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目的:观察应用去甲肾上腺素提高感染性休克患者平均动脉压至平时水平时对全身血流动力学及舌下微循环的影响,探讨其相关变化关系。方法:本研究为单中心、前瞻性、干预性研究。根据Rivers提出早期目标导向性治疗(Early Goal-Directed Therapy,EGDT),给予积极液体复苏或联合应用血管活性药物,使中心静脉压(Central Venous Pressure,CVP)达8mm Hg后,平均动脉压(Mean Arterial Pressure,MAP)达65mm Hg,应用NICOM系统(Cheetah Medical,Portland,OR)无创血流动力学监测仪监测心输出量(Cardiac Output,CO)、每搏量(Stroke Volume,SV)、总外周血管阻力指数(Systemic Vascular Resistance Index,SVRI),应用旁流暗视野成像技术(Sidestream dark field,SDFMicroscan,Micro Vision Medical,Amsterdam,Netherlands)观察舌下微循环:总血管密度(Total Vascular Density,TVD)、灌注血管密度(Perfused Vascular Density,PVD)、灌注血管比例(Proportion of Perfused Vascular,PPV),微血管流动指数(Microvascular Flow Index,MFI)。增加剂量滴定至患者MAP至平时水平,再次监测上述血流动力学指标和微循环指标。结果:共纳入20名诊断感染性休克24小时以内的患者,男14例,女6例,利用去甲肾上腺素滴定平均动脉压至平时水平可以明显提高CVP[(11±4)mm Hg至(13±4)mm Hg,P=0.002],CO[(5.4±1.4)L/min至(6.4±2.1)L/min,P=0.002],增加SVRI(1 587dyn·s·m-2·cm-5~1 890dyn·s·m-2·cm-5,P=0.004)和中心静脉血氧饱和度[Scv O2(81±7)%至(83±7)%,P=0.001]。血乳酸在血压滴定前后未有显著变化。与MAP滴定前相比,SDF观察到血压滴定后舌下PVD[(10.96±2.98)vessels/mm2至(11.99±2.55)vessels/mm2,P=0.009],PPV[(85±18)%至(92±14)%,P=0.002]均明显增加,MFI(2.45±0.61至2.80±0.68,P=0.009)明显增加。结论:应用去甲肾上腺素滴定感染性休克患者MAP至平时水平可以改善全身血流动力学和舌下微循环,从而在临床上达到精细化和个体化治疗目标。
OBJECTIVE: To observe the effects of norepinephrine on systemic hemodynamics and sublingual microcirculation in patients with septic shock when mean arterial pressure (MAP) changes to normal levels, and to explore the relationship between them. Methods: This study was a single-center, prospective, intervention study. According to Rivers’ proposal of Early Goal-Directed Therapy (EGDT), active liquid resuscitation or combination of vasoactive drugs was applied to make Mean Venous Pressure (CVP) of 8 mm Hg. Mean mean arterial pressure (Arterial Pressure, MAP) of 65 mm Hg was measured. Cardiac Output (CO), Stroke Volume (SV), Total Peripheral Circumference Sublingual microcirculation was observed using the Systemic Vascular Resistance Index (SVRI) using the Sidestream dark field (SDF Microsroscan, Micro Vision Medical, Amsterdam, Netherlands): Total Vascular Density (TVD) , Perfused Vascular Density (PVD), Proportion of Perfused Vascular (PPV) and Microvascular Flow Index (MFI). Increase the dose titration to MAP patients to normal levels, again to monitor the above hemodynamic indicators and indicators of microcirculation. Results: A total of 20 patients diagnosed septic shock within 24 hours, 14 males and 6 females, the use of norepinephrine titer mean arterial pressure to normal levels can significantly improve CVP [(11 ± 4) mm Hg to ( (14 ± 4) L / min to (6.4 ± 2.1) L / min, P = 0.002] and increased SVRI (1558dyn · s · m-2 · cm -5 ~ 1890dyn · s · m-2 · cm-5, P = 0.004) and central venous oxygen saturation [Scv O2 (81 ± 7)% to (83 ± 7)%, P = 0.001]. Blood lactate before and after blood pressure titration did not change significantly. SDF observed sublingual PVD [(10.96 ± 2.98) vessels / mm2 to (11.99 ± 2.55) vessels / mm2, P = 0.009], PPV [(85 ± 18)% to 92 ± 14)%, P = 0.002], MFI (2.45 ± 0.61 to 2.80 ± 0.68, P = 0.009) increased significantly. Conclusion: The application of norepinephrine titration septic shock patients with MAP to normal levels can improve systemic hemodynamics and sublingual microcirculation, so as to achieve the clinical goal of fine and individualized treatment.