每搏心输出量变异度和脉压差变异度在小潮气量下对严重感染容量反应的预测价值
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摘要
目的探讨每搏心输出量变异度(SVV)、脉压差变异度(PPV)在小潮气量下对严重感染容量反应的预测价值。方法选择严重感染伴急性呼吸窘迫综合征行小潮气量通气患者79例,容量负荷实验133次,以容量负荷实验前后心指数增加值(△CI)≥10%为容量反应阳性(R组),△CI<10%为容量反应阴性(NR组),监测两组容量负荷实验前后SVV、PPV、全心舒张末期容积指数(GEDVI)、中心静脉压(CVP)的差值,采用ROC曲线评估其对容量反应的预测价值。结果 R组容量负荷实验77例次,NR组容量负荷实验56例次。R组容量负荷前后SVV、PPV差值大于NR组,差异均有统计学意义(t分别=4.90、4.94,P均<0.05),两组容量负荷前后GEDVI、CVP的差值比较差异均无统计学意义(t分别=0.99、0.92,P均>0.05)。SVV、PPV预测容量反应性曲线下面积分别为0.88(95%CI0.82～0.94)、0.84(95%CI 0.77～0.91);最佳切点分别为8.50%、7.50%,灵敏度分别为79.10%、85.10%,特异度分别为80.40%、65.20%;CVP、GEDVI曲线下面积分别为0.51(95%CI 0.40～0.62)、0.52(95%CI 0.41～0.63)。结论 SVV、PPV能预测小潮气量机械通气下感染性休克患者的容量反应,GEDVI、CVP的预测价值较低。
Objective To explore the predictive value of stroke volume variation and pulse pressure variation fluid responsiveness in septic shock with low tidal volume ventilation. Methods One hundred and thirty three fluid resuscitation were executed in seventy-seven patients with septic shock and low tidal volume.Cardiac index increased ≥10% after fluid resuscitation was defined as positive reaction(group R),and cardiac index increased <10% was defined as negative reaction(group NR).The levels of SVV,PPV,GEDVI,CVP between two groups were compared.The predictive value on volume responsiveness was analyzed by receiver operating characteristic(ROC)curve. Results Totally 77 fluid resuscitation were executed in group R,and 56 fluid resuscitation were executed in group NR.△SVV and △PPV in group R were significantly higher than those in group NR(t=4.90,4.94,P<0.05).There was no significant difference in △GEDVI and △CVP between the two group(t=0.99,0.92,P>0.05). The area under the ROC curve(AUC)of SVV,PPV,CVP,GEDVI were 0.88(95%CI 0.82～0.94),0.84(95%CI 0.77～0.91),0.51(95%CI 0.40～0.62),0.52(95%CI 0.41～0.63),respectively.When using SVV≥8.50%,PPV≥7.50% as the threshold to predict fluid responsiveness,the sensitivities were 0.79,0.85,and specificities was 0.80,0.65 respectively. Conclusion SVV and PPV can be used as predictors of fluid responsiveness in septic shock with low tidal volume ventilation,but the predictive values of GEDVI and CVP are low.
Objective To explore the predictive value of stroke volume variation and pulse pressure variation fluid responsiveness in septic shock with low tidal volume ventilation. Methods One hundred and thirty three fluid resuscitation were executed in seventy-seven patients with septic shock and low tidal volume.Cardiac index increased ≥10% after fluid resuscitation was defined as positive reaction(group R),and cardiac index increased <10% was defined as negative reaction(group NR).The levels of SVV,PPV,GEDVI,CVP between two groups were compared.The predictive value on volume responsiveness was analyzed by receiver operating characteristic(ROC)curve. Results Totally 77 fluid resuscitation were executed in group R,and 56 fluid resuscitation were executed in group NR.△SVV and △PPV in group R were significantly higher than those in group NR(t=4.90,4.94,P<0.05).There was no significant difference in △GEDVI and △CVP between the two group(t=0.99,0.92,P>0.05). The area under the ROC curve(AUC)of SVV,PPV,CVP,GEDVI were 0.88(95%CI 0.82～0.94),0.84(95%CI 0.77～0.91),0.51(95%CI 0.40～0.62),0.52(95%CI 0.41～0.63),respectively.When using SVV≥8.50%,PPV≥7.50% as the threshold to predict fluid responsiveness,the sensitivities were 0.79,0.85,and specificities was 0.80,0.65 respectively. Conclusion SVV and PPV can be used as predictors of fluid responsiveness in septic shock with low tidal volume ventilation,but the predictive values of GEDVI and CVP are low.
引文
1金康平,余慧,陈鹏,等.下腔静脉管径呼吸变异指数对机械通气感染性休克容量反应预测[J].全科医学临床与教育,2015,13(4):386-389.
2陈鹏,崔巍,陈思,等.每搏变异度对失血性休克容量反应的预测[J].中华急诊医学杂志,2013,22(7):787-789.
3陈卫英,陈鹏.下腔静脉内径呼吸变异度对非机械通气脓毒性休克容量反应预测[J].全科医学临床与教育,2018,16(6):637-640.
4陈鹏,潘巧玲,陈思,等.被动抬腿实验预测心源性休克容量反应性[J].全科医学临床与教育,2018,16(2):156-159.
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7 Angappan S,Parida S,Vasudevan A,et al.The comparison of stroke volume variation with central venous pressure in predicting fluid responsiveness in septic patients with acute circulatory failure[J].Indian J Crit Care Med,2015,19(7):394-400.
8刘宁,顾勤,俞建峰,等.呼气末正压对每搏量变异评价容量准确性的影响[J].中华危重症急救医学杂志,2012,24(7):283-285.
9 Silva Ramos FJ,Oliveira EM,Park M,et al.Heartlung interactions with different ventilatory settings during acute lung injury and hypovolaemia:an experimental study[J].Br J Anaesth,2011,106(3):394-402.
10张晓明,金鹏,杨华,等.B型尿钠肽与肌钙蛋白I联合检测对严重脓毒症患者预后的临床研究[J].全科医学临床与教育,2013,11(2):162-164.
11 Masson S,Caironi P,Fanizza C,et al.Sequential N-terminal pro-B-type Natriuretic peptide and high-sensitivity cardiac troponin measurements during albumin replacement in patients with severe sepsis or septic shock[J].Crit Care Med,2016,44(4):707-716.
12 Eskesen TG,Wetterslev M,Perner A.Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness[J].Intensive Care Med,2016,42(3):324-332.
2陈鹏,崔巍,陈思,等.每搏变异度对失血性休克容量反应的预测[J].中华急诊医学杂志,2013,22(7):787-789.
3陈卫英,陈鹏.下腔静脉内径呼吸变异度对非机械通气脓毒性休克容量反应预测[J].全科医学临床与教育,2018,16(6):637-640.
4陈鹏,潘巧玲,陈思,等.被动抬腿实验预测心源性休克容量反应性[J].全科医学临床与教育,2018,16(2):156-159.
5 The ARDS Definition Task Force.Acute respiratory distress syndrome:The berlin definition[J].JAMA,2012,307(23):2526-2533.
6娄雪萍,郑贞苍,余玲丽,等.容量复苏后液体正负平衡对重症胰腺炎的影响[J].全科医学临床与教育,2014,12(1):30-34.
7 Angappan S,Parida S,Vasudevan A,et al.The comparison of stroke volume variation with central venous pressure in predicting fluid responsiveness in septic patients with acute circulatory failure[J].Indian J Crit Care Med,2015,19(7):394-400.
8刘宁,顾勤,俞建峰,等.呼气末正压对每搏量变异评价容量准确性的影响[J].中华危重症急救医学杂志,2012,24(7):283-285.
9 Silva Ramos FJ,Oliveira EM,Park M,et al.Heartlung interactions with different ventilatory settings during acute lung injury and hypovolaemia:an experimental study[J].Br J Anaesth,2011,106(3):394-402.
10张晓明,金鹏,杨华,等.B型尿钠肽与肌钙蛋白I联合检测对严重脓毒症患者预后的临床研究[J].全科医学临床与教育,2013,11(2):162-164.
11 Masson S,Caironi P,Fanizza C,et al.Sequential N-terminal pro-B-type Natriuretic peptide and high-sensitivity cardiac troponin measurements during albumin replacement in patients with severe sepsis or septic shock[J].Crit Care Med,2016,44(4):707-716.
12 Eskesen TG,Wetterslev M,Perner A.Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness[J].Intensive Care Med,2016,42(3):324-332.