulse blood oxygen saturation in non - teaching hospitals were significantly higher than those in non - teaching hospitals . In order to regulate the application of vascular active drugs in ICU , it is necessary to strengthen the application of vascular active drugs and the standardized training of shock management , so as to improve the level of clinical rescue shock patients .
【學(xué)位授予單位】：武漢大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R459.7

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