平均动脉压水平与EICU感染性休克患者肾功能关系的回顾性分析

doi:10.3760/cma.j.issn.1007-1245.2023.14.012

摘要/Abstract

摘要：

目的　探讨平均动脉压水平与急诊重症监护室（EICU）感染性休克患者肾功能的关系。方法　采用回顾性分析，纳入同济大学附属东方医院胶州医院2018年1月至2020年1月收治的83例EICU感染性休克患者为研究对象，按早期导向治疗后患者平均动脉压（MAP）实际维持水平分为3组。A组（46例）：MAP实际维持水平<入EICU前1年内平时MAP水平的75%；B组（25例）：入EICU前1年内平时MAP水平的75%<MAP实际维持水平<入EICU前1年内平时MAP水平的90%；C组（12例）：入EICU前1年内平时MAP水平的90%<MAP实际维持水平<入EICU前1年内平时MAP水平。记录治疗前后肾主动脉、肾叶间动脉血流动力学指标（舒张期峰值流速、平均流速、血流灌注指数）与肾功能指标（血清肌酐、血尿素氮、血清胱抑素C、血乳酸）的变化，观察治疗后72 h急性肾损伤发生情况。采用t、χ²检验和方差分析进行比较。结果　3组治疗后肾主动脉和肾叶间动脉的舒张期峰值流速、平均流速、血流灌注指数较均高于治疗前（均P<0.05）；治疗后，A组肾主动脉和肾叶间动脉的舒张期峰值流速、平均流速、血流灌注指数均低于B、C组，B组均低于C组（均P<0.05）。3组治疗后血清肌酐、血尿素氮、血清胱抑素C、血乳酸含量均低于治疗前（均P<0.05）；治疗后，A组血清肌酐、血尿素氮、血清胱抑素C、血乳酸含量均显著高于B、C组，B组均高于C组（均P<0.05）。治疗后72 h，A组急性肾损伤发生率为56.52%（26/46），B组为24.00%（6/25），C组为41.67%（5/12），B组急性肾损伤发生率显著低于A组（P<0.05）。结论　适度增大EICU感染性休克患者平均动脉压水平能够改善肾脏部位血流动力学，调节肾脏血供及肾功能，并降低急性肾损伤的发生，具有较高的临床应用价值。

关键词:

, 感染性休克, 急诊重症监护室, 平均动脉压, 肾功能

Abstract:

Objective　To explore the relationship between mean arterial pressure and renal function in emergency intensive care unit (EICU) patients with septic shock. Methods　Retrospective analysis was used. Eighty-three EICU patients with septic shock treated at Jiaozhou Hospital, Dongfang Hospital, Tongji University from January 2018 to January 2020 were included as the study objects. The patients were divided into group A (46 cases), group B (25 cases), and group C (12 cases) according to the actual maintenance level of mean arterial pressure (MAP) after early guided therapy. In group A, the actual MAP was maintained < 75% of the normal MAP in the one year before entering EICU; in group B, 75% of the daily MAP in the one year before entering EICU < the actual maintenance MAP < 90% of the daily MAP in the one year before entering the EICU; in group C, 90% of the daily MAP in the one year before entering the EICU < the actual maintenance MAP < the daily MAP in the one year before entering the EICU. The changes of renal aorta and interlobar artery hemodynamic indicator (peak diastolic value, mean flow rate, and blood perfusion index) and renal function indicators (serum creatinine, blood urea nitrogen, serum cystatin C, and blood lactic acid) were recorded before and after the treatment. The occurrence of acute renal injury 72 hours after the treatment was observed. The data were compared between the groups by t and χ² tests and analysis of variance. Results　The diastolic peak flow rates, mean flow velocities, and perfusion indexes of renal aorta and interlobar artery in the three groups were significantly higher after than before the treatment (all P<0.05). After the treatment, the diastolic peak flow rates, mean flow rates, and blood perfusion indexes of renal aorta and interlobar artery in group A were significantly lower than those in groups B and C (all P<0.05); the diastolic peak flow rates, mean flow rates, and blood perfusion indexes of renal aorta and interlobar artery in group B were significantly lower than those in group C (all P<0.05). The levels of serum creatinine, blood urea nitrogen, serum cystatin C, and blood lactic acid in the three groups were significantly lower after than before the treatment (all P<0.05). After the treatment, the levels of serum creatinine, blood urea nitrogen, serum cystatin C, and blood lactic acid in group A were significantly higher than those in groups B and C (all P < 0.05); the levels of serum creatinine, blood urea nitrogen, serum cystatin C, and blood lactic acid in group B were significantly higher than those in group C (all P<0.05). Seventy-two hours after the treatment, the incidence of acute kidney injury was 56.52% (26/46) in group A, was 24.00% (6/25) in group B, and was 41.67% (5/12) in group C; the incidence of acute kidney injury in group A was significantly lower than that in group B (P < 0.05). Conclusion　Moderate increase of mean arterial pressure in EICU patients with septic shock can improve their renal hemodynamics, regulate their renal blood supply and renal function, and reduce the incidence of acute renal injury, so it has high clinical value.

Key words:

Septic shock, Emergency intensive care unit, Mean arterial pressure, Renal function

王启飞孙明张卫平.

平均动脉压水平与EICU感染性休克患者肾功能关系的回顾性分析 [J]. 国际医药卫生导报, 2023, 29(14): 1974-1979.

Wang Qifei, Sun Ming, Zhang Weiping.

Relationship between mean arterial pressure and renal function in EICU patients with septic shock [J]. International Medicine and Health Guidance News, 2023, 29(14): 1974-1979.

参考文献

[1] Pérez MP, López AO, Lucendo AP, et al. Outcomes in patients with severe sepsis or septic shock with a urinary source of infection in the ICU[J]. Intensive Care Med, 2015, 3 Suppl 1:A84.DOI:10.1186/2197-425X-3-S1-A84.
[2] 吴乔,顾珮瑜,马静,等. 感染性休克患者应用去甲肾上腺素对心脏及血流动力学的影响[J]. 中华医院感染学杂志,2015,25(3):597-599. DOI:10.11816/cn.ni.2015-140255.
[3] Dahl RM, Grønlykke L, Haase N, et al. Variability in targeted arterial oxygenation levels in patients with severe sepsis or septic shock[J]. Acta Anaesthesiol Scand, 2015,59(7):859-869. DOI: 10.1111/aas.12528.
[4] 李忠勇,包新月,廖培军. ICU感染性休克患者病死的相关影响因素分析[J]. 中华医院感染学杂志,2014,24(7):1662-1664. DOI:10.11816/cn.ni.2014-135087.
[5] 梁昌强,喻安永,骆付丽,等. 感染性休克患者临床脉压水平与预后的相关性研究[J]. 中华医院感染学杂志,2016,26(19):4419-4421. DOI:10.11816/cn.ni.2016-160712.
[6] Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units[J]. Am J Respir Crit Care Med, 2015,191(11):1318-1330. DOI: 10.1164/rccm.201505-0924ST.
[7] 齐志宏,崔巍.重视急性肾损伤实验指标检测的影响因素及结果判读[J]. 中华检验医学杂志,2016,39(12):879-884. DOI:10.3760/cma.j.issn.1009-9158.2016.12.003.
[8] Brotfain E, Koyfman L, Toledano R, et al. Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge[J]. Am J Emerg Med, 2016,34(11):2122-2126. DOI: 10.1016/j.ajem.2016.07.058.
[9] Dabhi AS, Khedekar SS, Mehalingam V. A prospective study of comparison of APACHE-IV & SAPS-II scoring systems and calculation of standardised mortality rate in severe sepsis and septic shock patients[J]. J Clin Diagn Res, 2014,8(10):MC09-13. DOI: 10.7860/JCDR/2014/9925.5052.
[10] Schlapbach LJ, Straney L, Alexander J, et al. Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002-13: a multicentre retrospective cohort study[J]. Lancet Infect Dis, 2015,15(1):46-54. DOI: 10.1016/S1473-3099(14)71003-5.
[11] 丁春燕.综合性护理在ICU感染性休克患者中的应用效果[J].国际护理学杂志,2017,36(18):2579-2581.DOI:10.3760/cma.j.issn.1673-4351.2017.18.043.
[12] Houwink AP, Rijkenberg S, Bosman RJ, et al. The association between lactate, mean arterial pressure, central venous oxygen saturation and peripheral temperature and mortality in severe sepsis: a retrospective cohort analysis[J]. Crit Care, 2016,20:56. DOI: 10.1186/s13054-016-1243-3.
[13] Zhang H, Liu D, Wang X, et al. Variations of renal vascular score and resistive indices in septic shock patients[J]. Zhonghua Yi Xue Za Zhi, 2014,94(27):2102-2105.
[14] Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine[J]. Intensive Care Med, 2014,40(12):1795-1815. DOI: 10.1007/s00134-014-3525-z.
[15] 余超,刘大为,王小亭,等.微循环与氧代谢评估对感染性休克复苏后肾损伤评估的临床意义[J].中华内科杂志,2018,57(2):123-128.DOI:10.3760/cma.j.issn.0578-1426. 2018.02.008.
[16] 仝旭亚,刘卫芳,宋颖飞,等.平均动脉压维持水平对感染性休克患者肾功能及肾血流指标的影响研究[J].中华医院感染学杂志,2017,27(4):762-765. DOI:10.11816/cn.ni.2016-162989.
[17] Kaplan B, Schold J, Meier-Kriesche HU. Poor predictive value of serum creatinine for renal allograft loss[J]. Am J Transplant, 2003,3(12):1560-1565. DOI: 10.1046/j.1600-6135.2003.00275.x.
[18] Núñez J, Núñez E, Miñana G, et al. Differential mortality association of loop diuretic dosage according to blood urea nitrogen and carbohydrate antigen 125 following a hospitalization for acute heart failure[J]. Eur J Heart Fail, 2012,14(9):974-984. DOI: 10.1093/eurjhf/hfs090.
[19] 李鑫宇,刘丹颖,单福军,等.过度运动致急性肾脏病临床研究[J].中国中西医结合肾病杂志,2014,15(6):512-513.
[20] 杨志伟,石瑞春,尹文.急诊ICU感染性休克脉压与预后的相关性研究[J]. 中华医院感染学杂志,2015,25(14):3241-3242,3245.DOI:10.11816/cn.ni.2015-141726.
[21] 夏海娜,王璐,张超,等.感染性休克患者血必净治疗对血乳酸、降钙素原、C-反应蛋白及血流动力学的影响研究[J].中华医院感染学杂志,2016,26(15):3378-3380. DOI:10.11816/cn.ni.2016-154064.
[22] 郭健,鲁晓涵,金光,等.血清胱抑素C与代谢综合征的相关性研究[J]. 现代预防医学,2016,43(11):2098-2101.
[23] 叶林,周发春. ICU感染性休克患者不同平均动脉压维持水平与急性肾损伤的发生及预后的关系[J]. 第三军医大学学报,2016,38(15):1781-1787. DOI:10.16016/j.1000-5404. 201601175.
[24] 古旭云,陈炜,赵磊,等.早期液体复苏前后血流动力学参数对脓毒性休克患者短期预后的预测价值研究[J].中国全科医学,2015,18(16):1922-1926. DOI:10.3969/j.issn.1007- 9572.2015.16.013.