肝颈返流试验对感染性休克患者容量反应性的评估

目的探讨肝颈返流试验（HRT）评估感染性休克患者容量反应性中的临床应用价值。 方法采用前瞻性队列研究评估感染性休克患者的容量反应性，以脉搏指示持续心排量测定（PiCCO）联合容量负荷试验（VE）获取的心输出量变异度（ΔCO_VE）为金标准，将ΔCO_VE≥15%定义为液体反应阳性，反之为液体反应阴性。所有患者进行HRT和VE，获取心率、平均动脉压（MAP）、中心静脉压（CVP）、心输出量（CO）及每搏输出量（SV）等血液动力学参数，其中包括HRT 15 s和60 s的数据，并与ΔCO_VE相比，获得相关性指标。以受试者工作特征曲线（ROC）分析HRT后ΔCO_HRT、ΔSV_HRT对容量反应性的评估价值。 结果60例感染性休克患者中，液体反应阳性组36例，液体反应阴性组24例，2组患者一般临床资料比较无统计学意义。与HRT前基线值1相比较，液体反应阳性组中HRT后15 s血液动力学参数CVP、CO、SV显著增加［CVP：（8.9±2.1）cmH₂O vs（7.8±1.9）cmH₂O，CO：（3.7±0.7）L/min vs（3.4±0.7）L/min，SV：（30.2±6.2）ml vs（27.2±6.7）ml，P<0.05］，而液体反应阴性组无显著变化（P>0.05）。HRT 15 s与60 s相比，心率、MAP、CVP、CO及SV差异均无统计学意义。VE试验中，液体反应阳性组VE后MAP、CVP、CO及SV较补液前基线值2有所增加［MAP：（75.7±7.3）mmHg vs（72.0±7.6）mmHg，CVP：（9.1±1.5）cmH₂O vs （8.0±1.8）cmH₂O，CO：（3.8±0.7）L/min vs （3.5±0.6）L/min，SV：（30.2±5.6）ml vs （27.2±6.7）ml，P<0.05］。相关性分析显示，ΔCO_HRT、ΔSV_HRT与ΔCO_VE具有相关性（r=0.82、0.83，P均<0.01）。此外，HRT中，以ΔCO_HRT=11.7%为阈值，预测容量反应性的曲线下面积为0.95±0.03（95%CI：0.903~1.00，P<0.01），敏感度为91.7%，特异度为87.5%；以ΔSV_HRT=12.7%为阈值，预测容量反应性的曲线下面积为0.942±0.03（95%CI：0.884~0.999，P<0.01），敏感度为83.3%，特异度为91.7%。 结论HRT利用自体输液原理判断容量反应性，是一种无创、操作便捷、较可靠的评估感染性休克患者容量反应性的新方法，值得临床推广应用。

Value of hepatocervical reflux test in assessment of volume reactivity in patients with septic shock

ObjectiveTo assess the value of the hepatocervical reflux test (HRT) in assessing volume responsiveness in patients with septic shock. MethodsA prospective cohort study was performed to assess the volume status of patients with septic shock. Using the cardiac output variability (ΔCO_VE) obtained by pulse-directed continuous cardiac output measurement (PiCCO) combined with volume expansion (VE) as the gold standard, ΔCO_VE≥15% was defined as positive fluid responsiveness, otherwise it was defined as negative fluid responsiveness. All the patients underwent the VE test and HRT test to obtain flow dynamics parameters, including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), cardiac output (CO), and stroke volume (SV) (HRT 15 s and 60 s data were included), which were compared with ΔCO_VE metallographic to obtain correlated indexes. The value of HRT-induced ΔCO_HRT and ΔSV_HRT to predict volume responsiveness was evaluated by receiver operating characteristic (ROC) curve analysis. ResultsOf the 60 patients with septic shock, 36 had positive fluid responsiveness and 24 had negative fluid responsiveness. There was no significant difference in the general clinical data between the two groups (P>0.05). Compared with the baseline value 1 before HRT, the positive fluid responsiveness group had significantly increased CVP, CO, and SV after HRT 15 s [CVP (8.9±2.1) cmH₂O vs (7.8±1.9) cmH₂O, CO (3.7±0.7) L/min vs (3.4±0.7) L/min, SV (30.2±6.2) mL vs (27.2±6.7) mL, P<0.05], but the negative fluid responsiveness group had no significant change (P>0.05). There were no significant difference in HR, MAP, CVP, CO and SV between HRT 60 s with HRT 15 s. In the VE test, compared with baseline value 2 before rehydration, MAP, CVP, CO, and SV in the positive fluid responsiveness group significantly increased after rehydration [MAP: (75.7±7.3) mmHg vs (72.0±7.6) mmHg, CVP: (9.1±1.5) cmH₂O vs (8.0±1.8) cmH₂O, CO: (3.8±0.7) L/min vs (3.5±0.6) L/min, SV: (30.2±5.6) ml vs (27.2±6.7) ml, P<0.05]. Correlation analysis showed that ΔCO_HRT and ΔSV_HRT after VE showed a correlation with ΔCO_VE (r=0.82 and 0.83, respectively, P<0.01). What′s more, in the HRT, with ΔCO_HRT=11.7% as the threshold, the area under the curve of HRT for predicting volume reactivity was 0.95±0.03 (95%CI: 0.903~1.00, P<0.01), with a sensitivity of 91.7% and specificity of 87.5%; with ΔSV_HRT=12.7% as the threshold, the area under the curve was 0.942±0.03 (95% CI: 0.884~0.999, P<0.01), with a sensitivity of 83.3% and specificity of 91.7%. ConclusionThe HRT is a new method for assessing the volume reactivity by using the principle of autologous infusion. It is a non-invasive, easy-to-use, and reliable method for assessing the volume status of patients with septic shock, which is worthy of clinical application.