钟春妍,贾文钗,王征,宁辉,贺春晖,张晓燕,骆勇.脉搏指示连续心搏出量检测技术对严重肺部感染合并心力衰竭患者预后的影响和危险因素分析[J].内科急危重症杂志,2017,23(1):
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| 中文关键词: 脉搏指示连续心搏出量检测 重症肺炎 重度心力衰竭 液体管理 预后 |
| 英文关键词:PiCCO severe pneumonia advanced heart failure fluid management prognosis |
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| 中文摘要: |
| 目的 探讨脉搏指示连续心搏出量检测（PiCCO）指导液体管理对重症肺炎合并心衰竭的预后意义，并分析影响短期病死率的危险因素。方法 选择北京大学首钢医院重症监护室（ICU）自2013年1月～2015年1月收治并应用PiCCO技术指导液体管理的57例重症肺炎合并心力衰竭的患者作为PiCCO组，同期选择基础情况类似的应用中心静脉压（CVP）指导液体管理的64例重症肺炎合并心衰患者作为对照组，比较两组72h内液体管理数据，治疗1d和3d的APACHE II评分、SOFA评分、CPIS评分变化，以及住院期间血管活性药物使用时间、机械通气时间、床旁血液净化率、ICU住院时间和28天病死率。Kaplan-Meier生存分析评价两组的生存情况。Logistic回归分析28天病死率的危险因素。并应用受试者工作特征性（ROC）曲线分析危险因素的阈值和相应的敏感性和特异性。结果 共有121例患者入选，男73例，女48例，平均年龄62.3±17.2岁。两组间年龄、性别比例、既往病史、血乳酸、血肌酐、氧合指数、平均动脉压、APACHE II 评分、SOFA评分、CPIS评分等均无显著差异（均P>0.05）。PiCCO组患者的0～12h液体出量明显多于对照组（P<0.05），但24～48h、48～72h两组无显著差别（P>0.05）。治疗3d时，PiCCO组患者的APACHE II、 SOFA评分均较对照组显著降低，但CPIS评分两组无明显差异。住院期间PiCCO组的应用血管活性药物的比例、血液净化率、机械通气时间、ICU住院时间较对照组均显著减少（P<0.05），但Kaplan-Meier生存分析显示两组住院期间和28天生存均无显著差别（P>0.05）。Logistic回归分析显示年龄（OR 1.71, 95% CI, 1.13～2.73，P=0.003）、APACHE II评分（OR 1.92, 95% CI, 1.17～3.72，P=0.01）、SOFA评分（OR 2.32, 95% CI, 1.87～4.52，P=0.02）和机械通气时间（OR 2.08, 95% CI, 1.47～3.93，P=0.002）为28天病死率的独立危险因素，ROC曲线显示年龄≥67岁、SOFA ≥6分、APACHE II≥23分和机械通气时间≥7天为相应危险因素的阈值。结论 PiCCO技术可以精确指导重症肺炎合并心力衰竭患者液体管理，降低APACHE II、 SOFA评分，减少机械通气时间和ICU住院时间，但对短期病死率无明显影响。年龄、APACHE II评分、SOFA评分和机械通气时间为28天病死率的独立危险因素。 |
| 英文摘要: |
| Objective To evaluate the short-term effect of pulse indicator continuous cardiac output (PiCCO)-guided fluid management in patients with severe pneumonia and heart failure (HF) and the risk factor for 28-day mortality. Methods We retrospectively analyzed data from 121 patients with severe pneumonia and HF in Peking university Shougang hospital from January 2013 to January 2015. 57 patients who received PiCCO guided fluid management were in PiCCO group and 64 patients received central venous pressure (CVP)-guided fluid management in the control group. We compared the change of fluid resuscitation in first 72h, APACHE II score and SOFA score, CPIS score, rate of renal replacement therapy, duration of vasopressor, mechanical ventilation, ICU stay, and 28-day mortality. Furthermore, we evaluated the risk factor for 28-day mortality using Logistic regression and the receptor-operating characteristic (ROC) curves. Result 121 severe pneumonia and HF patients were enrolled. There were 73 males, 48 females. The mean age was 62.3±17.2 years old. Basic characteristics, such as age, male rate, previous history, blood lactate level, creatinine level, oxygen index, mean arterial blood pressure, SOFA score and APACHE II score, CPIS score were comparable between the two groups (P > 0.05). The fluid intake during the first 12 hours was significantly more than the control group (P < 0.05). However, within 24-48 and 48-72 hours, fluid intake volume similar between groups (P > 0.05). Additionally, PiCCO group was associated with significantly lower APACHE II and SOFA scores (P < 0.05), decreased rate of vasopressor usage, renal replacement therapy, duration of mechanical ventilation and days stayed in ICU (P < 0.05). However, risk of mortality was similar between groups (P > 0.05). Logistic regression analysis demonstrated that age, SOFA, APACHE II scores and ventilation duration were independent risk factors for 28-day mortality. ROC curve showed that age ≥67 years old、SOFA ≥6、APACHE II≥23 and ventilation duration ≥7 days are the thresholds. Conclusion: PiCCO could accurately guide fluid management in patients with severe pneumonia and HF, with less duration of mechanical ventilation and days stayed in ICU, though 28-day mortality was similar between groups. Age, APACHE II, SOFA score and ventilation duration were independent risk factors for 28-day mortality. |
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