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脑血流动力学及脑氧饱和度变化与感染性休克患者预后的相关性:前瞻性队列研究

冯清 艾美林 黄立 彭倩宜 艾宇航 张丽娜

冯清, 艾美林, 黄立, 彭倩宜, 艾宇航, 张丽娜. 脑血流动力学及脑氧饱和度变化与感染性休克患者预后的相关性:前瞻性队列研究[J]. 协和医学杂志, 2019, 10(5): 481-488. doi: 10.3969/j.issn.1674-9081.2019.05.010
引用本文: 冯清, 艾美林, 黄立, 彭倩宜, 艾宇航, 张丽娜. 脑血流动力学及脑氧饱和度变化与感染性休克患者预后的相关性:前瞻性队列研究[J]. 协和医学杂志, 2019, 10(5): 481-488. doi: 10.3969/j.issn.1674-9081.2019.05.010
Qing FENG, Mei-lin AI, Li HUANG, Qian-yi PENG, Yu-hang AI, Li-na ZHANG. Correlation of Cerebral Hemodynamics and Cerebral Oxygen Saturation with the Prognosis of Patients with Septic Shock: A Prospective Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2019, 10(5): 481-488. doi: 10.3969/j.issn.1674-9081.2019.05.010
Citation: Qing FENG, Mei-lin AI, Li HUANG, Qian-yi PENG, Yu-hang AI, Li-na ZHANG. Correlation of Cerebral Hemodynamics and Cerebral Oxygen Saturation with the Prognosis of Patients with Septic Shock: A Prospective Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2019, 10(5): 481-488. doi: 10.3969/j.issn.1674-9081.2019.05.010

脑血流动力学及脑氧饱和度变化与感染性休克患者预后的相关性:前瞻性队列研究

doi: 10.3969/j.issn.1674-9081.2019.05.010
基金项目: 

国家自然科学基金 81873956

湖南省卫健委科研计划课题横向项目 B2016110

详细信息
    通讯作者:

    张丽娜 电话:0731-84327095, E-mail:zln7095@126.com

  • 中图分类号: R63;R605.971

Correlation of Cerebral Hemodynamics and Cerebral Oxygen Saturation with the Prognosis of Patients with Septic Shock: A Prospective Cohort Study

More Information
    Corresponding author: ZHANG Li-na Tel: 86-731-84327095, E-mail:zln7095@126.com
  • 摘要:   目的  探讨大脑中动脉血流动力学相关指标及脑氧饱和度变化与感染性休克患者预后的相关性。  方法  前瞻性收集2018年5月至2019年3月在中南大学湘雅医院重症医学科住院治疗的感染性休克患者临床资料, 根据28 d内是否死亡, 将患者分为死亡组和存活组。比较两组患者一般资料, 入重症监护室即刻和初始复苏治疗6 h后动脉和中心静脉血气指标, 重症心脏超声指标, 器官功能指标, Sepsis生物标志物指标, 液体复苏治疗6 h后大脑中动脉血流速度、灌注指数、动态脑血管自动调节功能[瞬时脑充血反应率(transient hyperemic response ratio, THRR)]以及脑氧饱和度变化。采用多因素Logistic回归, 分析影响感染性休克患者预后的危险因素。  结果  51例符合纳入和排除标准的感染休克患者入选本研究, 男性31例, 女性20例, 年龄(53±13)岁, 28 d死亡率为43%。死亡组的序贯性器官衰竭评分(sequential organ failure assessment, SOFA)(P=0.007)、入室急性生理和慢性健康状况评估(acute physiology and chronic health evaluation Ⅱ, APACHE Ⅱ)评分(P=0.026)以及高峰APACHE Ⅱ评分(P < 0.001)均高于存活组。初始复苏治疗6 h后, 死亡组的氧合指数低于存活组(P=0.047), 而中心静脉-动脉二氧化碳分压差(central venous-to-arterial carbon dioxide difference, Pcv-aCO2)则高于存活组(P=0.044)。死亡组动态脑血管自动调节功能受损者(THRR < 1.09)多于存活组(P=0.025), 脑氧饱和度(regional cerebral oxygen saturation, rSO2)均值低于存活组(P=0.031)且rSO2均值< 60%者多于存活组(P=0.010)。多因素Logistic回归分析显示, 高峰APACHE Ⅱ评分(OR=1.099, 95% CI:1.009~1.196, P=0.030)、液体复苏治疗6 h后的Pcv-aCO2(OR=1.320, 95% CI:1.001~1.742, P=0.050)、THRR < 1.09(OR=4.952, 95% CI:1.130~21.70, P=0.034)和rSO2均值< 60%(OR=4.817, 95% CI:1.392~16.663, P=0.013)是预测感染性休克患者28 d内死亡的独立危险因素。  结论  感染性休克患者死亡率高, 脑血流动力学和rSO2指标中动态脑血管自动调节功能障碍(THRR < 1.09)与rSO2均值< 60%是28 d死亡率增加的独立预测因素。
    利益冲突  无
  • 图  1  51例感染性休克患者低风险组(rSO2≥60%)和高风险组(rSO2<60%)Kaplan-Meier生存曲线分析rSO2:同表 5

    表  1  51例感染性休克患者的一般临床特点

    临床特点 死亡组(n=22) 存活组(n=29) P
    年龄(x±s,岁) 53±13 54±14 0.892
    男性[n(%)] 16(73) 15(52) 0.128
    BMI(kg/m2x±s) 22.4±2.7 22.8±2.4 0.581
    教育水平[n(%)] 0.381
        小学 6(27) 13(45)
        中学 7(32) 6(21)
        高中 4(18) 7(24)
        大学及以上 5(23) 3(10)
    既往史[n(%)]
        高血压 6(27) 8(28) 0.980
        冠心病 3(10) 5(17) 0.726
        糖尿病 3(10) 6(21) 0.513
    复苏后体温(x±s,℃) 37.4±0.8 37.1±0.9 0.386
        最差体温(x±s,℃) 37.6±0.9 37.4±1.0 0.290
    复苏后心率(x±s, 次/min) 109±18 109±17 0.977
        最差心率(x±s, 次/min) 122±24 121±15 0.960
    复苏后呼吸(x±s, 次/min) 22±6 21±6 0.622
        最差呼吸(x±s, 次/min) 29±8 28±7 0.736
    复苏后脉搏血氧饱和度(x±s,%) 97±4 98±2 0.122
        最差脉搏血氧饱和度(x±s,%) 94±5 96±4 0.137
    血糖(x±s,mmol/L) 10.0±5.4 8.2±3.4 0.179
    平均动脉压(x±s,mmHg) 81±30 78±24 0.747
    SOFA(x±s) 10±5 7±4 0.007
    入室APACHEⅡ评分(x±s) 20±7 16±7 0.026
    高峰APACHEⅡ评分(x±s) 29±11 18±9 <0.001
    镇静[n(%)] 12(55) 13(45) 0.492
    镇痛[n(%)] 17(77) 17(57) 0.162
    病原菌检出[n(%)] 15(68) 14(48) 0.155
    连续肾脏替代治疗[n(%)] 8(36) 8(28) 0.503
    BMI:体质量质数;SOFA:序贯性器官衰竭评分;APACHEⅡ:急性生理和慢性健康状况评估
    下载: 导出CSV

    表  2  两组感染性休克患者血流动力学相关指标比较

    指标 死亡组(n=22) 存活组(n=29) P
    Lac(x±s,mmol/L)
        t0h 3.8±3.6 2.8±2.8 0.241
        t6h 4.3±3.5 2.6±2.5 0.056
    Pcv-aCO2(x±s,mm Hg)
        t0h 8.5±5.8 7.9±2.7 0.824
        t6h 8.3±4.1 5.5±2.6 0.044
    ScvO2(x±s,%)
        t0h 62±12 67±7 0.251
        t6h 64±15 70±11 0.187
    CVP(x±s,mm Hg)
        t0h 5.7±3.4 6.9±3.8 0.362
        t6h 7.3±4.2 5.8±3.6 0.263
    乳酸清除率[M(QR), mmol/L] -0.135(-0.521, 0.209) -0.001(-0.375, -0.250) 0.223
    PH(t6h, x±s) 7.36±0.09 7.37±0.08 0.868
    PaO2(t6hx±s,mm Hg) 117±43 121±41 0.739
    PaCO2(t6hx±s,mm Hg) 35±7 36±6 0.578
    氧合指数(t6hx±s) 246±114 316±130 0.047
    去甲肾上腺素[M(QR),μg/(kg·min)] 0.60(0.38, 0.70) 0.33(0.20, 1.09) 0.299
    液体总入量[t6hM(QR), ml] 1665(1138, 2100) 2000(1550, 2300) 0.948
    24 h尿量[t6hM(QR), ml] 245(50, 758) 700(255, 1125) 0.079
    CO[M(QR), L/min] 4.9(4.1, 7.1) 5.6(4.5, 6.2) 0.330
    LVEF(x±s, %) 57±18 58±14 0.772
    IVCD(x±s, mm) 15.4±9.0 15.6±4.4 0.915
    IVC-CI(x±s, %) 33±20 22±17 0.123
    t0h:入重症医学科即刻;t6h:入重症医学科初始复苏6 h后;Lac:乳酸;Pcv-aCO2:中心静脉-动脉二氧化碳分压差值;ScVO2:中心静脉血氧饱和度;CVP:中心静脉压;PaO2:氧分压;PaCO2:二氧化碳分压;CO:心输出量;LVEF:左心室射血分数;IVCD:下腔静脉呼气末绝对直径;IVC-CI:下腔静脉变异度
    下载: 导出CSV

    表  3  两组感染性休克患者器官功能及实验室指标比较

    指标 死亡组(n=22) 存活组(n=29) P
    WBC(x±s,109/L) 18.8±14.8 13.9±11.8 0.196
    Hb(x±s,g/L) 91.8±23.8 94.1±23.9 0.740
    Hct(x±s,%) 28.4±7.4 28.8±7.2 0.841
    PLT(x±s,109/L) 110.8±87.8 172.3±120.5 0.049
    ALB(x±s,g/L) 27±6 25±5 0.270
    TBIL[M(QR), μmol/L] 21.9(8.0, 109.7) 18.0(7.7, 28.3) 0.431
    DBIL[M(QR), μmol/L] 10.2(3.5, 56.7) 10.9(3.1, 21.6) 0.537
    ALT[M(QR), U/L] 34.9(14.8, 194.8) 21.0(10.3, 54.4) 0.269
    AST[M(QR), U/L] 39.0(20.4, 106.3) 45.2(20.9, 81.0) 0.308
    BUN(x±s, mmol/L) 10.6±7.4 8.0±6.2 0.173
    UA(x±s, μmol/L) 327.7±136.3 316.0±143.9 0.771
    Cr(x±s, mmol/L) 146.6±106.9 146.6±82.3 0.999
    APTT(x±s, s) 39.8±9.6 42.0±13.9 0.529
    INR(x±s) 1.5±0.8 1.3±0.3 0.221
    PCT[M(QR), ng/ml] 18.4(6.0, 50.0) 16.1(7.5, 30.0) 0.832
    NSE[M(QR), μg/L] 18.9(10.8, 27.1) 11.7(6.6, 19.1) 0.641
    S100β[M(QR), μg/L] 0.37(0.21, 0.63) 0.27(0.10, 0.52) 0.472
    WBC:白细胞计数;Hb:血红蛋白;Hct:血细胞比容;PLT:血小板;ALB:白蛋白;TBIL:直接胆红素;DBIL:间接胆红素;ALT:谷丙转氨酶;AST:谷草转氨酶;BUN:尿素氮;UA:尿酸;Cr:肌酐;APTT:活化部分凝血酶原时间;INR:国际化标准比值;PCT:降钙素原;NSE:神经元特异烯醇化酶
    下载: 导出CSV

    表  4  两组感染性休克患者复苏后经颅多普勒脑血流

    血流动力学参数 死亡组(n=22) 存活组(n=29) P
    MAP(x±s,mm Hg) 81±30 78±24 0.747
    VsMCA(x±s,cm/s) 136.1±37.0 121.7±38.1 0.185
    VmMCA(x±s,cm/s) 80.6±29.7 78.2±24.4 0.747
    VdMCA(x±s,cm/s) 58.3±19.3 56.2±19.5 0.709
    PI(x±s) 0.95±0.20 0.84±0.21 0.082
    CBFi(x±s) 632.5±171.9 661.0±188.0 0.581
    S1/S2峰融合[n(%)] 13(59) 17(57) 0.973
    THRR<1.09 [n(%)] 8(36) 3(10) 0.025
    MAP:平均动脉压;VsMCA:大脑中动脉收缩期血流速度;VmMCA:大脑中动脉平均血流速度;VdMCA:大脑中动脉舒张期血流速度;PI:搏动指数;CBFi:脑血流指数;THRR:瞬时充血反应率
    下载: 导出CSV

    表  5  两组感染性休克患者复苏后rSO2比较

    指标 死亡组(n=22) 存活组(n=29) P
    rSO2值(%)
    最小值 53±7 57±6 0.053
    最大值 60±6 63±6 0.057
    平均值 56±7 60±7 0.031
    不同rSO2平均值的患者例数[n(%)]
    rSO2均值<60% 17(77) 12(41) 0.010
    rSO2均值<55% 10(45) 6(21) 0.590
    rSO2均值<50% 4(18) 3(10) 0.421
    rSO2:局部脑氧饱和度
    下载: 导出CSV

    表  6  51例感染性休克患者28 d死亡危险因素的多因素分析

    危险因素 B SE Wals P Exp(B) 95% CI
    SOFA 0.138 0.151 0.842 0.359 1.148 0.855~1.543
    APACHEⅡ评分(t0h) -0.052 0.100 0.267 0.605 0.950 0.780~1.156
    高峰APACHE Ⅱ评分 0.094 0.043 4.718 0.030 1.099 1.009~1.196
    氧合指数(t6h) -0.002 0.003 0.392 0.531 0.998 0.991~1.005
    Pcv-aCO2(t6h) 0.278 0.142 3.849 0.050 1.320 1.001~1.742
    PLT -0.006 0.003 3.572 0.059 0.994 0.988~1.001
    THRR指数<1.09 1.600 0.754 4.505 0.034 4.952 1.130~21.700
    rSO2平均值<60% 1.572 0.633 6.163 0.013 4.817 1.392~16.663
    SOFA、APACHEⅡ、Pcv-aCO2、PLT、THRR、rSO2:同表 1~5
    下载: 导出CSV
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  • 收稿日期:  2019-06-14
  • 刊出日期:  2019-09-30

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    【温馨提醒】近日,《协和医学杂志》编辑部接到作者反映,有多名不法人员冒充期刊编辑发送见刊通知,鼓动作者添加微信,从而骗取版面费的行为。特提醒您,本刊与作者联系的方式均为邮件通知或电话,稿件进度通知邮箱为:mjpumch@126.com,编辑部电话为:010-69154261,请提高警惕,谨防上当受骗!如有任何疑问,请致电编辑部核实。谢谢!