Study On The Strategy Of Early Circulation Management For Emergency Patients With Septic Shock Based On Blood Gas Analysis

Background and Objective Septic shock is a major cause of death in emergency department,and the circulation management,especially fluid resuscitation,is one of the cornerstones of treatment.Early goal directed therapy(EGDT),which was recommended in 2001,was once the most classic early resuscitation strategy.However,this strategy was officially removed from the international guidelines in 2016,resulting in a lack of circulation management strategy with clear guiding goal in clinical practice.In recent years,oxygen metabol ism parameters based on blood gas(including central venous oxygen saturation and central venous-to-arterial carbon dioxide differential pressure)have been paid great attention in shock treatment,while central venous pressure(CVP),an old parameter which has been widely used in clinical practice for many years,has gained a new and in-depth understanding in recent years.These simple and easily available parameters provide emergency treatment for septic shock patients with new ideas.This study analyzes the fluid resuscitation process and prognosis of septic shock in emergency clinic,pays attention to the oxygen metabolism parameters of blood gas and central venous pressure,and hopes to summarize the early circulation management plan suitable for the emergency doctors of our country,in order to conclude the flow chart of early circulation management strategy for septic shock patients suitable for emergency department in china.Methods First,a retrospective research was done to analyse all the patients with septic shock admitted in the emergency intensive care unit(EICU)of Peking Union Medical College Hospital,from February 1,2018 to January 31,2020.The relevant data of all septic shock patients with initial lactate≥2 mmol/L were retrospectively collected by querying the medical records and electronic system.The monitoring values of sex,age,APACHEⅡ score,length of stay,and etiology of septic shock were collected by means of medical records inquiry.Blood gas analysis results of the patients at the time of 6 hours and 24 hours after admission were obtained by querying the electronic system.The central venous oxygen saturation(ScvO2),central venous blood gas carbon dioxide pressure,arterial blood gas carbon dioxide pressure,arterial blood gas lactate value were obtained.The central venous-arterial carbon dioxide differential pressure(Pcv-aCO2)and lactate clearance rate(LCR)were calculated.Prognostic indicators include survival or death,duration of bedside continuous renal replacement therapy(CRRT),duration of mechanical ventilation(MV).SPSS 25.0 was performed to analyse the correlation between the two parameters of ScvO2≥70%and Pcv-aCO2≤6 mmHg and the prognosis.The main prognostic index is survival or not,and the secondary prognostic index is CRRT time and MV time.Secondly,the monitoring value of CVP was analyzed.According to the CVP value,CVP was divided into low CVP group with CVP≤12mmHg and high CVP group with CVP>12mmHg.The role of CVP in septic shock was observed.For low CVP group,the actual prognosis difference of CVP lower than the target value(CVP≤7mmHg)and reaching the target value(8-12mmHg)in EGDT strategy were also observed.At the same time,if other invasive hemodynamic monitoring is performed,the corresponding parameters will also be recorded.Finally,we summarize the above two parts of research data,combined with the oxygen metabolism parameters of blood gas and the role of CVP,to make a comprehensive analysis,concluding a circulation management strategy flow-chart for emergency septic shock.Results During the study period from February 1,2018 to January 31,2020,there were 875 patients admitted into the EICU of Peking Union Medical College Hospital,of which 276 were septic shock patients,and finally 88 patients were included in this study,accounting for 10.1%of all admitted patients and 31.9%of all septic shock patients.The average age of the cases was 53.7±17.6 years old,with an average APACHE Ⅱ score of 14.7±6.1;of these,46 men accounted for 52.3%,with an average age of 57.6±17.9 years old;42 women accounted for 47.7%,with an average age of 49.3±16.4 years old.The average length of EICU stay was 11.1±6.7 days;20 cases(22.7%)received bedside CRRT treatment with an average time of 4.6±1.9 days;54 cases(61.4%)received MV treatment with an average time of 9.4±7.3 days;and 16 died,the death rate was 18.2%.Logistic regression analysis and Cox regression analysis showed that the survival rate of the people who had reached the three parameters of ScvO2≥70%,Pcv-aCO2≤6mmHg and CVP≤12mmHg at the time of 24 hours after admission was significantly better than that of the group who had not reached,the CRRT time was also shorter than that of the group who had not reached,and the MV time in the group of three items reaching the standard is shorter than that in the group of only one item reaching the standard,and there is no significant difference between the three and two items reaching the standard.As one of the indicators of EGDT,the effect of CVP≤7mmHg group is better than that of 8-12mmHg group.Conclusions Fluid resuscitation in patients with septic shock can improve survival rate and reduce CRRT time by targeted treatment with ScvO2、Pcv-aCO2.CVP should be a goal of limitation rather than a goal of achievement.It is of practical significance to adopt the circulation management strategy with lactate as the starting point,central venous oxygen saturation and central venous-to-arterial carbon dioxide differential pressure as the target and central venous pressure as the limit.But more research is needed to further verify this circulation management strategy.