【摘要】 目的探讨血浆胶体渗透压（plasma colloid osmotic pressure,PCOP）指导下的早期目标导向治疗（EGDT）对感染性休克患者的临床效果。方法选择2014-03²016-02贵州省人民医院急诊科ICU收治的40例感染性休克患者,按随机数字表法分为EGDT组（20例）和PCOP组（20例）。EGDT组给予常规感染性休克集束化治疗方案进行液体复苏;PCOP组除了常规EGDT治疗外同时采血监测PCOP值,并根据PCOP值指导液体复苏,始终稳定PCOP在正常值范围（19²5 mm Hg）。两组在诊断感染性休克0、6、24、72 h时间点监测患者急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、使用血管活性药物的例数、氧合指数（PaO₂/FiO₂）、血清降钙素原（PCT）水平、中心静脉压（CVP）、平均动脉压（MAP）、动脉血乳酸;并计算患者机械通气时间、住ICU时间、14d病死率等指标。结果两组患者治疗后APACHEⅡ评分、使用血管活性药物的例数均较治疗前逐渐降低,治疗后72h时PCOP组显著低于EGDT组[APACHEⅡ评分（分）:13.2±6.3比17.21±6.5,使用血管活性药物的例数:4比9,均P<0.05]。两组患者治疗后氧合指数均升高,PCOP组治疗后72 h明显高于EGDT组[PaO₂/FiO₂（mm Hg）:157.5±21.2比112±20.2]。治疗后两组PCT均逐渐下降,各时间点均明显低于治疗前（均P<0.05）,而两组间各时间点比较差异无统计学意义。两组治疗后乳酸清除率均逐渐增加,PCOP组各时间点乳酸清除率均明显高于EGDT组[6 h:（18.7±8.1）%比（15.4±7.1）%,t=-6.033,P=0.001;24 h:（21.3±7.3）%比（11.4±7.1）%,t=-4.516,P=0.001;72h:（28.6±5.9）%比（19.2±9.4）%,t=-6.836,P=0.001]。PCOP组治疗后6 h使用复苏液体量明显多于EGDT组（mL:3912±892比2796±795,t=-3.781,P=0.031）,而24 h和72 h复苏液体量均较EGDT组明显减少,以72 h为最低（mL:1023±452比1845±420,t=5.908,P=0.033）。PCOP组机械通气时间（h:93.4±21.3比125.3±29.6,t=9.753,P=0.001）、住ICU时间（d:7.3±2.9比9.8±3.6,t=2.993,P=0.004）也较EGDT组明显缩短,但14d病死率略低于EGDT组[27.27%（6/22）比33.33%（7/21）,t=0.433,P=0.752]。结论以PCOP为导向的EGDT能降低感染性休克患者的疾病严重程度,更准确地指导液体复苏、减少肺水提高氧合,缩短机械通气时间和住ICU时间,具有很大的临床意义。更多还原

【Abstract】 Objective To investigate the clinical effect of early goal directed therapy（EGDT）guided by plasma colloid osmotic pressure in patients with septic shock.Methods Forty cases of patients with septic shock were selected from March 2014 to February 2016 in the emergency department of Guizhou People’s Hospital,the patients were divided into EGDT group（20 cases） and plasma colloid osmotic pressure（PCOP） group（20 cases） according to the random number table method.The EGDT group was given routine septic shock bundle treatment program for fluid resuscitation,the blood sampling was selected to monitor PCOP value in PCOP group in addition to conventional EGDT treatment,and according to the PCOP value to guide the fluid recovery,always stabling the PCOP values in the normal ranges（19 25 mm Hg）.The following indicators were detected in two groups in the diagnosis of infection shock 0,6,24,72 h time point including acute physiology science and chronic health evaluationⅡ（APACHE Ⅱ） score,and number of application cases of vasoactive drugs,the oxygen index（PaO₂/FiO₂）,serum procalcitionin（PCT） level,central venous pressure（CVP）,mean arterial pressure（MAP）,blood lactic acid,and calculating the time of mechanical ventilation and living intensive care unit（ICU）time as well as 14 days fatality rate.Results The APACHE Ⅱ score and the number of application cases of vasoactive drugs were decreased gradually comparing with before treatment,the above indicates in the PCOP group were significantly lower than that of traditional liquid group in the treatment 72 h[APACHEⅡ score（sub）:（13.2±6.3）vs.（17.21±6.5）,use of vasoactive drugs cases:4 vs.9,P<0.05].After treatment,the oxygenation index of the two groups increased,the PCOP group was significantly higher than that of the traditional EGDT group in the treatment 72 h[PaO₂/FiO₂:（157.5±21.2） mm Hg vs.（112±20.2） mm Hg].The PCT levels were gradually decreased after treatment and significantly lower than those before treatment at the 72 h hours point（all P< 0.05）,but there was no significant difference between the two groups at each time point.The lactate clearance rate increased gradually in two groups,but the lactic acid clearance rate in the PCOP group at each time point were significantly higher than those of conventional liquid resuscitation group[6 h:（18.7±8.1）%vs.（15.4±7.l）%,t =-6.033,P =0.001;24 h:（21.3±7.3）%vs.（11.4±7.1）%,t =-4.516,P = 0.001;48 h:（28.6±5.9）%vs.（19.2±9.4）%,t =-6,836,P = 0.001].The volume of fluid resuscitation of PCOP group within 6 hours were significantly higher than that of EGDT group[（3912±892） mL vs.（2796±795） mL,t =-3.781,P =0.031);the volume of fluid resuscitation after the 24 h and 72 h were decreased significantly comparing with the traditional cluster group;it was the lowest after the 72 h[（1023±452） mL vs.（1845±420）mL,t = 5.908,P = 0.033).The mechanical ventilation time and the length of ICU stay were significantly shorter than the traditional EGDT,the mechanical ventilation time[（93.4±21.3）h vs.（12.53±29.6）h,t = 9.753,P = 0.001],length of ICU stay[（7.3±2.9） d vs.（9.8±3.6） d,t = 2.993,P = 0.004),but 14 days fatality rate was slightly lower than that of traditional EGDT[27.27%（6/22） than 33.33%（7/21）,t = 0.433,P = 0.752].Conclusion The early goal-directed therapy guided by the plasma colloid osmotic pressure can reduce the severity of the patients with septic shock,guide fluid resuscitation more accurately and reduce lung water to improve oxygenation,and shorten the time of mechanical ventilation and ICU stay,so it has great clinical significance.更多还原