The Evaluation Of The Incidence Of Right-to-left Shunt In The Patients With Hypoxemia And Its Influence On Right Heart Function By Echocardiography

Objective: According to the diagnosis of intracardiac shunt and intrapulmonary shunt and the evaluation of right heart function by the echocardiography,the main purpose was to: 1.to assess incidence of intracardic shunt and pulmonary shunt in patients with hypoxemia;2.to investigate the effect of right-to-left shunt on right heart function;3.to analyze the relationship between shunt and mechanical ventilation time,ICU length of stay,length of stay,28-day mortality in patients with hypoxemia.Methods: This study was a prospective observational study,including the patients with hypoxemia admitted to the Department of intensive care unit,the fourth hospital of Hebei Medical University from April 2016 to December 2016.Inclusion criteria: 1)acute hypoxemia caused by a variety of reasons,the oxygenation index <300mmHg;2)ICU stay time longer than 24 hours;3)diagnosis of hypoxemia within 6 hours;4)older than the 18 years old.Exclusion criteria: 1)ICU stay time less than 24 hours;2)younger than 18 years old;3)patients with pulmonary embolism;4)patients with right ventricular infarction;5)patients with chronic pulmonary heart disease and pulmonary encephalopathy;6)pregnant women and lactating women;7)Couldn’t get clear echocardiographic images.According to the results of ultrasound imaging,patients were divided into non-shunt group,intracardiac shunt group and pulmonary shunt group.The parameters of vital signs,acute physiology and chronic health evaluation II(Acute Physiology And Chronic Health Evaluation II,APACHEII),sequential organ failure assessment(Sequential Organ Failure Assessment,SOFA),blood gas analysis,the quantity of liquid and ventilation modes and parameters,the results of echocardiography,mechanical ventilation time,ICU length of stay,hospital stay,28-day mortality were recorded for all the patients.Results: 1 80 patients were included in this study,There were non-shunt group(n = 57,72.25%),intracardiac shunt group(n = 12,15%)and intrapulmonary shunt(n = 11,13.75%).Among them,35 patients with ARDS were divided into three groups,including non-shunt group(n = 25,71.42%),intracardiac shunt group(n = 5,14.29%)and intrapulmonary shunt(n = 5,14.29%).45 patients without ARDS were divided into three groups,including non-shunt group(n=32,71.11%),intracardiac shunt group(n=7,15.56%)and intrapulmonary shunt group(n=6,13.33%).2 Comparison of right heart function and prognosis in patients with hypoxemia.2.1 There was a significant difference in age among the three groups(69.33 years±10.41 years vs 54.64 years±16.27 years vs 65.73 years±11.87 years,P=0.002).There was no significant difference among the three groups in terms of gender,APACHEII score,SOFA score,vital signs,fluid volume,ventilator support condition(P>0.05).2.2 Three there was no significant difference in arterial blood gas among three groups(P>0.05).2.3 There was no significant difference among the three groups in E peak,A peak,E/A,e ’,E/e’,RVarea/LVarea,PASP,TAPSE,IVC(P> 0.05).2.4 There was no significant difference among the three groups in mechanical ventilation time,ICU length of stay,hospital days and 28-day mortality(P>0.05).3 Comparison of right heart function and prognosis in patients with ARDS.3.1 There was a significant difference in CVP among the three groups(10.80 mmHg±3.03 mmHg vs 8.04mmHg±2.49 mmHg vs 10.40mmHg±1.67 mmHg,P=0.032);there was no significant difference in gender,age,APACHEIIscore,SOFA score,other vital signs,fluid volume,ventilator support conditions etc.(P>0.05).3.2 There was no significant difference in blood gas analysis among the three groups(P>0.05).3.3 There was no significant difference in echocardiographic indexes(P>0.05).3.4 There was no significant difference in mechanical ventilation time,ICU length of stay,hospital days and 28-day mortality(P>0.05).4 Comparison of patients with or without ARDS.4.1 There was no significant difference in gender,age,APACHEIIscore,SOFA score,vital signs,fluid volume,ventilator support conditions etc.(P>0.05)。 4.2 There was significant difference in P/F(174.16mmHg±74.58 mmHg vs 242.44mmHg±90.74 mmHg,P=0.001)and lactate(2.39mmol/L±1.64 mmol/L vs 1.78 mmol/L ± 0.89 mmol/L,P=0.037).4.3 There was no significant difference in echocardiographic indexes(P>0.05).4.4 There was no significant difference in mechanical ventilation time,ICU length of stay,hospital days and 28-day mortality(P>0.05).4.5 There was no significant difference in the incidence of intracardiac shunt and intrapulmonary shunt(P>0.05).5 Comparison of survival group and died group 5.1 The died group had larger proportion of female patients(15.87% vs 50%,P=0.047),older(60.77years±13.52 years vs 69.09years±11.24 years,P=0.007),higher APACHE II(18.26±4.58 vs 23.82±7.44,P=0.003)and SOFA score(7.10±2.60 vs 10.55±3.75,P<0.001),and faster in heart than the survival group(95.67beats/min±26.98 beats/min vs 116.32 beats/min±28.83 beats/min,P=0.004),there was no difference in other vital signs(P>0.05).5.2 Survival group had less fluid balance(-59.00±1257.13 ml vs 881.41ml± 1162.96 ml,P=0.002),tidal volume(414.95ml±88.71 ml vs 481.43ml±104.11 ml,P=0.011)than died group.There was no significant difference in the other liquid index,mechanical ventilation parameters and blood gas analysis index(P>0.05).5.3 The survival group had lower PASP(29.28mmHg±12.97 mmHg vs 36.14 mmHg±13.93 mmHg,P=0.049)than the died group.There was no significant difference in other echocardiographic index(P>0.05).5.4 Compared in the two groups,the number of days of mechanical ventilation in the survival group was less(4.66d±2.78 d vs 6.96d±4.16 d,P=0.005),and there was no significant difference in the ICU length of stay,hospital days and 28-days mortality(P>0.05).5.5 There was no significant difference between the two groups in the incidence of intracardiac shunt and pulmonary shunt,and the incidence of ARDS(P>0.05).Conclusion:1 The incidence of intracardiac shunt in patients with hypoxemia was 15%,and the incidence rate of intrapulmonary shunt was13.75%.The incidence of intracardiac shunt in patients with ARDSwas 14.29%,and the incidence rate of intrapulmonary shunt was 14.29%.The incidence of intracardiac shunt in patients with ARDSwas 15.56%,and the incidence rate of intrapulmonary shunt was 13.33%.2 The effects of intracardiac shunt or intrapulmonary shunt on right heart function in patients with hypoxemia and ARDS were not found.3 We did not find the relationship between intracardiac shunt or intrapulmonary shunt and mechanical ventilation time,ICU length of stay,hospital days and 28-days mortality in patients with hypoxemia and ARDS.4 Survival patients with hypoxemia had less fluid balance during 24 h,less tital volume and lower PASP than dided patients.