脉搏指示连续心输出量监测在老年急性心肌梗死合并心源性休克患者中的应用

Applicaton of pulse-indicated continuous cardiac output in elderly acute myocardial infarction patients with cardiac shock

摘要:

目的 探讨脉搏指示连续心输出量(PICCO)监测技术在老年急性心肌梗死(AMI)合并心源性休克(CS)患者中的应用。 方法 回顾性分析2013年6月至2018年6月在解放军第三〇五医院重症监护室(ICU)收治的AMI合并CS患者60例。按照是否行PICCO监测,分为PICCO组30例及对照组30例。检查并记录2组患者治疗前后乳酸、尿量、血压和血清B型脑钠肽(BNP)变化趋势、患者ICU入住时间、机械通气时间、血管活性药物使用时间及疾病预后情况。PICCO组患者按照预后不同,分为死亡组及存活组。检查并记录2组患者之间及治疗前后心指数(CI)、血管外肺水指数(EVLWI)、全心舒张末期容积(GEDVI)、系统血管阻力指数(SVRI)及全心射血分数(GEF)的变化。评估上述指标对于老年AMI合并CS患者预后的预测价值。采用SPSS 13.0统计学软件进行数据处理,使用受试者工作特征(ROC)曲线分析相关指标对于患者预后的预测能力。 结果 PICCO组在治疗12、24及48h后,其乳酸及BNP水平较对照组明显降低,平均小时尿量较对照组明显增多,差异均有统计学意义(均P<0.05)。PICCO组ICU入住时间、机械通气时间及血管升压活性药物使用时间均显著小于对照组,差异均有统计学意义(均P<0.05)。PICCO组患者7d病死率较对照组显著降低(均P<0.05),但14及28d病死率比较,差异无统计学意义(P>0.05)。存活组及死亡组患者治疗后的CI及GEF均较治疗前明显增高,EVLWI及SVRI均较治疗前明显下降(均P<0.05)。且存活组的治疗前CI及GEF明显高于死亡组,SVRI明显低于死亡组；存活组在治疗48h后的CI、GEF仍明显高于死亡组,SVRI及EVLWI明显低于死亡组(均P<0.05)。ROC曲线分析提示治疗前CI、GEF、SVRI和治疗48h后的CI、GEF、SVRI和EVLWI均可有效预测患者28d的预后状况。结论 PICCO指导老年AMI合并CS患者的复苏较传统治疗方式有更好的效果,并且其指标对于患者的预后具有一定的预测作用。

Abstract:

Objective To explore the applicaton of pulse-indicated continuous cardiac output (PICCO) in the elderly acute myocardial infarction (AMI) patients with cardiogenic shock (CS). Methods A retrospective analysis was made of 60 AMI patients with CS, who were admitted to the intensive care unit (ICU) of our hospital from June 2013 to June 2018. The patients were divided into PICCO group (n=30) and control group (n=30). A central venous catheter was inserted into the patient of control group to measure the central venous pressure. The following items were observed and recorded before and after the treatment:lactic acid, urine volume, blood pressure, and serum B-type natriuretic peptide (BNP). Record was made of ICU admission time, mechanical ventilation time, administration time of vasoactive drug, and prognosis. The PICCO group was further divided into the survival group and the death group. The two groups were compared before and after treatment in cardiac index (CI), extravascular lung water index (EVLWI), global end-diastolic volume (GEDVI), systemic vascular resistance index (SVRI), and global ejection fraction (GEF). The above indicators were evaluated of the predictive value for the prognosis in the AMI elderly patients with CS. SPSS statistics 13.0 was used for data processing, and the receiver operating characteristic (ROC) curve was used to analyze the predictive ability of the relevant indicators for the patient′s prognosis. Results At 12,24 and 48h after the treatment, lactic acid and BNP in PICCO group were lower, and the mean hourly urine volume was higher than those in the control group, the differences being statistically significant (P<0.05 for all). The PICCO group had shorter ICU stay, mechanical ventilation and vasopressor use than the control group with statistically significant differences (P<0.05 for all). The 7-day fatality rate in the PICCO group was significantly lower than that in the control group; however, there was no statistical difference with 14-day and 28-day fatality rate. After the treatment, CI and GEF were significantly higher and EVLWI and SVRI significantly lower than those before the treatment in both survival and death groups. At 48h after the treatment, CI and GEF were significantly higher,and SVRI significantly lower in the survival group than in the death group before treatment (P<0.05 for all). ROC curve analysis suggested that CI, GEF, SVRI before the treatment and CI, GEF, SVRI, EVLWI at 48 hours after the treatment can effectively predict the 28-day prognosis. Conclusion Employment of PICCO is more effective than the traditional treatment in guiding the recovery of the elderly acute myocardial infarction patients with cardiogenic shock, and the indicators of PICCO contribute to predict prognosis.