脓毒性休克诱导心脏舒张功能障碍液体反应性的研究
|
摘要
目的:探讨脓毒性休克诱导心脏舒张功能障碍患者液体反应性的方法和应用价值。方法:选择脓毒性休克诱导心脏舒张功能障碍并行机械通气的患者42例,共进行补液试验92次。以心脏指数(CI)增加值(△CI)是否≥10%分为有液体反应性组(R组)及无液体反应性组(NR组)。观察补液试验前后血流动力学指标及心脏舒张功能变化,应用超声测量下腔静脉内径变异度(VIVC),分析VIVC及中心静脉压(CVP)与CI的相关性。应用受试者工作者特征曲线分析VIVC、每搏量变异度(SVV)、CVP对液体反应性的预测价值。结果:补液试验前R组VIVC显著高于NR组(30.7±4.6vs 21.3±3.1,P<0.05);R组补液试验后VIVC明显降低(30.7±4.6vs 19.5±3.1,P<0.05);NR组补液试验前后VIVC比较无统计学差异(21.3±3.1vs 21.1±3.2,P>0.05)。NR组补液试验后二尖瓣舒张早期峰流速与二尖瓣环舒张早期运动速度比值(E/e’)、N末端脑钠肽前体(NT-proBNP)及肌钙蛋白I较试验前明显升高[11.9±2.3、(1431.3±506.5) ng/ml、(0.98±0.48) ng/mlvs 9.4±1.1、(887.3±460.6) ng/ml、(0.73±0.59) ng/ml,P<0.05]。补液试验前VIVC与△CI显著相关(r=0.552,P=0.011),CVP与△CI无直线相关关系(r=-0.118,P=0.361)。VIVC、SVV、CVP预测液体反应性的曲线下面积分别为0.824、0.683、0.485,以VIVC≥19.50%为临界点时敏感度为72.7%,特异度为87.5%。结论:对于脓毒性休克诱导心脏舒张功能障碍的患者,VIVC能作为预测液体反应性的可靠指标。
Objective: To investigate methods and predictive value of fluid responsiveness in patients with cardiac diastolic dysfunction induced by septic shock. Method: A total of 92 times of volume expansion(VE) test were executed on 42 cases of mechanical ventilated patients with cardiac diastolic dysfunction induced by septic shock. The patients were divided into responsiveness(R) group and nonresponsiveness(NR) group according to cardiac index(CI) increased(△CI) ≥10% or<10%. The changes of hemodynamic parameters and cardiac diastolic function before and after VE tests were observed. Inferior vena cava variation(VIVC) was measured by ultrasound and the correlation between VIVC, central venous pressure(CVP) and CI were analyzed. The roles of VIVC, stroke volume variation(SVV), and CVP to predict fluid responsiveness were evaluated by receiver operating characteristic curve. Result: VIVC was significantly higher in R group than that in NR group before VE test(P<0.05). VIVC decreased notably after VE tests in R group(P<0.05), while there was no significantly difference of VIVC before and after VE test in NR group(P>0.05). The ratio of early peak flow velocity of mitral valve diastolic to early diastolic velocity of the mitral annulus(E/e'), and NT-proBNP and Troponin-I were elevated significantly in NR group after VE tests, and were higher than those in R group before VE tests(P<0.05). Before VE tests VIVC was positively correlated with △CI(r=0.552, P=0.011), while there was no correlation between CVP and △CI(r=-0.118, P=0.361). The area under the curve of VIVC, SVV, CVP to predict fluid responsiveness was 0.824, 0.683, 0.485. When the cut-off value of VIVC was ≥19.5%, the sensibility was 72.7% and specificity was 87.5%. Conclusion: VIVC can be used as a reliable predictor of fluid responsiveness in patients with cardiac diastolic dysfunction induced by septic shock.
Objective: To investigate methods and predictive value of fluid responsiveness in patients with cardiac diastolic dysfunction induced by septic shock. Method: A total of 92 times of volume expansion(VE) test were executed on 42 cases of mechanical ventilated patients with cardiac diastolic dysfunction induced by septic shock. The patients were divided into responsiveness(R) group and nonresponsiveness(NR) group according to cardiac index(CI) increased(△CI) ≥10% or<10%. The changes of hemodynamic parameters and cardiac diastolic function before and after VE tests were observed. Inferior vena cava variation(VIVC) was measured by ultrasound and the correlation between VIVC, central venous pressure(CVP) and CI were analyzed. The roles of VIVC, stroke volume variation(SVV), and CVP to predict fluid responsiveness were evaluated by receiver operating characteristic curve. Result: VIVC was significantly higher in R group than that in NR group before VE test(P<0.05). VIVC decreased notably after VE tests in R group(P<0.05), while there was no significantly difference of VIVC before and after VE test in NR group(P>0.05). The ratio of early peak flow velocity of mitral valve diastolic to early diastolic velocity of the mitral annulus(E/e'), and NT-proBNP and Troponin-I were elevated significantly in NR group after VE tests, and were higher than those in R group before VE tests(P<0.05). Before VE tests VIVC was positively correlated with △CI(r=0.552, P=0.011), while there was no correlation between CVP and △CI(r=-0.118, P=0.361). The area under the curve of VIVC, SVV, CVP to predict fluid responsiveness was 0.824, 0.683, 0.485. When the cut-off value of VIVC was ≥19.5%, the sensibility was 72.7% and specificity was 87.5%. Conclusion: VIVC can be used as a reliable predictor of fluid responsiveness in patients with cardiac diastolic dysfunction induced by septic shock.
引文
[1] Pulido JN,Afessa B,Masaki M,et al.Clinical spectrum,frequency,and significance of myocardial dysfunction in in severe sepsis and septic shock[J].Mayo Clin Proc,2012,87:620-628.
[2] Sasai T,Tokioka H,Fukushima T,et al.Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation inpatients with septic shock[J].J Intensive Care,2014,2(1):58.
[3] 董岩,杨立新,梁伟,等.下腔静脉内径呼吸变异度对休克患者容量反应性的评估价值[J].中国医学前沿杂志(电子版).2017,9(2):124-127.
[4] Dellinger RP,Levy MM,Rhodes A,et al.Surviving Sepsis Campaign:international guidelines for management of severe sepsis and septic shock:2012[J].Crit Care Med,2013,41(2):580-637.
[5] 王金荣,崔朝勃,杨晓亚,等.重症患者左心室舒张功能不全的诊疗进展[J].医学综述,2018,24(13):2613-2620,2626.
[6] 林笑女,姜晓霞,程青虹,等.脓毒症患者左心室舒缩功能的变化及B型钠尿肽诊断价值的探讨[J].中华医学杂志,2014,94(11):816-820.
[7] 张丽娜,王小亭.容量反应性评估:需关注心功能[J].中华重症医学电子杂志,2016,2(2):97-101.
[8] 中华医学会重症医学分会.中国严重脓毒症/脓毒性休克治疗指南(2014)[J].中华危重病急救医学杂志,2015,27(6):401-426.
[9] Lee JY,Kim JY,Choi CH,et al.The ability of stroke volume variation measured by a noninvasive cardiac output monitor to predict fluid responsiveness in mechanically ventilated children[J].Pediatr Cardiol,2014,35(2):289-294.
[10] De Backer D,Taccone FS,Holsten R,et al.Influence of respiratory rate on stroke volume variation in mechanically ventilated patients[J].Anesthesiology,2009,110(5):1092-1097.
[11] 李婷,阚艳敏,马琳,等.超声预测感染性休克患者容量反应性的临床研究[J].中国循环杂志,2016,31(4):354-357.
[12] Zhang Z,Xu X,Ye S,et al.Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients:systematic review and meta-analysis[J].Ultrasound Med Biol,2014,40(5):845-853.
[13] 周淑清,沈涛.高敏肌钙蛋白和N末端B型利钠肽检测对脓毒症心肌损伤的价值[J].临床急诊杂志,2019,20(2):102-106.
[14] 夏嘉鼎,苏震,王娜,等.肌钙蛋白I在脓毒性休克致左心室舒张功能障碍患者中的变化和意义[J].实用医学杂志,2017,33(9):1449-1452.
[2] Sasai T,Tokioka H,Fukushima T,et al.Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation inpatients with septic shock[J].J Intensive Care,2014,2(1):58.
[3] 董岩,杨立新,梁伟,等.下腔静脉内径呼吸变异度对休克患者容量反应性的评估价值[J].中国医学前沿杂志(电子版).2017,9(2):124-127.
[4] Dellinger RP,Levy MM,Rhodes A,et al.Surviving Sepsis Campaign:international guidelines for management of severe sepsis and septic shock:2012[J].Crit Care Med,2013,41(2):580-637.
[5] 王金荣,崔朝勃,杨晓亚,等.重症患者左心室舒张功能不全的诊疗进展[J].医学综述,2018,24(13):2613-2620,2626.
[6] 林笑女,姜晓霞,程青虹,等.脓毒症患者左心室舒缩功能的变化及B型钠尿肽诊断价值的探讨[J].中华医学杂志,2014,94(11):816-820.
[7] 张丽娜,王小亭.容量反应性评估:需关注心功能[J].中华重症医学电子杂志,2016,2(2):97-101.
[8] 中华医学会重症医学分会.中国严重脓毒症/脓毒性休克治疗指南(2014)[J].中华危重病急救医学杂志,2015,27(6):401-426.
[9] Lee JY,Kim JY,Choi CH,et al.The ability of stroke volume variation measured by a noninvasive cardiac output monitor to predict fluid responsiveness in mechanically ventilated children[J].Pediatr Cardiol,2014,35(2):289-294.
[10] De Backer D,Taccone FS,Holsten R,et al.Influence of respiratory rate on stroke volume variation in mechanically ventilated patients[J].Anesthesiology,2009,110(5):1092-1097.
[11] 李婷,阚艳敏,马琳,等.超声预测感染性休克患者容量反应性的临床研究[J].中国循环杂志,2016,31(4):354-357.
[12] Zhang Z,Xu X,Ye S,et al.Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients:systematic review and meta-analysis[J].Ultrasound Med Biol,2014,40(5):845-853.
[13] 周淑清,沈涛.高敏肌钙蛋白和N末端B型利钠肽检测对脓毒症心肌损伤的价值[J].临床急诊杂志,2019,20(2):102-106.
[14] 夏嘉鼎,苏震,王娜,等.肌钙蛋白I在脓毒性休克致左心室舒张功能障碍患者中的变化和意义[J].实用医学杂志,2017,33(9):1449-1452.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |