本文選題：PICCO　切入點(diǎn)：膿毒癥休克　出處：《大連醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：膿毒癥休克是機(jī)體對感染反應(yīng)失調(diào)出現(xiàn)器官功能障礙,且合并嚴(yán)重的循環(huán)障礙和細(xì)胞代謝紊亂。膿毒癥休克患者病情十分兇險,死亡率極高,是導(dǎo)致重癥監(jiān)護(hù)室患者死亡的重要原因之一。早期進(jìn)行液體復(fù)蘇仍是治療膿毒癥休克患者的關(guān)鍵措施,通過增加有效循環(huán)血容量來增加心輸出量,提高組織器官灌注,增加氧供,改善預(yù)后。但是盲目補(bǔ)液易導(dǎo)致容量負(fù)荷增加,加重心臟負(fù)擔(dān),出現(xiàn)肺水腫,增加病死率。因此,我們需要探求一種簡單、迅速、有效的監(jiān)測手段指導(dǎo)液體復(fù)蘇。目的:旨在研究脈搏指示連續(xù)心輸出量(PICCO)在膿毒癥休克患者液體復(fù)蘇中的應(yīng)用價值。方法:收集2014年1月至2016年12月收入大連醫(yī)科大學(xué)附屬第一醫(yī)院急診重癥監(jiān)護(hù)室的61例膿毒癥休克患者,依據(jù)治療方案不同分為早期目標(biāo)導(dǎo)向治療組(EGDT組)及脈搏指示連續(xù)心輸出量組(PICCO組),其中EGDT組有30例,PICCO組有31例。EGDT組根據(jù)早期目標(biāo)導(dǎo)向治療方案來指導(dǎo)液體復(fù)蘇,PICCO組則依據(jù)PICCO監(jiān)測的參數(shù)進(jìn)行液體復(fù)蘇指導(dǎo)。觀察并記錄兩組患者入院時、治療12h、治療24h及治療72h的心率、平均動脈壓、血乳酸值及尿量,同時進(jìn)行SOFA評分,并使用獨(dú)立樣本t檢驗(yàn)對比兩組之間的差異;記錄并比較比較兩組患者機(jī)械通氣時間、ICU留置時間、液體復(fù)蘇成功率及其28天死亡率的差異。應(yīng)用PICOO組根據(jù)存活與否,分為生存組及死亡組,對比兩組Oh的血流動力學(xué)指標(biāo)、OhSOFA評分、24hSOFA評分及24h乳酸清除率的差異;結(jié)果:在治療12h、24h和72h時,PICCO組MAP與尿量明顯高于EGDT組(P0.05),而HR、Lac、SOFA評分明顯低于EGDT組(P0.05);PICCO組機(jī)械通氣時間和ICU留置時間明顯低于EGDT組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);PICCO組的12h液體復(fù)蘇成功率明顯高于EGDT組,差異有統(tǒng)計(jì)學(xué)意義(P0.05),PICCO組的死亡率明顯低于EGDT組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。應(yīng)用PICCO的生存組和死亡組Oh血流動力學(xué)參數(shù)進(jìn)行對比,生存組血管外肺水指數(shù)(EVLWI)明顯低于死亡組,而每搏外周血管阻力指數(shù)(SSVRI)、脈壓與每搏指數(shù)比值(PP/SVI)明顯高于死亡組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);死亡組Oh SOFA及24h SOFA明顯高于生存組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);生存組24h乳酸清除率明顯高于死亡組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05);利用Spearman相關(guān)性分析法得到Oh PP/SVI與Oh SOFA評分呈負(fù)相關(guān)性(r=-0.732,P0.05),與24h乳酸清除率呈正相關(guān)(r=0.484,P0.05);Oh SSVRI 與 Oh SOFA 評分呈負(fù)相關(guān)性(r=-0.762,P0.05),與24h乳酸清除率呈正相關(guān)(r=0.40,P0.05)。結(jié)論:PICC0監(jiān)測在指導(dǎo)膿毒癥休克患者液體復(fù)蘇方面,具有其獨(dú)特的優(yōu)勢,可以提高早期液體復(fù)蘇成功率;膿毒癥休克患者治療開始前的血管彈性指標(biāo)PP/SVI、SSVRI與SOFA評分具有負(fù)相關(guān)性,提示PP/SVI、SSVRI值愈低,膿毒癥休克患者預(yù)后愈差;PP/SVI、SSVRI與24h乳酸清除率具有正相關(guān)性,提示PP/SVI、SSVRI值愈低,24h乳酸清除率愈低,預(yù)后值愈差,值得在臨床工作中推廣,有助于進(jìn)一步評估膿毒癥休克患者的預(yù)后。
[Abstract]:Septic shock is the body's response to infection with disorder of organ dysfunction, circulatory disorder and cell metabolic disorders. Severe septic shock patients is very dangerous, with high mortality, is one of the leading causes of death in ICU patients. Early is still the key measures for treatment of septic shock in patients with fluid resuscitation. By increasing the effective circulating blood volume to increase cardiac output, improve organ perfusion, increase the oxygen supply, improve the prognosis. But blindly rehydration easily lead to increased volume load, increase the burden on the heart, pulmonary edema, increase the mortality rate. Therefore, we need to find a simple, rapid and effective monitoring means to guide fluid resuscitation. Objective: To study the pulse indicator continuous cardiac output (PICCO) application value in septic shock fluid resuscitation in patients. Methods: from January 2014 to December 2016 Emergency ICU of the First Affiliated Hospital of Dalian Medical University, the income of 61 cases of patients with septic shock, according to the different treatment were divided into early goal-directed therapy group (EGDT group) and pulse indicator continuous cardiac output group (PICCO group), EGDT group had 30 cases, 31 cases of PICCO group.EGDT group to guide fluid resuscitation according to the early goal-directed therapy scheme, guiding PICCO group based on the parametric PICCO monitoring for fluid resuscitation. The two groups were observed and recorded at the time of admission, treatment 12h, treatment 24h and treatment 72h the heart rate, mean arterial pressure, blood lactate and urine volume at the same time, SOFA score, and use different independent samples t test comparison between the two groups; recorded and compared between the two groups of patients with mechanical ventilation time, indwelling time of ICU, different fluid resuscitation success rate and mortality in 28 days. The application of PICOO group according to survival or not, divided into survival group and death group, The hemodynamic indexes were compared between the two groups, Oh OhSOFA score, 24hSOFA score and the difference of lactate clearance rate of 24h; results: in the treatment of 12h, 24h and 72h, PICCO group MAP and urine volume was significantly higher than EGDT group (P0.05), HR, Lac, SOFA score was significantly lower than that of EGDT group (P0.05); PICCO group the mechanical ventilation time and indwelling time of ICU was significantly lower than that in EGDT group, the difference was statistically significant (P0.05); 12h PICCO resuscitation group success rate was significantly higher than that of EGDT group, the difference was statistically significant (P0.05), the mortality of PICCO group was significantly lower than that of EGDT group, the difference was statistically significant (P0.05). By comparing the PICCO survival group the death group and the Oh hemodynamic parameters, the survival group of extravascular lung water index (EVLWI) was significantly lower than the death group, while the stroke peripheral vascular resistance index (SSVRI), pulse pressure and stroke volume index (PP/SVI) was significantly higher than the death group, the difference was statistically significant (P0.05); death Oh SOFA and 24h SOFA death group was significantly higher than the survival group, the difference was statistically significant (P0.05); survival group 24h lactic acid clearance rate was significantly higher than that of death group, the difference was statistically significant (P0.05); analysis by Oh PP/SVI and Oh SOFA score was negatively associated with Spearman correlation (r=-0.732, P0.05), positive rate associated with 24h lactate clearance (r=0.484, P0.05); Oh SSVRI and Oh SOFA scores were negatively correlated (r=-0.762, P0.05), the rate of 24h was positively correlated with the lactate clearance (r=0.40, P0.05). Conclusion: PICC0 monitoring in guiding the septic shock patients fluid resuscitation, has its unique advantages, can improve the early the success rate of resuscitation; blood vessel elasticity index PP/SVI shock treatment of sepsis patients before, SSVRI and SOFA score had negative correlation, suggesting that PP/SVI, SSVRI value is low in patients with septic shock after the pre PP/SVI, SSVRI and 24h; lactate clearance rate with There is a positive correlation, suggesting that the lower the PP/SVI and SSVRI value, the lower the 24h lactate clearance rate and the worse prognosis. It is worth promoting in clinical work, and helps to further evaluate the prognosis of septic shock patients.

【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R459.7
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本文編號：1600062