| 倪主昂,吕 丹,张柯基,龚 好,徐欣晖,朱长清.中心静脉-动脉二氧化碳分压差与动脉-中心静脉氧含量差的比值(Pcv-aCO2/Ca-cvO2)变化率对急诊重症监护室脓毒症患者预后的评估价值[J].,2019,19(16):3073-3079 |
| 中心静脉-动脉二氧化碳分压差与动脉-中心静脉氧含量差的比值(Pcv-aCO2/Ca-cvO2)变化率对急诊重症监护室脓毒症患者预后的评估价值 |
| The Change Rate of Central Venous-arterial Carbon Dioxide Tension Difference to Arterial-central Venous Oxygen Content Difference Ratio for Evaluating Progression and Prognosis in Patients with Sepsis in the Emergency Intensive Care Unit |
| 投稿时间：2018-12-31 修订日期：2019-01-25 |
| DOI：10.13241/j.cnki.pmb.2019.16.013 |
| 中文关键词: 脓毒症 中心动静脉二氧化碳分压差/氧含量差 中心动静脉二氧化碳分压差/氧含量差变化率 中心动静脉二氧化碳分压差 预后 |
| 英文关键词: Sepsis Central venous-arterial carbon dioxide tension to arterial-venous oxygen content ratio The change rate of central venous-arterial carbon dioxide tension difference to arterial-venous oxygen content difference ratio Central venous-to-arterial carbon dioxide difference Prognosis |
| 基金项目:上海市卫生和计划生育委员会科研项目(201640220) |
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| 摘要 目的：探讨中心静脉动脉二氧化碳分压差/氧含量差(Pcv-aCO2/Ca-cvO2)变化率在急诊重症监护室(EICU)高乳酸脓毒血症患者病情及预后评估中的临床应用价值。方法：选择2017年1月到2018年9月入住急诊重症监护室的48例高乳酸(乳酸大于4 mmol/h)脓毒血症患者，均按2016年脓毒症指南进行液体复苏治疗。采集复苏前(T0h)和开始复苏后6h(T6h)、24h(T24h)的动脉血、上腔静脉血气分析以及动脉血乳酸浓度。计算并记录各时间点的乳酸，乳酸清除率，中心静脉动脉二氧化碳分压差(Pcv-aCO2)值，中心静脉动脉二氧化碳分压差/氧含量(Pcv-aCO2/Ca-cvO2)值及其变化率。根据治疗24h改良SOFA评分是否改善将患者分为两组，即改良SOFA改善组和未改善组，观察和比较两组间基本临床资料及化验参数，并分析各时间点各参数之间的相关性，以及这些参数能否有效预测高乳酸脓毒血症患者病情危重程度和预后。结果：45例患者纳入最终分析，3例因为24h内死亡或者自动出院脱落。其中，17例24hSOFA改善，28例未改善；20例死亡，25例存活。两组患者复苏前各项一般临床资料指标比较差异均无统计学意义(P>0.01)。24hSOFA改善组与未改善组患者Pcv-aCO2/Ca-cvO2（T24h）、Pcv-aCO2/Ca-cvO2变化率（0-24h）存在组间差异(P<0.01)。45例患者的乳酸清除率(0-24h)与Pcv-aCO2/Ca-cvO2变化率(0-24h)呈显著相关性(r=0.906，P=0.034)。ROC分析显示Pcv-aCO2/Ca-vO2变化率(0-24h)能有效预测24hSOFA评分改善，同其他指标相比，曲线下面积最大（AUROC=0.851），最佳界值是0.307（30.7%），敏感度是76.5%，特异度是92.9%；Pcv-aCO2/Ca-vO2变化率(0-24h)也能有效预测脓毒症患者院内死亡，AUROC=0.696，AUROC较24h乳酸值小，但不存在统计学差异，最佳界值是0.181（18.1%），敏感度是65%，特异度是68%。结论：液体复苏前到开始复苏后24h的Pcv-aCO2/Ca-cvO2变化率可以有效预测高乳酸脓毒症患者的器官功能改善情况，也能有效预测脓毒症患者院内死亡的发生。 |
| 英文摘要: |
| ABSTRACT Objective: To investigate the clinical value of change rate of central venous-arterial carbon dioxide tension difference to arterial-central venous oxygen content difference ratio (Pcv-aCO2/Ca-cvO2) for evaluating the progression and the prognosis of septic patients with high level of lactate in the emergency intensive care unit (EICU). Methods: Forty-eight septic patients with high level of lactate (lactic acid >4 mmol/h) admitted to EICU from January 2017 to September 2018 were enrolled. All the patients were given an initial resuscitation therapy according to the 2016 sepsis guidelines. The arterial and central venous blood gases and lactate level were measured simultaneously at baseline(T0h), 6 hours after resuscitation(T6h) and 24 hours after resuscitation(T24h). The lactate level, lactate clearance rate (LCR), Pcv-aCO2, Pcv-aCO2/Ca-cvO2 and Pcv-aCO2, Pcv-aCO2/Ca-cvO2 change rate were calculated. The patients were classified into two groups according to the improvement of 24-hour sequential organ failure assessment (SOFA) score. The basic clinical data and laboratory parameters of each group were analyzed and compared, and the relationship among Pcv-aCO2, Pcv-aCO2/Ca-cvO2, the change rate of Pcv-aCO2/Ca-cvO2 and lactate was analyzed. The relationship between the severity and prognosis of sepsis with hyperlactatemia and the above parameters was also analyzed. Results: Forty-five patients were included in the final analysis, and three patients were removed due to death or discharge within 24 hours. Twenty patients died and 25 survived eventually; 24-hour SOFA improved in 17 cases, and did not in 28 cases. There were no significant differences in the general clinical data between the two groups before resuscitation. The difference of Pcv-aCO2/Ca-cvO2 at 24 hours after resuscitation and its change rate at 0-24h were statistically significant between the SOFA improved group and the unimproved group (both P<0.01). There was a good correlation between the 24-hour LCR and the change rate of Pcv-aCO2/Ca-cvO2 in 45 patients (r=0.906, P=0.034). For the prediction of SOFA improvement, the area under ROC curve (AUC) of the change rate of Pcv-aCO2/Ca-cvO2 during the 24 hours after the onset of resuscitation was 0.851. At the cut-off value of 0.307(30.7%), the change rate of Pcv-aCO2/Ca-cvO2 (0-24h) had a sensitivity of 76.5%, a specificity of 92.9% in the prediction of SOFA improvement. ROC analysis of death prediction showed that the area under the Pcv-aCO2/Ca-cvO2 (0-24h) was 0.696, which had no significant statistical difference with the lactate level at 24h. At the cut-off value of 0.181(18.1%), the change rate of Pcv-aCO2/Ca-cvO2 (0-24h) had a sensitivity of 65%, a specificity of 68% in the prediction of the in-hospital death in septic patients. Conclusion: The change rate of Pcv-aCO2/Ca-cvO2 during the 24 hours after the onset of resuscitation can well predict the improvement of organ function in septic patients with hyperlactatemia and the death of septic patients with?hyperlactatemia. |
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