【摘要】 目的 探討微創經皮腎鏡碎石術后并發感染性休克的原因和防治措施。 方法 回顧性分析2005年1月-2010年12月5例經皮腎鏡術300例，其中術后并發感染性休克5例的臨床資料。男1例，女4例，均表現為術后2~8 h內出現寒戰、高熱、煩燥不安，血壓降至80/50 mm Hg（1 mm Hg=0.133 kPa）以下，心率超過120次/min。所有患者均行抗感染和抗休克治療。 結果 所有患者均在72 h內停用升壓藥，1周內體溫及血常規恢復正常，術后15 d治愈出院。 結論 感染性休克是微創經皮腎鏡碎石術嚴重的并發癥之一，術前有效抗感染、術中低壓灌注、術后加強生命體征的監測、早期發現并合理處理，可有效防治感染性休克的發生。【Abstract】 Objective To explore the etiology and treatment of septic shock after percutaneous nephrolithotomy. Methods From Janurary 2005 to December 2010, the clinical data of five patients with septic shock after percutaneous nephrolithotomy in our hospital were retrospectively analyzed. The patients, including one male and four females, had chillness and high temperature after the nephrolithotomy. The blood pressure decreased to under 80/50 mm Hg （1 mm Hg=0.133 kPa）, and the heart rate was more than 120 per minute. All patients underwent anti-shock and anti-infection therapies rapidly. Results Five patients were cured in the end, their temperature and blood routine tests returned to normal within one week. Conclusions Septic shock is one of the serious complications after percutaneous nephrolithotomy. Effective preoperative preparation, low pressure irrigation during operation, early diagnosis and treatment postoperatively are the effective ways to prevent the septic shock.
Objective To systemically review the efficacy and safety of dopamine versus norepinephrine in patients with septic shock. Methods Database searches of MEDLINE, EMbase, Cochrane Controlled Trials Register, VIP, CNKI, and CBM (from the date of database establishment to June 2011) were conducted. Additional studies for collecting relevant data were retrieved via both references of articles and direct contact with authors. Prospectively, randomized controlled trials (RCTs) of dopamine compared with norepinephrine therapy in septic shock patients were selected. The quality of included trials was assessed and relevant data were extracted. Then statistical analysis was performed using RevMan 5.1. Results Nine trials with 3 179 participants were included. The results of meta-analysis showed: compared with norepinephrine, dopamine was associated with a significant 12% elevation in the risk ratio of in-hospital death events of septic shock patients (RR=1.12, 95%CI 1.04 to 1.21, P=0.002). The risk of arrhythmias in dopamine group was 2.63-fold than that in norepinephrine group (RR=2.63, 95%CI 1.51 to 4.55, P=0.000 6). The cardiac index of septic patients in dopamine group was higher than that in norepinephrine group (MD=0.42, 95%CI 0.21 to 0.63, Plt;0.000 1). No significant difference could be found in the heart rate (MD=17.05, 95%CI –0.71 to 34.81, P=0.06) and mean arterial pressure (MD= –0.87, 95%CI –24.97 to 7.62, P=0.30). Conclusion Findings from this meta-analysis suggest that compared with dopamine, norepinephrine significantly reduces both 28-day mortality of septic shock patients and incidence rate of arrhythmias. Norepinephrine is better than dopamine in aspects of efficacy and safety.
ObjectiveTo explore the value of inferior vena cava inspiratory collapsibility (ΔIVC) in guiding septic shock resuscitation with early goal-directed therapy (EGDT).MethodsA single center, randomized controlled trial was conducted at an 812-bed hospital in Mianyang, Sichuan. Adult patients with early septic shock in the intensive care unit were assessed and treated at defined intervals over 6 h using an ΔIVC-guided resuscitation protocol or an EGDT protocol. Feasibility outcomes were fluid balance and norepinephrine administration. The primary clinical outcomes were in-hospital mortality rate, 90-day survival rate. Secondary outcomes included incidence of acute kidney injury and consumption of health resources.ResultsSixty-eight patients with septic shock were enrolled in this study. Baseline characteristics were similar between the two groups. The ΔIVC-guided septic shock resuscitation group was lower than the EGDT group in the ICU 24 h fluid replacement (L): 3.8 (4.0, 5.3) vs. 4.7 (4.0, 6.6), 72 h liquid positive balance (L): 0.2 (–0.65, 1.2) vs. 2.5 (0.0, 4.1), intensive care unit length of stay (d): 7.5 (5.0, 14.0) vs. 15.0 (7.0, 21.5), mechanical ventilation cumulative time (d): 3.0 (0.0, 7.0) vs. 7.5 (2.2, 12.0), ICU costs (ten thousand yuan): 3.4 (2.1, 5.9) vs. 8.6 (4.2, 16.5), bedside blood purification treatment costs (ten thousand yuan): 2.3 (1.1, 3.3) vs. 6.8 (2.1, 10.0) (P<0.05). No difference was observed in the incidence of acute kidney injury (P > 0.05), in-hospital mortality and 90-day survival between the two groups (log-rank χ2=0.35, P>0.05).ConclusionsAmong patients with septic shock, a ΔIVC-guided septic shock resuscitation, compared with EGDT, did not reduce in-hospital mortality. It might prevent the risk of over resuscitation, shorten the duration of mechanical ventilation, and lead to a better utilization of intensive care unit resources.
目的通過漂浮導管（Swan-Ganz導管）監測外周血管阻力指數（SVRI）作為優化的心功能不全狀態下感染性休克早期目標導向治療（EGDT）的臨床意義。 方法2012年1月至2014年1月第四軍醫大學附屬西京醫院心血管外科ICU收治體外循環心臟術后感染性休克患者8例，其中男7例、女1例，年齡（50.9±11.1）歲。以中心靜脈壓（CVP）為復蘇目標行經驗性容量復蘇治療，循環未見改善，則實施漂浮（Swan-Ganz）導管監測血流動力學指標，以外周血管阻力指數（SVRI）為優化目標復蘇，觀察Swan-Ganz導管復蘇前及復蘇6 h、24 h后的血流動力學及氧代謝指標，分析復蘇達標所需時間。 結果8例患者平均住ICU時間（16.87±3.35）d，發生肺部并發癥8例，急性腎功能衰竭5例，急性肝功能衰竭1例，消化道出血1例。6例28 d后病情好轉存活，死亡2例。8例感染性休克患者經Swan-Ganz導管目標導向治療6 h和24 h后平均動脈壓（MAP）分別為（65.8±2.76）mm Hg、（67.8±3.79）mm Hg，中心靜脈壓（CVP）分別為（12.75±3.37）cm H2O、（9.75±2.86）cm H2O，心排血量指數（CI）分別為（2.36±0.12）L·min-1·m-2、（2.41±0.39）L·min-1·m-2，外周血管阻力指數（SVRI）分別為（1 892.60±2 294.62）dyn·s·m2·cm-5、（2 053.90±205.54）dyn·s·m2·cm-5，各項指標均較治療前升高；治療6 h和24 h后動脈血乳酸分別為（11.83±1.16）mmol/L、（6.47±2.59）mmol/L，較治療前[（14.98±0.45）mmol/L]下降。 結論采用Swan-Ganz導管監測SVRI作為優化目標導向治療心功能不全狀態下感染性休克可以提高6 h復蘇成功率，改善患者預后。
ObjectiveTo evaluate the value of stroke volume variation (SVV) and intrathoracic blood volume index (ITBVI) to predict fluid responsiveness in mechanically ventilated septic shock patients with spontaneous breathing. MethodsA prospective observational study was conducted in the Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University. Fluid resuscitation data was collected in septic shock patients who received PiCCO monitoring from June 2013 to June 2014. Transpulmonary thermodilution data were collected before and after fluid resuscitation, including cardiac index (CI), SVV, ITBVI, and central venous pressure (CVP). Seventeen patients were defined as responders by an observed increase of≥15% in the cardiac index (CI) after fluid resuscitation, 12 patients were defined as non-responders. Pearson correlation between changes of CI (ΔCI) and SVV, ITBVI, CVP was established. Area under the receiver operating characteristic (ROC) curve of SVV, ITBVI and CVP was calculated for predicting fluid responsiveness. ResultsBaseline CI and ITBVI were significantly lower in the responders (P < 0.05).There was no significant difference in baseline SVV between the responders and the non-responders (P > 0.05). A significant correlation was found between baseline ITBVI andΔCI (r=-0.593, P < 0.001), but no significant correlation between SVV andΔCI (r=0.037, P=0.847) or CVP andΔCI (r=0.198, P=0.302). The area under ROC curve of SVV, ITBVI and SVV for predicting fluid responsiveness was 0.640 (P=0.207), 0.865 (P=0.001), and 0.463 (P=0.565), respectively. The cut-off value of ITBVI for predicting fluid responsiveness was 784 mL/m2 with a sensitivity of 100.0% and a specificity of 70.6%. ConclusionIn mechanically ventilated septic shock patients with spontaneous breathing, ITBVI may be a valuable indicator in predicting fluid responsiveness compared with SVV.
目的 探討孤立腎腎結石經皮腎鏡取石（PCNL）術并發感染性休克的護理。 方法 回顧性分析2010年3月－2012年10月5例孤立腎腎結石患者行PCNL術后并發感染性休克的臨床資料，對患者術后出現的休克及時補足血容量，使用有效的抗生素，早期足量應用激素、血管活性藥物，同時加強心理疏導、健康教育等護理措施。 結果 5例患者體溫均在3 d內降至正常；血管活性藥物平均使用時間為1.8 d （2～4 d）；1例因血氧飽和度＜80%，血壓＜85/50 mm Hg（1 mm Hg=0.133 kPa）轉往重癥監護病房行呼吸機輔助呼吸2 d后呼吸循環功能改善；另1例同時出現少尿無尿，及時行血液透析，第4天尿量逐漸恢復；5例患者均痊愈出院。 結論 感染性休克是PCNL術后最危險的并發癥之一，對其采取積極預防、及早發現、及時有效的治療和護理等措施，可有效促進患者康復。
Objective To evaluate the effects of intensive care unit (ICU)-acquired hypernatremia (IAH) on the outcome of septic shock patients. Methods This retrospective study analyzed 116 septic shock patients admitted to the ICU of the First Affiliated Hospital of Soochow University from August 2018 to December 2022. Patients were divided into two groups: IAH group and normonatremia group. χ2 test, t test and the Mann-Whitney U test of the non-parametric test were used to compare the differences in clinical data between the two groups. Independent risk factors for IAH were identified by unconditioned Logistic regression analysis, and receiver operating characteristic (ROC) curves were constructed to determine their role in predicting IAH. The Kaplan-Meier curve was used to evaluate the effects of IAH and its duration on 28-day survival. Results Renal insufficiency, K+ concentration, body temperature max, mechanical ventilation, chronic critical illness, rapid recovery, sepsis-associated encephalopathy, persistent inflammation, immunosuppression and catabolism syndrome, and the length of stay in ICU had significant differences (P<0.05). Multivariate logistic regression analysis showed: total urine volume in the previous 3 days [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.01 - 1.16, P=0.019] and sodium content in enteral nutrition preparations (670 mg) (OR 6.00, 95%CI 1.61 - 22.42, P=0.006) were independent risk factors for IAH. In addition, the area under the ROC curve of total urine output in the first 3 days was 0.800 (95%CI 0.678 - 0.922, P=0.001). Finally, the duration of IAH was significantly correlated with 28-day survival rate (P=0.020). Conclusions IAH is a common and serious complication in septic shock, and is the main cause of poor prognosis. Sodium status may act as an ideal screening tool for patients with septic shock.
Objective To evaluate the effects and the clinical significances of liquid resuscitation on blood gas analysis， acid-base balance， electrolytes， acute physiology and chronic health evaluationsⅡ（APACHEⅡ） score of patients with septic shock， and then to analyze the relations between serum chlorine （Cl－） level and APACHEⅡscore and the volume of liquid resuscitation. Methods According to the target of resuscitation （centre venous pressure 8-12mm Hg and mean arterial pressure≥65mm Hg）， 21 patients with septic shock received enough fluid for resuscitation during 24h . The results of blood gas analysis， acid-base balance， electrolytes， and APACHE Ⅱ score were compared between pre-resuscitation and 24h post-resuscitation by self-controlled prospective study. The relationships of the level of serum Cl－ and APACHEⅡ score with the volume of liquid used in resuscitation were analyzed . Results The mean resus-citation duration was （18.09±4.57） h， and the volume of liquid during 24 h resuscitation was 5 320-11 028mL with mean volume of （7 775±1 735） mL in 21 patients with septic shock. Serum sodium （Na＋， mmol/L） and Cl－（mmol/L）levels of post-resuscitation were significant higher than those of pre-resuscitation （Na＋：138.71±5.67 versus 135.62±7.23， P=0.024；Cl－：109.10±4.90 versus 101.67±8.59， P=0.000）. Compared with the levels of pre-resuscitation， the blood pH value， hematocrit （Hct，%）， anion gap （AG， mmol/L）， lactic acid （mmol/L）， and APACHE Ⅱscore significantly decreased （pH：7.31±0.05 versus 7.37±0.06， P=0.000；Hct：28.48±2.56 versus 32.76±9.19， P=0.049；AG：8.33±3.45 versus 14.17±8.83， P=0.004；lactic acid：1.66±0.89 versus 2.96±1.23， P=0.001；APACHEⅡ：10.90±3.73 versus 17.24±4.06， P=0.000） after 24h resuscitation. The correlation analysis showed that the level of serum Cl- was positively correlated with the volume of liquid used in resuscitation （r=0.717，P＜0.01）. However， there was no correlation between APACHEⅡscore and the volume of liquid used in resuscitation （P＞0.05）. Conclusions The target of liquid resuscitation in patients with septic shock should be cautiously determined， including control of the volume of crystal liquid for resuscitation， in order to avoid acid-base imbalance or hyperchloraemia. At the same time， the change in internal environment should be monitored. An optimistic fluid resuscitation to decrease APACHE Ⅱ score in patients with septic shock is unrelated to the volume of liquid resuscitation.