【作者】 刘小青；

【导师】 钱克俭；

【作者基本信息】 南昌大学 ， 急诊（专业学位）， 2021， 硕士

【摘要】 目的:讨论床旁超声联合早期目标导向治疗(EGDT)对重症肺炎合并脓毒性休克患者液体复苏的临床应用价值。方法:1.采用回顾性研究方法,从2019年1月至2019年12月南昌市第三医院重症监护病房收治的重症肺炎合并休克患者中选取符合纳入标准的30例为超声监测实验组,并从2018年1月至2018年12月收治的重症肺炎合并休克患者中选取30例为常规EGDT对照组。2.EGDT对照组施行早期目标导向治疗(EGDT)指导患者液体复苏;超声监测实验组实施超声联合EGDT指导液体复苏,比较两组患者治疗效果。3.两组患者入ICU后均给予抗感染、机械通气、镇痛镇静等治疗措施。4.EGDT组患者入住ICU6h内严格按照EGDT相关方案对患者实施治疗。中心静脉置管后,监测初次中心静脉压和中心静脉血氧饱和度数值,起初3h内给予30ml/Kg的晶体液体进行液体复苏,3h后液体无反应者使用去甲肾上腺素使MAP≥65mm Hg以上;积极复苏后仍低血压者或Lac>4mmol/L时,应在6小时内使CVP>8mm Hg、SCVO2≥70%。5.超声监测实验组患者在EGDT治疗的基础上,起初3h内给予30ml/Kg的晶体液体进行液体复苏,3h后实施EGDT联合床旁超声指导补液,监测心脏收缩情况、B线数量、下腔静脉直径以及下腔静脉变异率,适时调整补液方案。6.(1)记录6h液体量及去甲肾上腺素用量、机械通气时间;(2)记录患者复苏开始、复苏后6h的中心静脉压(CVP)、中心静脉血氧饱和度(Scv O2)、平均动脉压(MAP)、动脉血乳酸(LAC)及每小时尿量。(3)比较患者24h肺水肿发生率。结果:1.两组基本情况比较两组患者年龄、性别、BMI、SOFA评分无统计学意义(P>0.05).2.两组患者复苏指标比较开始时,两组CVP、Scv O2、MAP、LAC以及每小时尿量比较差异无统计学意义(P>0.05);液体复苏1h后,两组CVP、MAP、Scv O2、LAC以及每小时尿量均明显提高,与治疗前比较差异具有统计学意义(P<0.05);液体复苏6h后超声监测组CVP、Scv O2、MAP及每小时尿量均明显高于常规EGDT组,LAC明显低于常规EGDT组,两组经比较差异具有统计学意义(P<0.05);3.两组患者疗效指标比较超声监测组机械通气时间、6h液体复苏量及去甲肾上腺素量低于常规EGDT组,两组数据比较差异具有统计学意义(P<0.05);4.两组患者24h肺水肿发生率比较超声监测组出现肺水肿2例,发生率为6.67%;常规EGDT组出现肺水肿6例,发生率为20.00%,两组经比较后差异具有统计学意义(P<0.05)。结论:1.超声联合EGDT指导重症肺炎合并休克患者液体复苏能缩短机械通气时间、减少6h液体复苏量及去甲肾上腺素用量;2.超声结合EGDT指导重症肺炎合并脓毒性休克患者液体复苏,能有效减少肺水肿发生,改善患者心肺功能。更多还原

【Abstract】 Objective:To discuss the clinical value of bedside ultrasound combined with early target-based therapy(EGDT)for fluid resuscitation in patients with severe pneumonia complicated with septic shock.Methods:1.In retrospective study,30 patients with severe pneumonia complicated with shock admitted to the ICU of Nanchang Third Hospital from January 2019 to December 2019 were selected as the ultrasonic monitoring experimental group,who met the inclusion criteria.A total of 30 patients with severe pneumonia complicated with shock admitted from January 2018 to December 2018 were selected as the conventional EGDT control group.2.EGDT control group received early goal-directed therapy(EGDT)to guide fluid resuscitation;Ultrasonic monitoring The experimental group received ultrasound combined with EGDT to guide fluid resuscitation,and compared the treatment effect between the two groups.3.After admission to ICU,patients in both groups were treated with anti-infection,mechanical ventilation,analgesia and sedation.Therapeutic effect.4.Patients in the EGDT group were treated in strict accordance with the relevant EGDT protocol within 6 hours of admission to ICU.After central venous catheterization,the initial central venous pressure and oxygen saturation of central venous blood were monitored.In the first 3h,30ml/Kg crystalloid was given for fluid resuscitation.Patients with no liquid response after 3h were given noradrenaline to make MAP≥65mm Hg or above.In patients with hypotension or LAC >4mmol/L after active resuscitation,CVP>8mm Hg and Scv O2 ≥70% should be achieved within 6hours.5.Ultrasound monitoring Based on EGDT treatment,patients in the experimental group were given 30ml/Kg of crystalloid fluid for fluid resuscitation within the first 3h.After 3h,EGDT combined with bed side ultrasound guided fluid replacement was performed to monitor cardiac contraction,number of B-line,diameter of inferior vena cava and variation rate of inferior vena cava,and the fluid replacement program was adjusted timely.6.(1)6h fluid volume,norepinephrine dosage and mechanical ventilation time were recorded;(2)Central venous pressure(CVP),central venous oxygen saturation(Scv O2),mean arterial pressure(MAP),arterial lactic acid(LAC)and hourly urine volume were recorded at the beginning of resuscitation and 6h after resuscitation.(3)The incidence of 24 h pulmonary edema was compared.Results:1.Comparison of basic conditions between the two groups : There was no statistical significance in age,gender,BMI and SOFA score between the two groups(P>0.05);2.Comparison of resuscitation indexes between the two groups : AT the beginning of the comparison of resuscitation indexes between the two groups,there were no significant differences in CVP,scv O2,MAP,LAC and hourly urine volume between the two groups(P>0.05).After 1 hours of fluid resuscitation,CVP,MAP,scv O2,LAC and hourly urine volume were significantly increased in both groups,with statistical significance compared with before treatment(P < 0.05).After 6 hours of fluid resuscitation,CVP,scv O2,MAP and hourly urine volume in the ultrasound monitoring group were significantly higher than those in the conventional EGDT group,while LAC was significantly lower than that in the conventional EGDT group,and the difference between the two groups was statistically significant(P < 0.05);3.Comparison of curative effect indexes between two groups:The mechanical ventilation time,6h fluid resuscitation volume and norepinephrine volume in the ultrasonic monitoring group were lower than those in the conventional EGDT group,and the differences between the two groups were statistically significant(P < 0.05);4.Comparison of the incidence of 24 h pulmonary edema between two groups:The incidence of 24 h pulmonary edema between the two groups was compared in 2 cases(6.67%)of the ultrasonic monitoring group.There were 6 cases of pulmonary edema in the conventional EGDT group,the incidence was 20.00%,and the difference between the two groups was statistically significant after comparison(P < 0.05).Conclusion:1.Fluid resuscitation guided by ultrasound combined with EGDT in patients with severe pneumonia complicated with shock can shorten mechanical ventilation time,reduce 6h fluid resuscitation volume and norepinephrine consumption;2.Ultrasound combined with EGDT to guide fluid resuscitation in patients with severe pneumonia complicated with septic shock can effectively reduce the occurrence of pulmonary edema and improve the cardiopulmonary function of patients.更多还原