心室动脉偶联与脓毒症患者血流动力学的关系及对预后的预测价值

doi:10.11958/20242154

摘要/Abstract

摘要：

目的探讨心室动脉偶联（VAC）与脓毒症患者血流动力学的关系及其对患者28 d预后的预测价值。方法选取脓毒症患者164例，给予液体复苏（3 h内输注30 mL/kg的晶体液）治疗并观察其复苏0 h、24 h、72 h的VAC[有效主动脉弹性（Ea）/心室收缩末期弹性（Ees）]及血流动力学参数变化情况，计算复苏24 h、72 h与0 h之间的差值24 hΔEa/Ees、72 hΔEa/Ees，采用Pearson法分析Ea/Ees与Δ中心静脉压（CVP）、Δ心搏出量指数（SVI）及Δ心脏指数（CI）的相关性。根据28 d预后分为存活组（123例）和死亡组（41例），收集2组患者一般资料，采用多因素Cox回归模型及受试者工作特征（ROC）曲线分析患者28 d死亡的影响因素及24 hΔEa/Ees、72 hΔEa/Ees对预后的预测价值。结果 164例患者复苏24 h、72 h的Ea/Ees低于0 h，且72 h的Ea/Ees低于24 h（均P<0.05），164例患者复苏24 h、72 h的CVP、SVI、CI均高于0 h，且24 h的CVP、SVI、CI高于72 h（均P<0.05）；24 hΔEa/Ees低于72 hΔEa/Ees （P<0.05），24 hΔCVP、ΔSVI、ΔCI高于72 h对应指标（P<0.05）；24 hΔEa/Ees与24 hΔCVP、24 hΔSVI、24 hΔCI呈负相关（P<0.05）；死亡组急性生理与慢性健康状况评分Ⅱ（APACHEⅡ）≥20分、序贯器官衰竭评分（SOFA）≥10分占比以及24 hΔEa/Ees、72 hΔEa/Ees均高于存活组（P<0.05）；APACHEⅡ、SOFA、24 hΔEa/Ees以及72 hΔEa/Ees升高均为影响脓毒症患者28 d预后不良的危险因素（P<0.05）；24 hΔEa/Ees、72 hΔEa/Ees对脓毒症患者28 d预后预测效能较好（P<0.05）。结论 Ea/Ees变化情况能较好地反映脓毒症患者治疗早期血流动力学改变，有助于预测脓毒症患者28 d预后。

关键词: 脓毒症, 血流动力学, 预后, 心室动脉偶联

Abstract:

Objective To investigate the relationship between ventricular arterial coupling (VAC) and haemodynamics of patients with sepsis and the predictive value for the 28-day prognosis. Methods A total of 164 patients with sepsis were selected and given fluid resuscitation treatment (infusion of 30 mL/kg of crystalloid over 3 h), and changes of VAC[effective aortic elasticity (Ea)/ventricular end-systolic elasticity (Ees)]values and hemodynamic parameters of patients resuscitated for 0 h, 24 h and 72 h were observed. The difference between Ea/Ees for 24 h and 72 h of resuscitation and 0 h was calculated. Pearson method was used to analyze the correlation between Ea/Ees and Δcentral venous pressure (CVP), Δspiratory volume index (SVI) and Δcardiac index (CI). According to the 28-day prognosis, patients were divided into two groups: the survival group (123 cases) and the death group (41 cases). General information was collected in two groups of patients. The predictive values of 24 h ΔEa/Ees and 72 h ΔEa/Ees for 28-day death in sepsis patients were analyzed by multivariate Cox regression models and receiver operating characteristics (ROC) curve. Results The Ea/Ees of 164 patients resuscitated for 24 h and 72 h were lower than those of 0 h, and the Ea/Ees of 72 h was lower than that of 24 h (all P<0.05). CVP, SVI and CI of 164 patients resuscitated for 24 h and 72 h were higher than those of 0 h, and the CVP, SVI and CI of 24 h was higher than that of 72 h (all P< 0.05). The 24 h ΔEa/Ees was significantly lower than that of 72 h ΔEa/Ees (P<0.05), and 24 h ΔCVP, SVI and CI were higher than those of 72 h (P<0.05). There was a negative correlation between 24 h ΔEa/Ees and 24 h ΔCVP, 24 h ΔSVI and 24 h ΔCI (P<0.05). Acute Physiology and Chronic Health Status Score II (APACHE II) ≥20 points, Sequential Organ Failure Score (SOFA)≥10 points, 24 h ΔEa/Ees and 72 h ΔEa/Ees were higher in the death group than those in the survival group (P<0.05). Elevated APACHE II, SOFA, 24 h ΔEa/Ees and 72 h ΔEa/Ees were risk factors affecting the 28-day prognosis of patients with sepsis (P<0.05). The 24-hour ΔEa/Ees and 72-hour ΔEa/Ees were more effective in predicting the 28 d prognosis of patients with sepsis (P<0.05). Conclusion Changes of Ea/Ees can better reflect the haemodynamic changes in sepsis patients in the early stages of treatment and help to predict the 28-day prognosis of sepsis patients.

Key words: sepsis, hemodynamics, prognosis, ventricular arterial coupling

中图分类号:

R631

图/表 7

参考文献 20

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时间	Ea/Ees	CVP/mmHg	SVI/mL	CI/[L/（min·m²）]
0 h	1.25±0.12	4.16±1.73	23.19±3.21	4.58±1.12
24 h	1.21±0.14^a	6.21±1.75^a	27.89±3.32^a	5.26±1.15^a
72 h	1.16±0.16^ab	5.53±1.73^ab	26.37±3.27^ab	4.93±1.12^ab
F_主效应	16.785^＊＊	59.285^＊＊	88.385^＊＊	14.849^＊＊

时间	Ea/Ees	CVP/mmHg	SVI/mL	CI/[L/（min·m²）]
0 h	1.25±0.12	4.16±1.73	23.19±3.21	4.58±1.12
24 h	1.21±0.14^a	6.21±1.75^a	27.89±3.32^a	5.26±1.15^a
72 h	1.16±0.16^ab	5.53±1.73^ab	26.37±3.27^ab	4.93±1.12^ab
F_主效应	16.785^＊＊	59.285^＊＊	88.385^＊＊	14.849^＊＊

时间	ΔEa/Ees	ΔCVP/ mmHg	ΔSVI/ mL	ΔCI/[L/ （min·m²）]
24 h	-0.08（-0.11，0.03）	2.05±0.23	4.70±0.84	0.67±0.17
72 h	-0.11（-0.15，0.02）	1.37±0.20	3.17±0.68	0.35±0.08
Z或t	7.024^＊＊	16.912^＊＊	10.560^＊＊	11.614^＊＊

时间	ΔEa/Ees	ΔCVP/ mmHg	ΔSVI/ mL	ΔCI/[L/ （min·m²）]
24 h	-0.08（-0.11，0.03）	2.05±0.23	4.70±0.84	0.67±0.17
72 h	-0.11（-0.15，0.02）	1.37±0.20	3.17±0.68	0.35±0.08
Z或t	7.024^＊＊	16.912^＊＊	10.560^＊＊	11.614^＊＊

指标	24 hΔEa/Ees	指标	72 hΔEa/Ees
24 hΔCVP	-0.654^＊＊	72 hΔCVP	-0.046
24 hΔSVI	-0.567^＊＊	72 hΔSVI	-0.082
24 hΔCI	-0.451^＊＊	72 hΔCI	-0.073