Swan-Ganz导管监测下血管活性药物优化对心脏重症患者血流动力学及预后的影响 |
| 饶晓丽 刘超 |
| 吉林心脏病医院，吉林长春，130117 |
| 摘要：目的? 本研究旨在探讨在Swan-Ganz导管监测下，以米力农、多巴酚丁胺及去甲肾上腺素为核心的血管活性药物优化策略对心脏重症患者血流动力学参数及预后的影响，以期为心脏重症患者的规范化治疗提供高级别循证证据，推动从“经验治疗”向“目标导向治疗”的临床模式转变。方法? 本研究为回顾性队列研究，数据来源于某三级医院心脏重症监护病房（CICU）2018年1月至2023年12月收治的连续住院患者。纳入标准包括年龄≥18岁，诊断为急性心力衰竭、心源性休克或心脏术后低心排综合征，置入Swan-Ganz导管并持续监测≥48小时，以及使用米力农、多巴酚丁胺或去甲肾上腺素中的≥2种药物联合治疗≥24小时。排除标准包括终末期肾病、严重主动脉瓣狭窄、妊娠期或产后1周内患者，以及存在Swan-Ganz导管禁忌症的患者。最终纳入126例患者，按用药策略分为优化组（n=68）与对照组（n=58）。优化组基于Swan-Ganz导管实时监测数据调整药物剂量，对照组则依据临床经验及常规生命体征调整用药。主要观察指标包括血流动力学指标（心指数CI、肺动脉楔压PAWP、外周血管阻力指数SVRI、右心房压力RAP）、预后指标（28天死亡率、ICU停留时间、急性肾损伤AKI发生率）及药物使用强度（血管活性药物评分VIS）。结果? 优化组患者用药后48小时CI显著提升23%（P<0.01），PAWP显著下降18%（P=0.02），SVRI下降12.6%（P<0.05）。优化组28天死亡率为12.7%，显著低于对照组的25.9%（P=0.03），且Cox回归分析确认优化用药是降低死亡风险的独立保护因素（HR=0.41，95%CI?0.22-0.78，P=0.006）。此外，优化组ICU平均停留时间显著短于对照组（7.2±2.1天?vs.?9.8±3.4天，P<0.01），AKI发生率也显著降低（22.1%?vs.?39.7%，P=0.02）。优化组VIS评分显著低于对照组（25.6±8.2?vs.?34.1±9.7，P<0.01），且去甲肾上腺素使用剂量中位数显著低于对照组（0.15?vs.?0.28?μg/kg/min，P=0.002）。亚组分析显示，优化用药策略在急性心力衰竭、心源性休克及心脏术后低心排综合征亚组中均表现出一致的血流动力学改善及预后优势。结论? 本研究表明，在Swan-Ganz导管监测下，以米力农、多巴酚丁胺及去甲肾上腺素为核心的血管活性药物优化策略，可显著改善心脏重症患者的血流动力学参数，降低28天死亡率及并发症发生率，缩短ICU停留时间，并减少血管活性药物的使用总量。该策略通过精准调控药物剂量，实现了血流动力学状态的优化，为心脏重症患者的规范化治疗提供了有力证据。 |
| 关健词：Swan-Ganz导管；血管活性药物优化；血流动力学监测；心脏重症；预后改善 |
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| Impact of Vasoactive Drug Optimization Under Swan-Ganz Catheter Monitoring on Hemodynamics and Prognosis in Critically Ill Cardiac Patients |
| Xiaoli Rao Chao Liu |
| Jilin Heart Disease Hospital，Changchun Jilin 130117, China |
| Abstract：Objective This study aimed to investigate the effects of a vasoactive drug optimization strategy, centered on milrinone, dobutamine, and norepinephrine, guided by Swan-Ganz catheter monitoring, on hemodynamic parameters and prognosis in critically ill cardiac patients. The goal was to provide high-level evidence for standardized treatment in this population and promote a clinical shift from “empirical therapy” to “goal-directed therapy.”Methods A retrospective cohort study was conducted using data from consecutive hospitalized patients admitted to the cardiac intensive care unit (CICU) of a tertiary hospital between January 2018 and December 2023. Inclusion criteria were: age ≥18 years, diagnosis of acute heart failure, cardiogenic shock, or postoperative low cardiac output syndrome, Swan-Ganz catheter placement with continuous monitoring ≥48 hours, and combination therapy with ≥2 of the following drugs (milrinone, dobutamine, or norepinephrine) for ≥24 hours. Exclusion criteria included end-stage renal disease, severe aortic stenosis, pregnancy/postpartum status within 1 week, or contraindications to Swan-Ganz catheters. A total of 126 patients were enrolled and divided into an optimization group (n=68) and a control group (n=58). The optimization group adjusted drug dosages based on real-time Swan-Ganz catheter data, while the control group relied on clinical experience and routine vital signs. Primary outcomes included hemodynamic indices (cardiac index [CI], pulmonary artery wedge pressure [PAWP], systemic vascular resistance index [SVRI], right atrial pressure [RAP]), prognostic indicators (28-day mortality, ICU length of stay, incidence of acute kidney injury [AKI]), and vasoactive drug intensity (vasoactive-inotropic score [VIS]).Results In the optimization group, CI increased signiffcantly by 23% at 48 hours post-intervention (P<0.01), PAWP decreased by 18% (P=0.02), and SVRI decreased by 12.6% (P<0.01), with a median norepinephrine dose reduction (0.15 vs. 0.28 μg/kg/min, P=0.002). Subgroup analyses demonstrated consistent hemodynamic improvements and prognostic beneffts across acute heart failure, cardiogenic shock, and postoperative low cardiac output syndrome subgroups. Conclusion This study demonstrates that a Swan-Ganz catheter-guided optimization strategy for vasoactive drugs (milrinone, dobutamine, and norepinephrine) signiffcantly improves hemodynamic parameters, reduces 28-day mortality and complication rates, shortens ICU stays, and lowers overall vasoactive drug usage in critically ill cardiac patients. By precisely titrating drug doses, this approach optimizes hemodynamic status and provides robust evidence for standardized care in this population. |
| Keywords：Swan-Ganz catheter; vasoactive drug optimization; hemodynamic monitoring; critical cardiac care; prognostic im-provement |
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