对比观察脓毒性休克患者以常规血流动力学指标为导向的液体复苏与常规复苏联合外周灌注指数（PPi）指导液体复苏的复苏效果及预后，并探究以PPi指导液体复苏的临床意义。

选择2018年10月至2020年6月杭州师范大学附属医院重症医学科收治的40例脓毒性休克成人患者，分为常规组和观察组（PPi<1.4），每组各20例。所有入组患者均行脉搏指示持续心输出量和PPi监测。两组患者均按照临床指南进行治疗，常规组达到以下血流动力学目标即终止液体复苏：中心静脉压8~12 mmHg；尿量>0.5 mL·kg^-1·h^-1；中心静脉血氧饱和度（ScvO₂）≥ 70%；平均动脉压≥ 65 mmHg。观察组在达到上述目标的基础上，PPi<1.4则继续根据"2-5法则"进行液体复苏，如不适合继续补液则调整血管活性药物提高平均动脉压直至目标PPi ≥ 1.4。记录患者的一般资料，复苏0、6 h的急性病生理学和长期健康评价（APACHE）Ⅱ评分及复苏0、6、24、48 h的心率、平均动脉压、心输出量、ScvO₂、静动脉二氧化碳分压差（Pcv-aCO₂）、血乳酸水平，计算复苏6、24 h乳酸清除率和ICU死亡情况。

在两种目标导向的液体复苏前后，两组患者复苏0、6、24、48 h心率、平均动脉压、心输出量、ScvO₂、Pcv-aCO₂比较，差异均无统计学意义（F=0.197、0.070、2.658、2.424、1.687，P=0.846、0.958、0.080、0.119、0.182）；而血乳酸水平比较，差异具有统计学意义（F=18.792，P<0.001）。进一步两两比较发现，观察组6、24 h血乳酸水平均低于常规组，且其6、24 h乳酸清除率均高于常规组（P均<0.05）。复苏6 h后，观察组患者APACHEⅡ评分显著低于常规组[（21 ± 4）分vs.（25 ± 5）分，t=2.450，P=0.019]。此外，观察组的ICU死亡患者虽少于常规组，但组间比较差异无统计学意义（5/20 vs. 7/20，χ²=0.476，P=0.490）。

液体复苏能够改善脓毒性休克患者的血流动力学状态，以常规血流动力学指标联合PPi指导液体复苏能够有效降低血乳酸，加快血乳酸清除能力，并能降低APACHEⅡ评分，有望改善预后。

To compare the resuscitation effect and prognosis of patients with septic shock between using conventional hemodynamic index-oriented fluid resuscitation and using peripheral perfusion index (PPi)-oriented fluid resuscitation guided by conventional hemodynamic indexes, and to investigate the clinical value of using PPi to guide fluid resuscitation.

From October 2018 to June 2020, 40 adult patients with septic shock admitted to the Department of Critical Care Medicine of the Affiliated Hospital of Hangzhou Normal University were divided into a conventional group and an observation group (PPi < 1.4), with 20 cases in each group. All enrolled patients were monitored for pulse-indicated continuous cardiac output and PPi. Patients in both groups were treated according to clinical guidelines. Patients in the conventional group should achieve the following hemodynamic goals to terminate fluid resuscitation: central venous pressure 8 ~ 12 mmHg, urine output > 0.5 mL·kg^-1·h^-1, central venous oxygen saturation (ScvO₂) ≥ 70% and mean arterial pressure ≥ 65 mmHg. On the basis of achieving the above goals, patients in the observation group continued fluid resuscitation by the 2-5 rule with PPi < 1.4, and vasoactive drugs were adjusted to increase the mean arterial pressure until the target PPi ≥ 1.4 if it was not suitable to continue fluid replacement. The general information, the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score after 0 and 6 h of resuscitation, and the heart rate, mean arterial pressure, cardiac output, ScvO₂, venous-to-arterial carbon dioxide difference (Pcv-aCO₂) and blood lactate after 0, 6, 24 and 48 h of resuscitation were recorded. The lactate clearance rate and ICU mortality rate at 6 and 24 h of resuscitation were calculated.

Before and after the two goal-oriented fluid resuscitation methods, there were no significant differences in the heart rate, mean arterial pressure, cardiac output, ScvO₂ and Pcv-aCO₂ at 0, 6, 24, and 48 h between the two groups (F = 0.197, 0.070, 2.658, 2.424, 1.687; P = 0.846, 0.958, 0.080, 0.119, 0.182), while the difference in blood lactate levels was statistically significant (F = 18.792, P < 0.001). Further pairwise comparison showed that the blood lactate levels at 6 and 24 h in the observation group were lower than those in the conventional group, and the lactate clearance rates at 6 and 24 h were higher (all P < 0.05). After 6 h of resuscitation, the APACHEⅡ score in the observation group was significantly lower than that in the conventional group [(21 ± 4) vs. (25 ± 5), t = 2.450, P = 0.019]. In addition, although the ICU deaths in the observation group were fewer than those in the conventional group, there was no significant difference in ICU mortality between the two groups (5/20 vs. 7/20, χ² = 0.476, P = 0.490).

Fluid resuscitation can improve the hemodynamic status of patients with septic shock, and the fluid resuscitation guided by conventional hemodynamic indexes combined with PPi can effectively reduce blood lactate, accelerate blood lactate clearance and decrease APACHEⅡ, which is expected to improve prognosis.