以大脑自动调节为导向的最佳血压管理降低了脓毒性休克患者出现谵妄的风险

Journal of intensive medicine Pub Date : 2024-02-02 DOI:10.1016/j.jointm.2023.12.003

Qianyi Peng , Xia Liu , Meilin Ai , Li Huang , Li Li , Wei Liu , Chunguang Zhao , Chenghuan Hu , Lina Zhang

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引用次数: 0

摘要

背景在抢救脓毒性休克患者时，通过使用近红外光谱监测区域脑氧饱和度（rSO2）来计算脑血管反应性参数，从而确定最佳血压。在此，我们旨在分析脑自动调节引导下的最佳血压管理对脓毒性休克患者谵妄发生率和预后的影响。方法这项前瞻性随机对照临床研究在中南大学湘雅医院进行。51例脓毒性休克患者（2020年12月-2022年5月）被纳入研究，并随机分配至实验组（26例）或对照组（25例）。我们使用 ICM+ 软件监测 rSO2 和平均动脉压 (MAP) 的动态变化，并计算脑血管反应性参数组织氧反应性指数，以确定实验组在复苏期间维持正常脑自动调节功能的最佳血压。对照组按照《脓毒症生存运动指南》进行治疗。结果 51例患者中，男性39例，女性12例，平均年龄（57.0±14.9）岁。谵妄发生率为 40.1%（23/51），28 天死亡率为 29.4%（15/51）。与对照组相比，实验组患者在入住重症监护室（ICU）头 24 小时内的平均血压较高（[84.5±12.2] mmHg vs. [77.4±11.8] mmHg，P=0.040），谵妄发生率较低（30.8% vs. 60.0%，P=0.036）。实验组比对照组的谵妄发生率更低（30.8% 对 60.0%，P=0.036），使用脑自动调节引导的最佳血压（几率比 [OR]=0.090，95% 置信区间 [CI]：0.009至0.923，P=0.043）和ICU住院时间（OR=1.473，95% CI：1.093至1.985，P=0.011）是脓毒性休克期间谵妄的危险因素。血管活性药物剂量（OR=8.445，95% CI：1.26 至 56.576，P=0.028）和氧分压（PaO2）（OR=0.958，95% CI：0.921 至 0.996，P=0.032）是 28 天死亡率的风险因素。结论休克复苏期间使用脑自动调节引导的最佳血压管理可降低脓毒性休克患者谵妄的发生率。试验注册ClinicalTrials.gov ldentifer: NCT03879317

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Cerebral autoregulation-directed optimal blood pressure management reduced the risk of delirium in patients with septic shock

Background

When resuscitating patients with septic shock, cerebrovascular reactivity parameters are calculated by monitoring regional cerebral oxygen saturation (rSO₂) using near-infrared spectroscopy to determine the optimal blood pressure. Here, we aimed to analyze the impact of cerebral autoregulation-directed optimal blood pressure management on the incidence of delirium and the prognosis of patients with septic shock.

Methods

This prospective randomized controlled clinical study was conducted in the Xiangya Hospital of Central South University, China. Fifty-one patients with septic shock (December 2020–May 2022) were enrolled and randomly allocated to the experimental (n=26) or control group (n=25). Using the ICM⁺ software, we monitored the dynamic changes in rSO₂ and mean arterial pressure (MAP) and calculated the cerebrovascular reactivity parameter tissue oxygen reactivity index to determine the optimal blood pressure to maintain normal cerebral autoregulation function during resuscitation in the experimental group. The control group was treated according to the Surviving Sepsis Campaign Guidelines. Differences in the incidence of delirium and 28-day mortality between the two groups were compared, and the risk factors were analyzed.

Results

The 51 patients, including 39 male and 12 female, had a mean age of (57.0±14.9) years. The incidence of delirium was 40.1% (23/51), and the 28-day mortality rate was 29.4% (15/51). The mean MAP during the first 24 h of intensive care unit (ICU) admission was higher ([84.5±12.2] mmHg vs. [77.4±11.8] mmHg, P=0.040), and the incidence of delirium was lower (30.8% vs. 60.0%, P=0.036) in the experimental group than in the control group. The use of cerebral autoregulation-directed optimal blood pressure (odds ratio [OR]=0.090, 95% confidence interval [CI]: 0.009 to 0.923, P=0.043) and length of ICU stay (OR=1.473, 95% CI: 1.093 to 1.985, P=0.011) were risk factors for delirium during septic shock. Vasoactive drug dose (OR=8.445, 95% CI: 1.26 to 56.576, P=0.028) and partial pressure of oxygen (PaO₂) (OR=0.958, 95% CI: 0.921 to 0.996, P=0.032) were the risk factors for 28-day mortality.

Conclusions

The use of cerebral autoregulation-directed optimal blood pressure management during shock resuscitation reduces the incidence of delirium in patients with septic shock.