doktorska disertacija
Povzetek
Izhodišče. Glavni namen srčno-žilnega sistema je pripeljati dovolj kisika za presnovne potrebe vsega telesa. Neuspeh je povezan z večjo smrtnostjo. Ocena oskrbe tkiv s kisikom je nujna pri zdravljenju kritično bolnih. V vsakdanji praksi pri kritično bolnih uporabljamo invazivne metode nadzora globalne oksigenacije tkiv (zasičenosti hemoglobina s kisikom v mešani venski krvi iz pljučne arterije – SvO2, zasičenosti hemoglobina s kisikom v v zgornji votli veni – ScvO2). Bližnja infrardeča spektroskopija (NIRS) je novejša neinvazivna metoda nadzora regionalne oksigenacije tkiva.
Namen. Preveriti ujemanja meritev z bližnjo infrardečo spektroskopijo (NIRS) z meritvami globalne oksigenacije tkiv pri kritično bolnih s hudim srčnim popuščanjem in pri bolnikih s hudim srčnim popuščanjem in dodatno hudo sepso ali septičnim šokom.
Vrsta raziskave. Prospektivna opazovalna raziskava
Okolje. 15-posteljni internistični intenzivni oddelek v univerzitetni terciarni bolnišnici
Bolniki in preiskovanci. V raziskavo smo vključili zaporedno sprejete bolnike s hudim srčnim popuščanjem (EF manj od 40%, zagozditveni tlak v pljučni arteriji > 18 mm Hg), pri katerih so se lečeči zdravniki odločili za vstavitev plavajočega katetra v pljučno arterijo (Swan-Ganzev kateter, n = 117). V kontrolni skupini je sodelovalo 15 zdravih prostovoljcev.
Posredovanje. Ishemijo roke smo povzročili s hitrim avtomatskim napihnjenjem pnevmatske manšete, nameščene okoli nadlahti.
Metode in glavni rezultati. Oksigenacijo v skeletni mišici palčeve kepe smo merili neinvazivno z NIRS, hkrati pa smo iz pljučne arterije odvzeli vzorce krvi za meritev SvO2. V drugem delu preiskave smo pri bolnikih s hudo sepso ali septičnim šokom merili hitrost zmanjševanja StO2 ob zažemu nadlahti, hkrati pa merili SvO2 in ScvO2.
Naše meritve tkivne oksigenacije z NIRS v skeletni mišici palčeve kepe pri bolnikih s hudim srčnim popuščanjem in hudo sepso (n =24) ali brez nje (n =41) po začetnem zdravljenju so pokazale večjo oksigenacijo skeletne mišice (StO2) pri bolnikih z dodatno sepso (90% proti 58%, p < 0.001). Ti bolniki so imeli večji StO2 tudi od zdravih prostovoljcev (90% proti 84%, p = 0.02). Skupini bolnikov se nista razlikovali hemodinamsko, niti po demografskih lastnostih ali stopnji obolelosti. Pri bolnikih brez sepse smo našli dobro korelacijo med StO2 in SvO2 in med StO2 in plazemskim laktatom. V tej skupini bolnikov so se dobro ujemale tudi spremembe StO2 in SvO2 v času, ugotovili pa smo, da StO2 precenjuje SvO2 z nagnjenostjo - 2.3% in natančnostjo 4.6%. Pri bolnikih z dodatno hudo sepso ni bilo najti ujemanja med StO2 in SvO2, niti med StO2 in laktatom.
Zato smo v drugem delu raziskave primerjali SvO2 in ScvO2 pri bolnikih s hudim srčnim popuščanjem in dodatno hudo sepso ali septičnim šokom (n = 52). Vrednosti SvO2 so statistično značilno korelirale s ScvO2 (r = 0.659, p = 0.001), Bland-Altmanova analiza pa je pokazala klinično pomembno razliko med obema spremenljivkama (ScvO2 in SvO2 povprečje 72 ± 8%, ScvO2 - SvO2 razlika 9.4 ± 7.5%). Velikost razlike med ScvO2 in SvO2 je korelirala z vrednostjo plazemskega laktata v arterijski krvi (r = 0.4, p = 0.003) in hitrostjo zmanjševanja StO2 v palčevi kepi (r = 0.651, P = 0.001).
Zaključki. Rezultati raziskave kažejo, da bi meritve StO2 z NIRS v skeletni mišici palčeve kepe, lahko uporabili kot hitro neinvazivno in kontinuirano zamenjavo za invazivno merjeni SvO2 pri bolnikih s hudim srčnim popuščanjem in ohranjeno tkivno porabo kisika (bolniki brez sepse). StO2 pa ni zanesljiva zamenjava za SvO2 pri septičnih bolnikih s hudim srčnim popuščanjem. Pri takih bolnikih bolj upočasnjeno zmanjševanje StO2 (upočasnjena tkivna poraba kisika) v skeletni mišici palčeve kepe po zažemu nadlakti, kaže na večje neujemanje SvO2 in ScvO2 pri bolnikih s hudim srčnim popuščanjem in sepso. Uporaba tega dinamičnega kazalca tako lahko prepreči napake pri zdravljenju.
Ključne besede
urgentna medicina;kritično bolni;srčno popuščanje;sepsa;saptični šok;skeletne mišice;oksigenacija;nadzor;metode;bližnja infrardeča spektroskopija;disertacije;
Podatki
Jezik: |
Slovenski jezik |
Leto izida: |
2015 |
Tipologija: |
2.08 - Doktorska disertacija |
Organizacija: |
UM MF - Medicinska fakulteta |
Založnik: |
H. Možina] |
UDK: |
616.12-008.315:612.127(043.3) |
COBISS: |
280482304
|
Št. ogledov: |
3064 |
Št. prenosov: |
242 |
Ocena: |
0 (0 glasov) |
Metapodatki: |
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Ostali podatki
Sekundarni jezik: |
Angleški jezik |
Sekundarni naslov: |
Skeletal muscle tissue oxygenation in in critically ill patients |
Sekundarni povzetek: |
Background. The primary task of the cardiovascular system is to de¬liver enough oxygen to meet the metabolic demands of the body. When it fails to satisfy metabolic demands adequately, organ dysfunc¬tion and death occur. Therefore, assessment of the adequacy of global systemic and tissue oxygenation in critically ill patients is indispensable in their treatment. In everyday practice two invasive methods are used to assess global body oxygenation: mixed venous oxygen saturation (SvO2) and central venous oxygen saturation (ScvO2). Evaluation of the regional skeletal muscle tissue oxygenation using near infrared spectroscopy (NIRS) is a new non-invasive method.
Objective. We investigated the relationship between skeletal (thenar) muscle tissue oxygenation (StO2) estimated noninvasively by NIRS and invasively measured global whole body index of oxygenation (SvO2, ScvO2) in patients with severe left heart failure with or without additional severe sepsis.
Design. Prospective observational study
Setting. Medical ICU in university hospital
Patients and participants. Consecutive patients admitted to ICU with primary heart disease, low cardiac output and no signs of hypovolaemia in whom right heart catheterization with a pulmonary artery floating catheter was performed at the discretion of the treating physician (n = 117). Control group of 15 healthy volunteers.
Interventions. Upper limb ischemia was induced by rapid automatic pneumatic cuff inflation around upper arm.
Measurements and main results. Patients were divided into two groups: groups A (n
= 24) and B (n = 41) included patients without and with additional severe sepsis/septic shock, respectively. Thenar muscle StO2 was measured using NIRS. Simultaneously SvO2 was measured. We showed that StO2 was higher in patients with sepsis (90% versus 58%, p < 0.001). In non septic patients, there was a good correlation between StO2 and SvO2 and between SvO2 and plasma lactate. StO2 and SvO2 tracked well with each other over time, although StO2 overestimated SvO2 with a bias of - 2.3% and a precision 4.6%. No correlation or agreement was found between StO2 and SvO2 or between StO2 and lactate in septic patients.
In the second part of research, fifty-two patients with severe left heart failure due to primary heart disease with additional severe sepsis/septic shock were included. SvO2 and ScvO2 were compared to the thenar muscle StO2 before and during arterial occlusion. SvO2 correlated significantly with ScvO2 (r = 0.659, p = 0.001), however, Bland Altman analysis showed a clinically important difference between both variables (ScvO2 - SvO2 mean 72 ± 8%, ScvO2 -SvO2 difference 9.4 ± 7.5 %). The ScvO2 - SvO2 difference correlated with plasma lactate (r = 0.400, p = 0.003) and the StO2 deoxygenation rate (r = 0.651, p = 0.001).
Conclusions. Skeletal muscle StO2 does not estimate SvO2 in patients with severe left heart failure and additional severe sepsis or septic shock. However, in patients with severe left heart failure without additional severe sepsis or septic shock, StO2 values could be used to provide rapid, noninvasive estimation of SvO2; furthermore, the trend in StO2 may be considered a surrogate for the trend in SvO2. In patients with severe heart failure with additional severe sepsis/septic shock the ScvO2-SvO2 discrepancy presents a clinical problem. In these patients the skeletal muscle StO2 deoxygenation rate is inversely proportional to the difference between ScvO2 and SvO2; dobutamine does not influence this relationship. When
using ScvO2 as a treatment goal, the NIRS measurement may prove to be a useful non-invasive diagnostic test to uncover patients with a normal ScvO2 but potentially an abnormally low SvO2. |
Sekundarne ključne besede: |
Near infrared spectroscopy;skeletal muscle;vascular occlusion test;mixed venous oxygen saturation;central venous oxygen saturation;critically ill;severe sepsis;severe heart failure;shock; |
URN: |
URN:SI:UM: |
Vrsta dela (COBISS): |
Doktorska disertacija |
Komentar na gradivo: |
Univ. v Mariboru, Medicinska fak. |
Strani: |
74 f. |
ID: |
8758368 |