本文選題：低氧血癥 + 右向左分流�。� 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:本研究擬通過床旁經(jīng)胸超聲心動圖對低氧血癥患者進行心內(nèi)分流及肺內(nèi)分流的診斷及右心功能的評估,主要目的為:1、評估低氧血癥患者心內(nèi)分流和肺內(nèi)分流發(fā)生率;2、探討分流對右心功能的影響;3、分析分流對低氧血癥患者預(yù)后,包括機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)、28天全因死亡率的影響。方法:本研究為前瞻性臨床觀察性研究,納入2016年4-12月在河北醫(yī)科大學(xué)第四醫(yī)院重癥醫(yī)學(xué)科收治的急性低氧血癥的患者。入選標準:1)各種原因?qū)е碌募毙缘脱跹Y,氧合指數(shù)300mm Hg;2)入住ICU時間≥24小時;3)年齡≥18周歲。排除標準:1)入住ICU時間24小時;2)年齡18周歲;3)肺栓塞患者;4)右心室梗塞患者;5)慢性肺源性心臟病患者、肺性腦病患者;6)孕產(chǎn)婦及哺乳期婦女;7)由于各種原因超聲圖像顯示不清晰的患者。所有入組患者由臨床主管醫(yī)生決定治療方案。根據(jù)生理鹽水微氣泡造影試驗結(jié)果分為無分流組、心內(nèi)分流組、肺內(nèi)分流組,記錄三組患者24小時內(nèi)的急性生理慢性健康評分II(Acute Physiology And Chronic Health Evaluation II,APACHEII)、序貫器官衰竭評分(Sequential Organ Failure Assessment,SOFA),行超聲檢查時的生命體征、呼吸機模式及參數(shù);入組24小時內(nèi)的液體出入量;血氣分析指標、超聲心動圖結(jié)果、機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)、28天全因死亡率等。結(jié)果:1本研究共納入80名患者,無分流組57例,心內(nèi)分流組12例(15%),肺內(nèi)分流組11例(13.75%)。其中,ARDS患者35例:分別包括無分流組25例,心內(nèi)分流組5例(14.29%),肺內(nèi)分流組5例(14.29%);非ARDS患者45例:分別包括無分流組32例,心內(nèi)分流組7例(15.56%),肺內(nèi)分流組6例(13.33%)。2低氧血癥患者無分流組、心內(nèi)分流組、肺內(nèi)分流組右心功能及預(yù)后的比較。2.1無分流、心內(nèi)分流、肺內(nèi)分流三組患者年齡差異有統(tǒng)計學(xué)意義,分別為69.33years±10.41years vs 54.64years±16.27years vs 65.73years±11.87years,P=0.002。性別、APACHEII評分、SOFA評分、生命體征、液體出入量、呼吸機支持條件等差異無統(tǒng)計學(xué)意義(P0.05)(Table1)。2.2三組患者動脈血氣分析顯示,p H值、二氧化碳分壓(Pa CO2)、中心靜脈-動脈二氧化碳分壓差(Gap)、堿剩余(BE)、氧合指數(shù)(Pa O2/Fi O2)、乳酸(Lac)差異無統(tǒng)計學(xué)意義(P0.05)(Table 1)。2.3三組患者超聲結(jié)果顯示,E峰、A峰、E/A、e’、E/e’、RVarea/LVarea、PASP、TAPSE、IVC內(nèi)徑差異均無統(tǒng)計學(xué)意義(P0.05)(Table 2)。2.4三組患者機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)及28天全因死亡率差異均無統(tǒng)計學(xué)意義(P0.05)(Table 3)。3 ARDS患者無分流組、心內(nèi)分流組、肺內(nèi)分流組右心功能及預(yù)后的比較。3.1無分流組、心內(nèi)分流組、肺內(nèi)分流組三組患者CVP差異有統(tǒng)計學(xué)意義,分別為10.80mm Hg±3.03mm Hg vs 8.04mm Hg±2.49mm Hg vs 10.40mm Hg±1.67mm Hg,P=0.032;性別、年齡、APACHEII、SOFA評分、其余生命體征、液體出入量、呼吸機支持條件等差異無統(tǒng)計學(xué)意義(P0.05)(Table4)。3.2三組患者血氣分析各項指標無統(tǒng)計學(xué)差異(P0.05)(Table 4)。3.3三組患者超聲結(jié)果無統(tǒng)計學(xué)差異(P0.05)(Table 5)。3.4三組患者機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)及28天全因死亡率無統(tǒng)計學(xué)差異(P0.05)(Table 6)。4 ARDS與非ARDS患者比較4.1兩組患者性別、年齡、APACHEII、SOFA評分、生命體征、液體出入量、呼吸機支持條件等差異無統(tǒng)計學(xué)意義(P0.05)(Table 7)。4.2兩組患者血氣分析氧合指數(shù)差異有統(tǒng)計學(xué)意義,分別為:174.16mm Hg±74.58mm Hg vs 242.44mm Hg±90.74mm Hg,P=0.001;乳酸差異有統(tǒng)計學(xué)意義,分別為:2.39mmol/L±1.64 mmol/L vs 1.78 mmol/L±0.89mmol/L,P=0.037,其余指標差異無統(tǒng)計學(xué)意義(P0.05)。4.3兩組患者超聲結(jié)果差異無統(tǒng)計學(xué)意義(P0.05)(Table 7)。4.4兩組患者機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)及28天全因死亡率差異無統(tǒng)計學(xué)意義(P0.05)(Table 7)。4.5兩組患者心內(nèi)分流及肺內(nèi)分流發(fā)生率差異無統(tǒng)計學(xué)意義(Table 7)5低氧血癥患者存活組與死亡組患者比較5.1存活組與死亡組比較,死亡組女性患者所占比例較大,分別為15.87%vs 50%,P=0.047,年齡較大,分別為60.77years±13.52years vs 69.09years±11.24years,P=0.007,APACHE II評分及SOFA評分均高于存活組分別為18.26±4.58 vs 23.82±7.44,P=0.003;7.10±2.60 vs 10.55±3.75,P0.001,心率較存活組更快分別為95.67 beats/min±26.98 beats/min vs 116.32beats/min±28.83 beats/min,P=0.004,其余生命體征差異無統(tǒng)計學(xué)意義(P0.05)(Table 8)。5.2兩組患者液體量相比較,存活組較死亡組液體平衡量更少,分別為-59.00ml±1257.13ml vs 881.41ml±1162.96ml,P=0.002,潮氣量更小,分別為414.95ml±88.71ml vs 481.43ml±104.11ml,P=0.011,其余液體指標、機械通氣指標及血氣分析各項指標差異無統(tǒng)計學(xué)意義(P0.05)(Table 8)。5.3兩組患者超聲結(jié)果比較顯示,存活組較死亡肺動脈收縮壓更低,分別為29.28mm Hg±12.97 mm Hg vs 36.14 mm Hg±13.93 mm Hg,P=0.049,其余超聲指標差異無統(tǒng)計學(xué)意義(P0.05)(Table 8)。5.4兩組患者比較,存活組機械通氣天數(shù)更少,分別為4.66d±2.78d vs6.96d±4.16d,P=0.005,ICU住院天數(shù)及總住院天數(shù)差異無統(tǒng)計學(xué)意義(Table 8)。5.5兩組患者心內(nèi)分流及肺內(nèi)分流發(fā)生率、ARDS發(fā)生率比較差異均無統(tǒng)計學(xué)意義(P0.05)(Table 8)。6 28天全因死亡率的相關(guān)危險因素分析結(jié)果以28天全因死亡率作為因變量,納入血流動力學(xué)或呼吸參數(shù)指標中具有顯著差異的變量進行Logistic回歸分析,提示主要危險因素為年齡、入組24小時內(nèi)的液體平衡量、潮氣量。(Table 9)結(jié)論:1低氧血癥患者出現(xiàn)心內(nèi)分流的發(fā)生率為15%,肺內(nèi)分流發(fā)生率為13.75%;ARDS患者心內(nèi)分流發(fā)生率為14.29%,肺內(nèi)分流發(fā)生率為14.29%;非ARDS心內(nèi)分流發(fā)生率15.56%,肺內(nèi)分流發(fā)生率為13.33%。2未發(fā)現(xiàn)心內(nèi)分流或肺內(nèi)分流對低氧血癥患者、ARDS患者右心功能的影響。3未發(fā)現(xiàn)心內(nèi)分流或肺內(nèi)分流對低氧血癥患者、ARDS患者機械通氣天數(shù)、ICU住院天數(shù)、總住院天數(shù)、28天全因死亡率的關(guān)系。4低氧血癥存活患者中入組24小時內(nèi)的液體出入量更少,潮氣量更小,肺動脈壓更低。
[Abstract]:Objective: This study by bedside transthoracic echocardiographic evaluation of intracardiac shunt and shunt diagnosis and right ventricular function of hypoxemia in patients with map, the main purpose is to: 1, to assess the incidence of hypoxemia in patients with heart shunt and pulmonary shunt; 2, to investigate the effect of shunt on right ventricular function; 3 Analysis on the prognosis of patients with shunt, hypoxemia, duration of mechanical ventilation, ICU length of stay, total hospital stay, 28 day all-cause mortality. Methods: This study was a prospective clinical observational, in 2016 4-12 months in the ICU of Hebei Medical University Fourth Hospital of acute hypoxemia in patients with inclusion criteria: 1). Acute hypoxemia caused by a variety of reasons, the oxygenation index 300mm Hg; 2) ICU stay longer than 24 hours; 3) aged 18 years of age. Exclusion criteria: 1) in the ICU time for 24 hours; 2) aged 18 years); 3 patients with pulmonary embolism; 4) of right heart In patients with ventricular infarction; 5) in patients with chronic pulmonary heart disease, patients with pulmonary encephalopathy; 6) pregnant women and lactating women; 7) due to various reasons, the ultrasonic images of patients is not clear. All of the patients were determined by clinical doctor in charge of treatment. According to physiological saline microbubble contrast test results divided into shunt group, group of intracardiac shunt, intrapulmonary shunt group, acute physiology records of three groups of patients within 24 hours of chronic health evaluation II (Acute Physiology And Chronic Health Evaluation II, APACHEII), sequential organ failure assessment (Sequential Organ Failure Assessment, SOFA), ultrasound vital signs, ventilation modes and parameters into; group within 24 hours of liquid intake; blood gas analysis index, the results of echocardiography, mechanical ventilation time, ICU length of stay, total hospital stay, 28 day all-cause mortality. Results: 1 this study included 80 patients No, the shunt group 57 cases, 12 cases of intracardiac shunt group (15%), 11 cases with intrapulmonary shunt group (13.75%). Among them, 35 cases of ARDS patients were included non shunt group 25 cases, 5 cases of intracardiac shunt group (14.29%), 5 cases with intrapulmonary shunt group (14.29%); 45 cases of non ARDS patient: including the free flow group 32 cases, 7 cases of intracardiac shunt group (15.56%), 6 cases with intrapulmonary shunt group (13.33%).2 group without shunt hypoxemia, cardiac shunt group, pulmonary shunt.2.1 group right heart function and prognosis of non diversion, intracardiac shunt, shunt in three patients age differences in lung has statistical significance, respectively, 69.33years + 10.41years vs 54.64years + 16.27years vs 65.73years + 11.87years P=0.002., sex, APACHEII score, SOFA score, vital signs, fluid intake and output, there was no significant difference of ventilator support condition (P0.05).2.2 (Table1) three groups of patients with arterial blood gas analysis showed that the p value of H (Pa, partial pressure of carbon dioxide CO2),涓績闈欒剦-鍔ㄨ剦浜屾哀鍖栫⒊鍒嗗帇宸，

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