PiCCO联合被动抬腿试验预测感染性休克容量反应性研究

目的:探讨脉搏指示连续心输出量联合被动抬腿试验对感染性休克患者容量反应性的预测作用,为临床容量治疗提供更多思路和依据。方法:选取2015年6月～2019年6月急诊重症病区收治的感染性休克患者50例为研究对象,通过患者的容量反应性,依据患者每搏输出量增加大于10%为有容量反应的标准,将患者分为有反应组和无反应组,结合脉搏指示连续心输出量技术,测定并比较被动抬腿试验及补液试验前后动脉收缩压、中心静脉压、平均动脉压、脉压、心率、每搏输出量等参数,并采用受试者工作曲线评价脉搏指示连续心输出量联合被动抬腿试验对容量反应性的预测价值。结果:有反应组中心静脉压、平均动脉压、动脉收缩压治疗前后均无显著性差异(P0.05),治疗后脉压、每搏输出量较治疗前显著升高(P0.05);无反应组各指标治疗前后比较均无显著性差异(P0.05);被动抬腿试验诱导脉压变化率对容量反应性预测的灵敏度为80.2%,特异度为78.9%;被动抬腿试验诱导每搏量变化率对容量反应性预测的灵敏度为88.2%,特异度为78.4%。结论:脉搏指示连续心输出量联合被动抬腿试验对容量反应性的预测价值较高,被动抬腿试验诱导脉压变化率和被动抬腿试验诱导每搏量变化率可作为容量治疗的指导指标。     

被动抬腿试验在容量复苏管理中的价值

被动抬腿试验(PLR)是预测容量反应性的一种新方法。在初始的重症监护室(ICU)复苏后,液体过负荷对危重病患者是有害的,ICU患者需要一些方法帮助判断容量反应性的情况。现已明确静态前负荷指标的无法有效预测液体反应性,动态前负荷指标则可达到这一目的。比如每搏量变异率(SVV)和脉压变异率(PPV)等具有较好的效果,但它们不能用于自主呼吸活动、心律失常、小潮气量或低肺顺应的患者。PLR可解决上述PPV等指标解决不了的问题。PLR是预测容量反应性的一种新方法,通过监测被动抬腿试验诱导的心搏量或其替代指标的变化大小来预测机体的容量反应性,是功能性血流动力学监测指标,是可逆的自体容量负荷试验。该试验能够精确预测容量反应性,并具有操作简单、安全性高、不受自主呼吸和心律失常干扰、不受监测设备限制的优点,值得在临床上推广应用,指导液体治疗。     

被动抬腿试验联合无创心排血量监测系统预测容量反应性的临床研究

目的 评价被动抬腿试验联合无创心排血量监测系统(USCOM)预测自主呼吸患者的容量反应性.方法 采用前瞻性、观察性队列研究设计方法,选择33例有自主呼吸且需补液的患者,先后进行被动抬腿试验和容量负荷试验,在每个试验前后分别采用经胸超声心动图(TTE)和USCOM测量每搏量(SV).根据对容量负荷试验的反应(以容量负荷试验后SVTTE增加≥15%者为有反应)将患者分为有反应组和无反应组.观察试验后SV的变化(△SV)及其相关性.结果 33例患者共行容量负荷试验36例次,有反应组24例次,无反应组12例次.两组一般资料及初始床头抬高45°时的血流动力学指标无明显差异.被动抬腿试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(21.7±13.2)%比(4.8±9.4)%,△SVUSCOM:(23.5±13.0)%比(4.6±8.9)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.792,P＜0.01).容量负荷试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(27.3±14.1)%比(7.2±8.4)%,△SVUSCOM:(25.4±13.8)%比(6.7±8.6)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.855,P＜0.01).用△SVTTE≥15%预测容量反应性,其敏感性为100.0%[95%可信区间(95%CI)85.0～100.0],特异性为83.3%(95%CI 68.4～98.2);而用△SVUSCOM≥15%预测容量反应性,其敏感性为83.3%(95%CI 66.1～100.0),特异性为94.4%(95%CI 83.9～100.0).被动抬腿试验后△SVTTE与△SVUSCOM的受试者工作特征曲线下面积比较差异无统计学意义(0.95±0.04比0.93±0.05,P＞0.05).结论 用USCOM测量被动抬腿试验后的△SV可反映自主呼吸患者液体治疗时的容量反应性,用以指导患者的液体治疗.

Abstract：

Objective To investigate whether passive leg raising(PLR)combined with ultrasonic cardiac output monitoring system(USCOM)could be used to predict the hemodynamic response to volume expansion(VE)in patients with spontaneous respiration. Methods The study was performed with prospective, cohort study method. Thirty-three patients with spontaneous breathing activity who were admitted to the intensive care unit(ICU)from October 2009 to April 2010 were included. Measurements of stroke volume(SV)were obtained with transthoracic echocardiography(TTE)and USCOM. Patients were considered to be responders to VE if SVTTE increased≥ 15%. Based on the responsiveness of VE, all the patients were divided into responders and non-responders. The change in SV(△SV)after the experiment and its correlation were observed. Results A total of 36 fluid load tests in 33 patients were evaluated resulting in 24 responders and 12 non-responders. There was no significant difference between two groups in the clinical data and hemodynamics parameters at incipient stage when head side of bed was raised for 45°. After PLR,the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(21.7±13.2)% vs.(4.8±9.4)%, △SVUSCOM:(23.5±13.0)% vs.(4.6±8.9)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r = 0. 792, P＜0. 01). After VE, the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(27.3±14.1)% vs.(7.2±8.4)%, △SVUSCOM:(25.4±13.8)% vs.(6.7±8.6)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r= 0. 855, P＜0. 01). The △SVTTE≥ 15%during PLR was predictive of response to VE with a sensitivity of 100. 0%[95% confidence interval (95%CI)85.0 - 100. 0]and a specificity of 83. 3%(95%CI 68.4 - 98. 2). The △SVUSCOM≥15% during PLR was predictive of response to VE with a sensitivity of 83.3%(95%CI 66. 1 - 100. 0)and a specificity of 94.4%(95%CI 83. 9 - 100. 0). There was no difference between the area under the receiver operating characteristic(ROC)curve for PLR-induced △SVTTE and △SVUSCOM(0. 95±0. 04 vs. 0. 93±0. 05, P＞0. 05).Conclusion PLR combined with USCOM can predict the hemodynamic response to VE in spontaneously breathing patients, and the procedure can be used to guide fluid therapy in spontaneously breathing patients.     

被动抬腿试验预测严重感染和感染性休克患者的容量反应性

目的 观察被动抬腿试验(PLR)预测严重感染和感染性休克患者容量反应性的价值.方法 采用前瞻性观察性研究方法,选择2009年2月至2010年1月北京大学深圳医院重症监护病房(ICU)的30例严重感染和感染性休克患者.在患者平卧位、PLR期间和扩容后进行血流动力学监测,用超声心排血量监测仪无创监测每搏量(SV)、心排血量(CO)、外周血管阻力(SVR)等血流动力学指标,持续监测有创动脉血压、中心静脉压(CVP).将扩容后SV增加值(△SV)≥15%定义为有容量反应性,用受试者工作特征曲线(ROC曲线)评价PLR预测容量反应性的价值.结果 扩容后有15例患者有容量反应.PLR期间无反应组和有反应组患者CVP(cm H2O,1 cm H2O=0.098 kPa)均较平卧位时增加(13.6±6.6比12.1±6.0,11.9±5.5比10.8±5.2,均P＜0.01);有反应组PLR期间△SV明显高于无反应组[(16.6±5.5)%比(3.8±8.2)%,P=0.000];PLR期间△SV与扩容后△SV呈显著正相关(r=0.681,P=0.000);PLR预测容量反应性的ROC曲线下面积(AUC)为0.944±0.039(P=0.000),PLR期间△SV＞11%预测容量反应性的敏感性和特异性分别为86.7%和93.3%,阳性预测率和阴性预测率分别为92.9%和87.5%.结论 PLR能精确预测严重感染和感染性休克患者的容量反应性,可指导临床治疗.

Abstract：

Objective To evaluate the role of passive leg raising(PLR)test in predicting volume responsiveness in severe sepsis and septic shock patients. Methods Thirty severe sepsis and septic shock patients in intensive care unit(ICU)of Peking University Shenzhen Hospital were prospectively observed from February 2009 to January 2010. The hemodynamics including stroke volume(SV), cardiac output (CO)and systemic vascular resistance(SVR)were measured non-invasively by ultrasonic cardiac output monitor(USCOM)device in the supine position, during PLR and after volume expansion(VE), and invasive arterial blood pressure and central venous pressure(CVP)were monitored consecutively. Responders were defined by the appearance of an increase in SV(△SV)≥15% after VE. The role of PLR for predicting volume responsiveness was evaluated by receiver operating characteristic(ROC)curves. Results The CVP (cm H2O, 1 cm H2O=0. 098 kPa)during PLR was increased compared with that at supine position in both responder group(n= 15)and non-responder group(n= 15, 13. 6± 6. 6 vs. 12. 1 ± 6. 0, 11.9± 5.5 vs.10. 8±5.2, both P＜0. 01). △SV was higher in responder group than in non-responder group during PLR [(16. 6±5.5)% vs.(3. 8±8. 2)%, P=0. 000]. △SV during PLR was highly correlated to △SV after VE (r=0. 681, P=0. 000). The area under the ROC curve(AUC)for PLR predicting volume responsiveness was 0. 944±0. 039(P=0. 000). The △SV＞11% during PLR was found to predict volume responsiveness with a sensitivity of 86. 7%, specificity of 93. 3 %, positive predictive value of 92. 9 % and negative predictive value of 87.5%. Conclusion PLR can be used generally to predict volume responsiveness accurately in severe sepsis and septic shock patients, and it can be used to direct clinical practice.     

无创超声心输出量监测技术联合被动抬腿试验评估心脏术后患者容量反应性的作用

目的 探讨无创超声心输出量监测技术(USCOM)联合被动抬腿试验(PLR)评估心脏术后患者容量反应性的作用.方法 2010-02～2010-06心脏瓣膜置换术后需要扩容的患者纳入本研究,按四个阶段进行:半卧位;躯体仰卧位,下肢抬高45°进行PLR;回到半卧位;30 min内静脉输注500 mL 6%羟乙基淀粉进行扩容.通过USCOM连续进行心输出量(CO)和每搏输出量(SV)监测.根据扩容后SV的变化值(ΔSV)是否 ≥15% 分为反应组和无反应组.受试者工作特征曲线评价PLR所致ΔSV预测容量反应性的价值.结果 80例需要扩容的患者纳入本研究,9例因不能得到满意的USCOM多普勒信号被排除,32例(45.1%)患者ΔSV≥15%为反应组.PLR所致ΔSV曲线下面积(AUC)是0.84±0.05,ΔSV≥15%预测容量反应性的敏感度和特异度分别为56%和100%,阳性预测值和阴性预测者分别是65%和100%.结论 通过USCOM监测PLR所致ΔSV对评估心脏术后患者容量反应性具有一定的指导意义.     

脉搏氧灌注指数和灌注变异指数的临床应用

脉搏氧灌注指数(PI)和灌注变异指数(PVI)是新一代脉搏氧饱和度仪新增的测量参数.PI和PVI分别是连续评价组织灌注和容量状态的无创性监测工具,在危重病救治、麻醉手术和临床研究等方面具有重要价值.     

主动脉峰值流速变异度联合被动抬腿试验评估重症急性胰腺炎休克患者容量反应性

目的探讨主动脉峰值流速变异度（?Vpeak_AO）联合被动抬腿试验（PLR）在重症急性胰腺炎（SAP）休克患者容量反应性中的预测价值。 方法选取2017年8月至2020年8月北京大学人民医院收治的SAP休克患者134例。记录患者临床资料,对患者进行PLR和容量负荷试验（VE）,利用床旁超声仪器检测PLR和VE前后血流动力学及超声指标的变化。根据VE后每搏量（SV）变化值（?SV）是否≥15%将患者分为有反应组和无反应组。采用Pearson相关法分析?SV-VE与?Vpeak_AO-PLR的相关性。利用ROC曲线分析?Vpeak_AO联合PLR在SAP休克患者容量反应性评估中的预测价值。 结果PLR前,有反应组SV、Vpeak_AO均低于无反应组,差异均有统计学意义（P均=0.000）。PLR和VE后,有反应组SV、Vpeak_AO均高于PLR前,差异均有统计学意义（P均＜0.05）。PLR和VE后,有反应组?SV、?Vpeak_AO均高于无反应组,差异均有统计学意义（P均=0.000）。Pearson相关性分析显示,?Vpeak_AO-PLR与?SV-VE呈正相关（r=0.769,P＜0.05）。?Vpeak_AO-PLR预测SAP休克患者容量反应性的ROC曲线下面积为0.924（95%CI：0.879~0.969）,临界值为10.9%时,敏感度为86.3%,特异度为88.5%。 结论?Vpeak_AO联合PLR在SAP休克患者容量反应性评估中具有良好的预测价值,对临床应用具有积极意义。     

超声联合小剂量容量负荷试验评估感染性休克患者容量反应性的临床价值

目的探讨超声联合小剂量容量负荷试验评估感染性休克患者容量反应性的临床价值。方法回顾性选取2017年2月至2022年2月空军第986医院收治的感染性休克患者80例,依据快速输注500 mL晶体液后超声检测的心排血量(CO)增加量(△CO500)分为容量反应组(△CO500≥15%)、容量无反应组(△CO500<15%)两组,每组各40例。比较两组者患者试验前、试验中、试验后的血流动力学参数,分析△CO500与血流动力学参数相关性,并比较两组患者的临床指标。结果试验前,容量反应组患者的CO、主动脉速度时间积分(VTI)均明显低于容量无反应组,差异均有统计学意义(P<0.05),但两组患者的心率、中心静脉压(CVP)、平均动脉压(MAP)、左室射血分数(LVEF)之间差异均无统计学意义(P>0.05);试验中,容量反应组患者的CVP、CO、VTI均明显低于容量无反应组,差异均有统计学意义(P<0.05),但两组患者的心率、MAP、LVEF比较,差异均无统计学意义(P>0.05);试验后,容量反应组患者的CVP明显低于容量无反应组,LVEF明显高于容量无反应组,差异均有统计学意义(P<0.05),但两组患者的心率、MAP、CO、VTI比较,差异均无统计学意义(P>0.05)。两组患者试验前、试验中、试验后的心率均逐渐降低,CVP、MAP、CO、LVEF、VTI均逐渐升高,差异均有统计学意义(P<0.05)。△CO500与心率、CVP、MAP均无相关性(P>0.05)。容量反应组患者的丙泊酚维持使用时间明显短于容量无反应组,机械通气时间明显短于容量无反应组,差异均有统计学意义(P<0.05),但两组患者的去甲肾上腺素用量、氧合指数、总PEEP、潮气量之间差异均无统计学意义(P>0.05)。结论超声联合中小剂量容量负荷试验联合评估感染性休克患者容量反应性有较高的临床价值,有助于稳定血流动力学指标,缩短丙泊酚维持使用时间和机械通气时间。     

被动抬腿试验预测呼吸机脱机结局：一项系统综述和荟萃分析

目的评估被动抬腿试验（PLR）对呼吸机脱机结局的预测能力。 方法以关键词"被动抬腿试验"、"机械通气"、"脱机"在中国知网、维普网、百度学术、中国临床试验注册中心搜索文献及相关临床研究,以关键词"passive leg raising or raise"、"mechanical ventilation or ventilator"、"weaning"在PubMed、Embase、the Cochrane Library、clinicaltrials.gov上搜索文献及相关临床研究;搜索日期为建库至2018年2月11日。文献搜索和数据提取由两人独立进行,所获文献采用诊断准确性研究的质量评价工具（QUADAS-2）评估其研究质量,相关数据则使用RevMan 5.3.5和Meta-disc软件进行分析。 结果最终有3篇文献被纳入,其中中文1篇,英文2篇,均具有较高的质量评分。患者总数为145人,共进行228例次PLR和脱机试验。其中,PLR阳性123例次,脱机成功87例次,失败36例次;PLR阴性105例次,脱机成功18例次,失败87例次。PLR预测脱机的正确率为76%。PLR阳性预测脱机成功的敏感度为0.83（95%CI：0.74~0.90）,特异度为0.71（95%CI：0.62~0.79）;汇总受试者操作特征曲线（SROC）曲线下面积为0.82±0.04,约登指数为0.54。 结论被动抬腿试验能用于预测呼吸机脱机结局。     

Passive leg raising

Objective To assess whether the passive leg raising test can help in predicting fluid responsiveness. Design Nonsystematic review of the literature. Results Passive leg raising has been used as an endogenous fluid challenge and tested for predicting the hemodynamic response to fluid in patients with acute circulatory failure. This is now easy to perform at the bedside using methods that allow a real time measurement of systolic blood flow. A passive leg raising induced increase in descending aortic blood flow of at least 10% or in echocardiographic subaortic flow of at least 12% has been shown to predict fluid responsiveness. Importantly, this prediction remains very valuable in patients with cardiac arrhythmias or spontaneous breathing activity. Conclusions Passive leg raising allows reliable prediction of fluid responsiveness even in patients with spontaneous breathing activity or arrhythmias. This test may come to be used increasingly at the bedside since it is easy to perform and effective, provided that its effects are assessed by a real-time measurement of cardiac output. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Passive leg raising for predicting fluid responsiveness: importance of the postural change

Objective  For predicting fluid responsiveness by passive leg raising (PLR), the lower limbs can be elevated at 45° either from the 45° semi-recumbent position (PLR_SEMIREC) or from the supine position (PLR_SUPINE). PLR_SUPINE could have a lower hemodynamic impact than PLR_SEMIREC since it should not recruit the splanchnic venous reservoir. Design  Prospective study Setting  A 24-bed medical intensive care unit. Patients and participants  A total of 35 patients with circulatory failure who responded to an initial PLR_SEMIREC by an increase in cardiac index ≥ 10%. Interventions  PLR_SEMIREC, a transfer from the semi-recumbent to the supine position and PLR_SUPINE were performed in all patients in a random order before fluid expansion (500 mL saline). Measurements and results  PLR_SEMIREC, supine transfer and PLR_SUPINE significantly increased the pulse-contour derived cardiac index (PiCCOplus) by 22 (17–28)%, 9 (5–15)% and 10 (7–14)% (P < 0.05 vs. PLR_SEMIREC for the latter two), respectively. These maneuvers significantly increased the right ventricular end-diastolic area (echocardiography) by 20 (14–29)%, 9 (5–16)% and 10 (5–16)% (P < 0.05 vs. PLR_SEMIREC for the latter two) and the central venous pressure by 33 (22–50)%, 15 (10–20)% and 20 (15–29)% (P < 0.05 vs. PLR_SEMIREC for the latter two), respectively. Volume expansion significantly increased cardiac index by 27 (21–38)% and all patients were responders to volume expansion. If an increase in cardiac index ≥ 10% is considered as a positive response to PLR_SUPINE, 15 (43%) patients would have been unduly predicted as non-responders to fluid administration by PLR_SUPINE. Conclusions  PLR_SEMIREC induces larger increase in cardiac preload than PLR_SUPINE and may be preferred for predicting fluid responsiveness. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Hemodynamic effects of passive leg raising: an echocardiographic study in patients with shock

OBJECTIVES: To determine the effects of passive leg raising (PLR) on hemodynamics and on cardiac function according to the preload dependency defined by the superior vena cava collapsibility index (DeltaSVC). RESULTS: Forty patients with shock, sedated and mechanically ventilated, were included. Transesophageal echocardiography was performed. At baseline (T1), two groups were defined according to DeltaSVC. Eighteen patients presenting a DeltaSVC > 36%, an indicator of preload dependency, formed group 1, whereas 22 patients (group 2) exhibited a DeltaSVC < 30% (not preload-dependent). Measurements were then performed during PLR (T2), back to baseline (T3), and after volume expansion (T4) in group 1 only. At T1, DeltaSVC was significantly higher in group 1 than in group 2, 50 +/- 9% and 7 +/- 6%, respectively. In group 1, we found a decrease in DeltaSVC at T2 (24 +/- 9%) and T4 (17 +/- 7%), associated with increased systolic, diastolic and arterial pulse pressures. Cardiac index also increased, from 1.92 +/- 0.74 (T1) to 2.35 +/- 0.92 (T2) and 2.85 +/- 1.2 l/min/m(2) (T4) and left ventricular end-diastolic volume from 51 +/- 41 to 61 +/- 51 and 73 +/- 51 ml/m(2). None of these variations was found in group 2. No change in heart rate was observed. CONCLUSION: Hemodynamic changes related to PLR were only induced by increased cardiac preload.     

Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity

Objective In hemodynamically unstable patients with spontaneous breathing activity, predicting volume responsiveness is a difficult challenge since the respiratory variation in arterial pressure cannot be used. Our objective was to test whether volume responsiveness can be predicted by the response of stroke volume measured with transthoracic echocardiography to passive leg raising in patients with spontaneous breathing activity. We also examined whether common echocardiographic indices of cardiac filling status are valuable to predict volume responsiveness in this category of patients. Design and setting Prospective study in the medical intensive care unit of a university hospital. Patients 24 patients with spontaneously breathing activity considered for volume expansion. Measurements We measured the response of the echocardiographic stroke volume to passive leg raising and to saline infusion (500 ml over 15 min). The left ventricular end-diastolic area and the ratio of mitral inflow E wave velocity to early diastolic mitral annulus velocity (E/Ea) were also measured before and after saline infusion. Results A passive leg raising induced increase in stroke volume of 12.5% or more predicted an increase in stroke volume of 15% or more after volume expansion with a sensitivity of 77% and a specificity of 100%. Neither left ventricular end-diastolic area nor E/Ea predicted volume responsiveness. Conclusions In our critically ill patients with spontaneous breathing activity the response of echocardiographic stroke volume to passive leg raising was a good predictor of volume responsiveness. On the other hand, the common echocardiographic markers of cardiac filling status were not valuable for this purpose. This article is discussed in the editorial available at:     

Passive leg raising as an indicator of fluid responsiveness in patients with severe sepsis

BACKGROUND:

In the management of critically ill patients, the assessment of volume responsiveness and the decision to administer a fluid bolus constitute a common dilemma for physicians. Static indices of cardiac preload are poor predictors of volume responsiveness. Passive leg raising (PLR) mimics an endogenous volume expansion (VE) that can be used to predict fluid responsiveness. This study was to assess the changes in stroke volume index (SVI) induced by PLR as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis.

METHODS:

This was a prospective study. Thirty-two mechanically ventilated patients with severe sepsis were admitted for VE in ICU of the First Affiliated Hospital, Zhejiang University School of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to December 2011. Patients with non-sinus rhythm or arrhythmia, parturients, and amputation of the lower limbs were excluded. Measurements of SVI were obtained in a semi-recumbent position (baseline) and during PLR by the technique of pulse indicator continuous cardiac output (PiCCO) system prior to VE. Measurements were repeated after VE (500 mL 6% hydroxyethyl starch infusion within 30 minutes) to classify patients as either volume responders or non-responders based on their changes in stroke volume index (ΔSVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between the two groups. The changes of ABPs, ABPm, CVPm, and SVI after PLR and VE were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and the change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS 17.0 software was used for statistical analysis.

RESULTS:

Among the 32 patients, 22 were responders and 10 were non-responders. After PLR among the responders, some hemodynamic variables (including ABPs, ABPd, ABPm and CVPm) were significantly elevated (101.2±17.6 vs.118.6±23.7, P=0.03; 52.8±10.7 vs. 64.8±10.7, P=0.006; 68.3±11.7 vs. 81.9±14.4, P=0.008; 6.8±3.2 vs. 11.9±4.0, P=0.001). After PLR, the area under curve (AUC) and the ROC curve of ΔSVI and ΔCVPm for predicting the responsiveness after VE were 0.882±0.061 (95%CI 0.759–1.000) and 0.805±0.079 (95%CI 0.650–0.959) when the cut-off levels of ΔSVI and ΔCVPm were 8.8% and 12.7%, the sensitivities were 72.7% and 72.7%, and the specificities were 80% and 80%.

CONCLUSION:

Changes in ΔSVI and ΔCVPm induced by PLR are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.KEY WORDS: Passive leg raising, Volume resuscitation, Hemodynamic monitoring, Stroke volume index, Central venous pressure, Severe sepsis, Fluid responsiveness, ROC curve     

被动直腿抬高试验在严重脓毒症患者容量判断中的作用

目的 探讨被动直腿抬高试验(passive leg raising,PLR)在判断严重脓毒症的机械通气患者中血流动力学反应的作用,指导脓毒性患者的容量复苏.方法 前瞻性研究,入选2010年5月至2011年5月浙江大学医学院附属第一医院ICU和宁波市医疗中心李惠利医院ICU,符合严重脓毒症诊断标准的机械通气患者28例进行液体复苏.排除非窦性心律者、心律不齐者和产妇.用脉搏波指示剂连续心排血量( pulse indicator continuous cardiac output,PiCCO)技术分别记录在半卧位、PLR后、液体输注后(30 min内快速输注6％羟乙基淀粉500 ml)的血流动力学参数.根据每搏量指数变化(△SVI)是否大于等于15％,分为液体反应阳性组和液体反应阴性组.比较两组间基线水平时心率(HR)、收缩压(ABPs)、舒张压(ABPd)、平均动脉压(ABPm)、平均中心静脉压(CVPm)和心指数(CI)的差异;比较两组患者PLR后及快速输液后ABPs、ABPm、CVPm、SVI与基线水平之间的差异;ROC曲线评价△SVI、△CVPm对预测患者液体反应的价值.用SPSS17.0统计软件包进行统计分析.结果 28例患者中液体反应阳性组18例,液体反应阴性组10例.液体反应阳性组PLR后ABPs、ABPm、CVPm比基线水平显著升高[(115.9±13.1) vs.(100.1±18.1),(77.8±13.0) vs,(68.1±12.4),(10.1±4.1)vs.(7 2±3.4)],分别为P=0.005,P=0.03,P=0.03.PLR后,△SVI和△CVPm预测液体反应阳性的ROC曲线下面积分别为0.897±0.059(95％CI=0.762 ～ 1.000)和0.819±0.081(95％CI=0.661～0.977).分别取△SVI=10.5％和△CVPm=12.7％为界值,预测患者液体反应阳性的敏感性为72.2％和72.2％,特异性为90.0％和80.0％.结论 PLR后的△SVI和△CVPm可以作为严重脓毒症机械通气患者的一项准确而可逆的液体反应预测指标.