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无创心排量联合中心静脉血氧饱和度监测对高脂血症性重症胰腺炎早期目标导向性液体复苏的指导作用
DOI: 10.3969/j.issn.1001-5256.2022.07.026
伦理学声明：本研究方案于2018年4月2日经广州市花都区人民医院伦理委员会审批，批号：2018050，所有纳入患者均签署知情同意书。
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明：曹天生、马克强、巫泓生负责研究的设计；廖碧玲、嵇腾飞、黄健斌负责患者资料及数据采集；巫泓生负责数据统计分析、论文撰写；曹天生负责稿件的校审及定稿。
Guiding effect of noninvasive monitoring of cardiac output and central venous oxygen saturation on early goal-directed fluid resuscitation in hyperlipidemic severe acute pancreatitis
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摘要:
目的 探讨无创心排量(CO)联合中心静脉血氧饱和度(ScvO2)监测对高脂血症性重症胰腺炎患者早期目标导向性液体复苏的指导作用。 方法 选取广州市花都区人民医院2018年1月—2020年12月收治的84例高脂血症性重症胰腺炎患者为研究对象，患者随机分为研究组和对照组两组，每组各42例。对照组通过监测患者平均动脉压(MAP)及中心静脉压(CVP)进行目标导向性液体复苏；研究组通过床旁多普勒无创血流动力学检测仪动态监测患者CO，及PreSep导管经中心静脉导管监测患者ScvO2，指导患者目标导向性体液复苏。比较两组患者早期容量达标时间、腹痛症状缓解时间、胃肠功能恢复时间及甘油三酯(TG)恢复时间、治疗后6 h的血乳酸清除率，治疗前、治疗后第3、7天的APACHE-Ⅱ评分的变化情况及急性胰腺炎早期并发症发生情况。计量资料组间比较采用t检验，计数资料组间比较采用χ2检验。 结果 研究组容量达标时间较对照组明显提前[(8.7±1.6)h vs (19.6±2.1)h, t=-18.86, P＜0.05]、腹痛症状缓解时间较对照组明显缩短[(3.4±1.2)d vs (5.8±1.5)d, t=-16.74, P＜0.05]、胃肠道功能恢复时间较对照组明显提前[(5.6±2.3)d vs (8.2±2.5)d, t=-11.74, P＜0.05]及血清TG降至正常水平时间较对照组明显缩短[(5.5±1.6)d vs (9.7±1.7)d, t=10.76, P＜0.05]；研究组第3天和第7天的APACHE-Ⅱ评分较对照组降低(11.86±1.88 vs 20.75±1.63, t=-17.36, P＜0.05; 6.21±1.13 vs 14.36±1.53, t=-18.41, P＜0.05)，研究组入院后6 h动脉血乳酸水平较对照组明显降低[(4.24±0.23)mmol/L vs (5.07±0.17)mmol/L, t=-17.76, P＜0.05], 而6 h动脉血乳酸清除率明显高于对照组[(23.74±0.44)% vs (10.74±0.67)%, t=-17.73, P＜0.05]；对两组患者早期并发症对比分析，研究组胰周急性坏死积聚发生率明显低于对照组(4.76% vs 19.05%, χ2=16.63, P＜0.05)、肺部感染发生率较对照组明显降低(9.52% vs 38.10%, χ2=15.78, P＜0.05)、胸腔积液发生率较对照组明显降低(35.71% vs 88.10%, χ2=8.96, P＜0.05)、消化道出血发生率较对照组明显降低(7.14% vs 16.67%, χ2=7.45, P＜0.05) 及器官功能衰竭发生率较对照组明显降低(11.90% vs 30.95%, χ2=7.96, P＜0.05)。 结论 临床上应用无创CO联合ScvO2监测对高脂血症性重症胰腺炎患者的早期目标导向性液体复苏具有重要指导意义，能明显改善高脂血症性重症胰腺炎的临床救治效果。 -
关键词:
- 胰腺炎, 急性坏死性 /
- 高脂血症 /
- 复苏术 /
- 心排血量 /
- 血气分析
Abstract:Objective To investigate the guiding effect of noninvasive monitoring of cardiac output (CO) and central venous oxygen saturation (ScvO2) on early goal-directed fluid resuscitation in patients with hyperlipidemic severe acute pancreatitis. Methods A total of 84 patients with hyperlipidemic severe acute pancreatitis who were admitted to the People's Hospital of Huadu District from January 2018 to December 2020 were enrolled as subjects and randomly divided into research group and control group, with 42 patients in each group. In the control group, goal-directed fluid resuscitation was performed by monitoring mean arterial pressure and central venous pressure, and in the research group, goal-directed fluid resuscitation was guided by the dynamic monitoring of CO through a bedside Doppler noninvasive hemodynamic detector and the monitoring of ScvO2 through PreSep central venous catheter. The two groups were compared in terms of time to early volume reaching standard (hour), time to relief of abdominal pain (day), time to gastrointestinal function recovery (day), time to triglyceride (TG) recovery (day), lactate clearance rate at 6 hours after treatment, change of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE-Ⅱ) score from before treatment to days 3 and 7 after treatment, and early complications of acute pancreatitis. The t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups. Results Compared with the control group, the research group had significantly shorter time to volume reaching standard (8.7±1.6 hours vs 19.6±2.1 hours, t=-18.86, P < 0.05), time to relief of abdominal pain (3.4±1.2 days vs 5.8±1.5 days, t=-16.74, P < 0.05), time to gastrointestinal function recovery (5.6±2.3 days vs 8.2±2.5 days, t=-11.74, P < 0.05), and time for TG to decrease to the normal level (5.5±1.6 days vs 9.7±1.7 days, t=10.76, P < 0.05). Compared with the control group, the research group had a significantly lower APACHE-II score on days 3 and 7 (day 3: 11.86±1.88 vs 20.75±1.63, t=-17.36, P < 0.05; day 7: 6.21±1.13 vs 14.36±1.53, t=-18.41, P < 0.05), a significantly lower arterial blood lactate level at 6 hours after admission (4.24±0.23 mmol/L vs 5.07±0.17 mmol/L, t=-17.76, P < 0.05), and a significantly higher arterial blood lactate clearance rate at 6 hours (23.74%±0.44% vs 10.74%±0.67%, t=-17.73, P < 0.05). The comparison of early complications showed that compared with the control group, the research group had significantly lower incidence rates of peripancreatic acute necrotic collection (4.76% vs 19.05%, χ2=16.63, P < 0.05), pulmonary infection (9.52% vs 38.10%, χ2=15.78, P < 0.05), pleural effusion (35.71% vs 88.10%, χ2=8.96, P < 0.05), gastrointestinal bleeding (7.14% vs 16.67%, χ2=7.45, P < 0.05), and organ failure (11.90% vs 30.95%, χ2=7.96, P < 0.05). Conclusion Noninvasive monitoring of CO and ScvO2 in clinical practice has an important guiding significance for early goal-directed fluid resuscitation in patients with hyperlipidemic severe acute pancreatitis and can significantly improve the clinical treatment outcome of hyperlipidemic severe acute pancreatitis. -
Key words:
- Pancreatitis, Acute Necrotizing /
- Hyperlipidemias /
- Resuscitation /
- Cardiac Output /
- Blood Gas Analysis
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表 1 Marshall评分内容
Table 1. The content of Marshall scoring systerm
器官和系统 1分 2分 3分 4分 呼吸(PaO2/FiO2) 301~400 201~300 101~200 ＜101 肾功能(Cr, μmol/L) 110~170 171~299 300~440 ＞440 肝功能(胆红素, μmol/L) 20~32 33~101 102~204 ＞204 循环系统(收缩压，mmHg) ＜90，补液后纠正 ＜90，补液后不能纠正 ＜90，pH＜7.3 ＜90，pH＜7.2 注：PaO2，动脉血氧分压；FiO2，吸入氧气浓度。 
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表 2 两组患者的基本资料比较
Table 2. Comparison of basic data between two groups
项目 研究组(n=42) 对照组(n=42) 统计值 P值 男/女(例) 31/11 29/13 χ2=0.623 0.446 年龄(岁) 52.21±1.82 55.15±2.11 t=-0.325 0.724 脉搏(次/min) 118.34±7.63 114.27±5.94 t=-0.344 0.763 呼吸(次/min) 23.87±2.21 25.16±2.73 t=-0.318 0.649 白细胞计数(×109/L) 15.14±3.43 16.42±2.91 t=0.486 0.972 红细胞比容(%) 46.74±2.86 47.65±3.14 t=0.369 0.877 血红蛋白(×1012/L) 117.77±4.75 120.21±5.27 t=0.435 0.761 CRP(mg/L) 108.68±24.30 113.13±22.80 t=0.034 0.895 血肌酐(μmol/L) 160.52±15.83 164.21±17.22 t=0.036 0.831 尿素氮(mmol/L) 27.33±3.14 26.59±2.74 t=-0.434 0.698 白蛋白(g/L) 31.37±2.85 30.45±2.23 t=0.562 0.773 ALT(U/L) 158.66±8.91 164.35±9.62 t=0.763 0.579 血糖(mmol/L) 14.91±2.54 15.52±3.16 t=0.567 0.733 血淀粉酶(U/L) 1 245.57±80.42 1 250.27±78.76 t=0.048 0.769 血清钙离子(mmol/L) 1.82±0.71 1.89±0.52 t=0.288 0.583 动脉血pH值 7.38±0.23 7.42±0.37 t=-1.256 0.342 血乳酸(mmol/L) 5.56±0.34 5.68±0.25 t=-1.257 0.355 血清TG(mmol/L) 37.43±3.15 39.58±3.84 t=-0.486 0.674
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表 3 两组患者容量达标、腹痛症状消失及血清TG降至正常水平的时间比较
Table 3. Comparison of the time of volume reached standard, symptoms of abdominal pain disappeared and the serum TG reached to normal level between two groups
项目 研究组(n=42) 对照组(n=42) t值 P值 容量达标时间(h) 8.7±1.6 19.6±2.1 -18.86 ＜0.05 腹痛症状消失时间(d) 3.4±1.2 5.8±1.5 -16.74 ＜0.05 胃肠功能恢复时间(d) 5.6±2.3 8.2±2.5 -11.74 ＜0.05 TG降至正常时间(d) 5.5±1.6 9.7±1.7 10.76 ＜0.05
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表 4 两组患者APACHE-Ⅱ评分及6 h动脉血乳酸清除结果比较
Table 4. Comparison of APACHE-Ⅱ and 6h arterial blood lactate clearance between two groups
项目 研究组(n=42) 对照组(n=42) t值 P值 APACHE-Ⅱ评分 治疗前 25.12±2.41 24.33±2.62 -1.78 0.087 治疗3 d 11.86±1.88 20.75±1.63 -17.36 ＜0.05 治疗7 d 6.21±1.13 14.36±1.53 -18.41 ＜0.05 血乳酸(mmol/L) 治疗前 5.56±0.31 5.68±0.22 -1.69 0.093 治疗6 h 4.24±0.23 5.07±0.17 -17.76 ＜0.05 6 h血乳酸清除率(%) 23.74±0.44 10.74±0.67 -17.73 ＜0.05
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表 5 两组患者并发症发生率的比较
Table 5. Comparison of the incidence of complications between two groups
早期并发症 研究组(n=42) 对照组(n=42) χ2值 P值 胰周急性坏死积聚[例(%)] 2(4.76) 8(19.05) 16.63 ＜0.05 肺部感染[例(%)] 4(9.52) 16(38.10) 15.78 ＜0.05 胸腔积液[例(%)] 15(35.71) 37(88.10) 8.96 ＜0.05 消化道出血[例(%)] 3(7.14) 7(16.67) 7.45 ＜0.05 器官衰竭[例(%)] 5(11.90) 13(30.95) 7.96 ＜0.05
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