目标导向液体管理策略对脓毒性休克患者血流动力学及脏器功能的影响

Impact of goal⁃directed fluid management strategy on hemodynamics and organ function in patients with septic shock

摘要

目的：研究目标导向液体管理策略对脓毒性休克患者血流动力学及脏器功能的影响。方法：纳入2025年1—6月武汉大学人民医院重症监护病房收治的脓毒性休克患者，随机分为常规组和目标导向管理组，两组患者均根据脓毒症指南开展诊断、治疗处理及标准化的液体复苏流程；目标导向液体管理组根据临床体征、心脏超声、肺超声评估容量反应性，如有反应性，继续液体复苏，如无反应性，停止液体复苏并重新评估。比较两组患者的血流动力学参数、液体管理达标情况、微循环监测数据、脏器损伤及临床结局指标。结果：常规组纳入40例，目标导向液体管理组52例，两组基线资料无显著差异（P>0.05）。与常规组相比，目标导向液体管理组在复苏24 h后血乳酸水平显著更低［1.4（1.0，2.0）vs 1.8（1.3，2.2）mmol·L^-1，P<0.05］，去甲肾上腺素用量更少［0.2（0.1，0.3）vs 0.3（0.1，0.4）μg·kg^-1·min^-1，P=0.045］，微循环指标改善更为显著[总血管密度(TVD)：(27.4±2.9 vs 25.4±3.1) mm·mm^-2，灌注血管密度(PVD)：(22.8±3.5 vs 21.5±2.7) mm·mm^-2，均P<0.05]。在临床结局方面，目标导向组急性肺水肿发生率（1.9%vs 12.5%，P=0.039）和28天死亡率（19.2% vs 40.0%，P=0.044）均显著低于常规组，而两组急性肾损伤发生率、机械通气时间等次要结局差异无统计学意义。结论：目标导向性液体管理策略可有效优化脓毒性休克患者的液体管理，改善组织灌注，减轻器官损伤，提升救治安全性。

Abstract

Objective: To investigate the effect of a goal-directed fluid management (GDFM) strategy on hemodynamics and organ function in patients with septic shock. Methods: Patients with septic shock admitted to the ICU of Renmin Hospital of Wuhan University between January and June 2025 were enrolled and randomly assigned to either the conventional management group or the GDFM group. Both groups received diagnosis and treatment in accordance with established guidelines. In the GDFM group, fluid responsiveness was dynamically assessed using clinical signs, cardiac ultrasound, and lung ultrasound. Fluids were administered if responsiveness was confirmed, and withheld or reassessed if absent. The two groups were compared regarding hemodynamic parameters, fluid balance, microcirculatory monitoring data, organ injury, and clinical outcomes. Results: Forty and fifty-two patients were included in the conventional and GDFM groups, respectively, with no significant differences in baseline characteristics (P>0.05). Compared with the conventional group, the GDFM group exhibited significantly lower blood lactate levels (1.4 (1.0, 2.0)vs 1.8 (1.3, 2.2) mmol·L^-1, P<0.05), and reduced norepinephrine requirements (0.2 (0.1, 0.3)vs 0.3 (0.1, 0.4) µg·kg^-1·min^-1, P=0.045) at 24 hours post-resuscitation. Microcirculatory parameters, total vessel density (TVD) and perfused vessel density (PVD), were also significantly better in the GDFM group (TVD: (27.4±2.9) vs (25.4±3.1) mm·mm^-2; PVD: (22.8±3.5) vs (21.5±2.7) mm·mm^-2; both P<0.05). Regarding clinical outcomes, the incidence of acute pulmonary edema (1.9%vs 12.5%, P=0.039) and the 28-day mortality rate (19.2% vs 40.0%, P=0.044) were significantly lower in the GDFM group than in the conventional group. However, no statistically significant differences were observed in secondary outcomes such as the incidence of acute kidney injury and duration of mechanical ventilation. Conclusion: The goal-directed fluid management strategy can effectively optimize fluid therapy in patients with septic shock, improve tissue perfusion, mitigate organ injury, and enhance treatment safety.

关键词

目标导向液体管理 / 脓毒性休克 / 血流动力学 / 器官功能

Key words

Goal-Directed Fluid Management / Septic Shock / Hemodynamics / Organ Function

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基金资助

新发突发与重大传染病防控国家科技重大专项(2025ZD01902600)