左室流出道血流速率时间积分联合被动抬腿试验对保留自主呼吸的机械通气感染性休克患者容量反应性的评估价值

目的分析左室流出道血流速率时间积分(VTI)联合被动抬腿试验(PLR)对保留自主呼吸的机械通气感染性休克患者液体容量反应性的评估价值。方法选择2017年3月-2018年3月海南医学院第二附属医院重症医学科收治保留自主呼吸的机械通气感染性休克患者120例作为研究对象。患者均行液体复苏和PLR试验,同时采用外周动脉压心排量(APCO)对扩容及PLR前后各项血流动力学指标变化进行监测记录,根据患者液体复苏前后心排血指数(CI)分为反应组(增加率≥15%,n=76)和无反应组(CI增加率<15%,n=44)。比较不同时间点2组患者VTI、中心静脉压(CVP)、平均动脉压(MAP)、心率(HR)、心输出量(CO)及每搏变异度(SVV)变化。采用Pearson法对血流动力学指标与CI的相关性进行分析,并通过受试者工作特征曲线(ROC)分析PLR及VTI对保留自主呼吸机械通气感染性休克患者的液体容量反应性的预测价值。结果反应组患者PLR后和液体复苏后VTI、CVP指标明显升高,SVV明显降低(t/P=9.610/<0.001、6.152/<0.001、9.386/<0.001、7.729/<0.001、6.259/<0.001、12.762/<0.001)。对液体复苏前及PLR前VTI、CVP、SVV与△CI进行相关性分析显示,VTI与△CI呈负相关(r/P=-0.593/<0.001、-0.573/<0.001),SVV与△CI呈正相关(r/P=0.565/0.001、0.459/0.005)。SVV和VTI的ROC曲线下面积为0.687和0.879,当SVV的cut-off值为13.5时,预测液体容量反应性的敏感度为89.65%,特异度为84.63%,约登指数为0.743;当VTI的cut-off值为18.6时,预测容量反应性的敏感度为83.34%,特异度为98.69%,约登指数为0.820。结论SVV和VTI的变化可有效地反映保留自主呼吸机械通气感染性休克患者的液体容量反应性,指导患者临床液体治疗,具有一定的参考价值。

Value of left ventricular outflow tract blood flow rate time integral combined with passive leg lift test in evaluating volume responsiveness in patients with septic shock undergoing mechanical ventilation with spontaneous breathing

Objective The value of the left ventricular outflow tract blood flow rate time integral combined with the passive lift leg test was evaluated in the volume responsiveness of patients with mechanical ventilation septic shock who retained spontaneous respiration.Methods From March 2017 to March 2018,120 patients with mechanical ventilation septic shock who retained spontaneous breathing were enrolled in the Department of Critical Care Medicine,Second Affiliated Hospital of Hainan Medical College.All patients underwent fluid resuscitation and passive leg lift(PLR)tests,and APCO was used to monitor and document changes in hemodynamic indicators before and after the dilatation and PLR.After that,the response group was defined as having CI increase the rate≥15%before and after the fluid resuscitation,while the nonresponse group was defined as having a CI increase rate<15%(n=44).The Pearson method was used to analyze the correlation between hemodynamic parameters and CI.The receiver operating characteristic(ROC)curve was used to analyze the predictive value of PLR and VTI for the volume responsiveness of patients with spontaneous respiratory ventilatory shock.Results In the reaction group,the VTI and CVP indexes were significantly increased after PLR and fluid resuscitation,and SVV was significantly decreased(t/P=9.610/<0.001,t/P=6.152/<0.001,t/P=9.386/<0.001,t/P=7.729/<0.001,t/P=6.259/<0.001,t/P=12.762/<0.001).Correlation analysis of VTI,CVP,SVV,and△CI before liquid resuscitation and before PLR showed a negative correlation between VTI and△CI(r/P=-0.593/<0.001,r/P=-0.573/<0.001).SVV was positively correlated with△CI(r/P=0.565/0.001,r/P=0.459/0.005);there was no significant correlation between CVP and△CI(r/P=0.198/0.302,r/P=0.037/0.847).Conclusion The changes of SVV and VTI can effectively reflect the volume responsiveness of patients with spontaneous respiratory ventilatory septic shock and guide patients with clinical fluid therapy,which has certain reference value.