目的 观察祛瘀解毒利水法辅助治疗脓毒症心肌病(sepsis-induced cardiomyopath,SICM)右心功能障碍的临床疗效及对血流动力学的影响.方法 将60例患者随机分为观察组(30例)和对照组(30例).对照组给予脓毒症集束化治疗;观察组在对照组的基础上给予祛瘀解毒利水法治疗(血必净注射液50 mL,静脉滴注,2次/d,和加味苓桂术甘汤内服,1剂/d),两组疗程均为7 d.采用脉搏指示连续心输出量(pulse indicator continuous cardiac output,PiCCO)监测血流动力学指标[血管外肺水指数(extra vascular lung water index,E VLWI)、全心舒张末期容积指数(global end-diastolic volume index,GEDVI)、胸腔内血容积指数(intrathoracic blood volume index,ITBVI)及心脏功能指数(cardiac function in-dex,CFI)和外周血管阻力指数(systemic vascular resistance index,SVRI)],测量治疗前后混合静脉血氧饱和度(saturation of venous oxygen,SvO2)、中心静脉血二氧化碳分压(partial pressure of carbon dioxide,PcvCO2)、血乳酸(blood lactic acid,Lac)、中心静脉-动脉血二氧化碳分压差(central venous-to-arterial carbon dioxide difference,Pcv-aCO2)=PcvCO2-PaCO2、左室射血分数(left ventricular ejection fraction,LVEF)、E/A、E/e'、右心室舒张末期面积(right ventricular end-dias-tolic area,RVEDA)/左心室舒张末期面积(left ventricular end-diastolic area,LVEDA)比值、三尖瓣环收缩期位移(tricus-pid annular plane systolic excursion,TAPSE);检测治疗前后高敏心肌肌钙蛋白 I(high-sensitivity cardiac troponin I,hs-cT-nI)、N-末端 B 型钠尿肽前体(N-terminal pro-B-type natriuretic peptide,NT-proBNP)、肌酸激酶同工酶(creatine ki-nase isoenzyme,CK-MB)和高迁移率族蛋白B1(high mobility group protein B1,HMGB1);进行治疗 前后急性生理及慢性健康评分(acute physiology and chronic health evaluation Ⅱ,APACHE Ⅱ)和脓毒症相关序贯器官衰竭评分(sequential organ failure assessment,SOFA)评分.结果 治疗后 3～7 d,EVLWI、ITBVI、SVRI 逐渐下降(P＜0.05),GEDVI 和 CFI 逐渐升高(P＜0.05);在治疗后第3、5、7天,观察组患者EVLWI、SVRI低于对照组(P＜0.05),在治疗后第3天,观察组患者ITBVI低于对照组(P＜0.05),GEDVI高于对照组(P＜0.05),在治疗后第5、7天,观察组患者CFI高于对照组(P＜0.05).观察组患者Pcv-aCO2、Lac低于对照组,SvO2、ScvO2高于对照组(P＜0.01);观察组患者E/e'、RVEDA/LVEDA低于对照组,LVEF、E/A和TAPSE高于对照组(P＜0.01);观察组患者hs-cTnI、NT-proBNP、CK-MB和HMGB1水平低于对照组(P＜0.01);观察组患者APACHE Ⅱ和SOFA评分低于对照组(P＜0.01).结论 在西医常规集束化治疗基础上,针对SICM伴右心功能障碍患者病机特点进行祛瘀解毒利水法治疗,采用加味苓桂术甘汤联合血必净注射液辅助干预,可有效改善患者血流动力学和组织灌注情况,减轻了心肌的损伤,提高了心功能,特别是可减轻右心功能障碍,从而减轻了病情程度,起到改善预后的效果.
Effect of Dispelling Blood Stasis,Removing Blood Stasis and Promoting Urination on Hemodynamics of Right Ventricular Dysfunction in Septic Cardiomyopathy
Objective To observe the clinical effect of dispelling blood stasis,removing blood stasis and promoting urination in adjuvant treatment of right ventricular dysfunction in septic cardiomyopathy(SICM)and its effect on hemodynamics.Method Six-ty patients were randomly divided into observation group(30 cases)and control group(30 cases).The patients in the control group were given bundle therapy for sepsis.On the basis of the control group,the patients in observation group were given the method of dispelling blood stasis,removing blood stasis and promoting urination[Xuebijing Injection(血必净注射液)50 mL,in-travenous drip,2 times/day and Jiawei Linggui Zhugan Decoction(加味苓桂术甘汤)orally,1 dose/day].The course of treat-ment in both groups was 7 days.Pulse-indicated continuous cardiac output(PiCCO)was used to monitor hemodynamic parame-ters[extravascular lung water index(EVLWI),global end-diastolic volume index(GEDVI),intrathoracic blood volume index(ITBVI),index(CFI)and peripheral vascular resistance index(SVRI)].Before and after treatment,mixed venous oxygen satu-ration(SvO2),central venous carbon dioxide partial pressure(PcvCO2),blood lactate(Lac),central venous-arterial carbon di-oxide partial pressure(Pcv-aCO2)=PcvCO2-PaCO2,left ventricular ejection fraction(LVEF),E/A,E/e',right ventricular end-diastolic area(RVEDA)/left ventricular end-diastolic area(LVEDA)ratio,tricuspid annular systolic displacement(TAPSE)were detected.The values of high-sensitivity cardiac troponin I(hs-cTnI),N-terminal precursor B-type natri-uretic peptide(NT-proBNP),creatine kinase isoenzyme(CK-MB),high mobility group box protein B1(HMGB1),acute physi-ology and chronic health score(APACHE Ⅱ)and sepsis-related sequential organ failure score(SOFA)before and after treat-ment were detected.Result On 3 to 7 day after treatment,the levels of EVLWI,ITBVI and SVRI gradually decreased(P＜0.05),while the levels of GEDVI and CFI gradually increased(P＜0.05).On the 3rd,5th and 7th day after treatment,the levels of EVLWI and SVRI of the observation group were lower than those of the control group(P＜0.05).On the 3rd day after treat-ment,the level of ITBVI of the observation group was lower than that of the control group(P＜0.05),and the level of GEDVI was higher than that of the control group(P＜0.05).On the 5th and 7th day after treatment,the level of CFI of the observation group was higher than that of the control group(P＜0.05).After treatment,the values of Pcv-aCO2 and Lac in the observation group were lower than those in the control group,while the values of SvO2 and ScvO2 in the observation group were higher than those in the control group(P＜0.01).The values of E/e'and RVEDA/LVEDA in the observation group were lower than those in the con-trol group.The levels of LVEF,E/A and TAPSE were higher than those in the control group(P＜0.01).The levels of hs-cT-nI,NT-proBNP,CK-MB and HMGB1 in the observation group were lower than those in the control group(P＜0.01).The A-PACHE Ⅱ and SOFA scores of the observation group were lower than those of the control group(P＜0.01).Conclusion On the basis of conventional western medicine bundle treatment,according to the pathogenesis characteristics of patients with SICM and right ventricular dysfunction,the method of dispelling blood stasis,removing blood stasis and promoting urination and adjuvant in-tervention with Jiawei Linggui Zhugan Decoction(苓桂术甘汤)combined with Xuebijing Injection can effectively improve the hemodynamics and tissue perfusion of patients,reduce myocardial damage and improve cardiac function.In particular,it can re-duce the dysfunction of the right heart,thereby reducing the severity of the disease and improving the prognosis.
sepsis cardiomyopathyright ventricular dysfunctiondispelling blood stasis,removing blood stasis and promoting urinationLinggui Zhugan Decoction(苓桂术甘汤)Xuebijing Injectioni(血必净注射液)hemodynamicstissue perfusioncar-diac function
万方数据
维普
