左心室流出道血流速度时间积分变异度评估机械通气治疗脓毒症患者容量反应性的价值
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摘要
目的探讨行机械通气治疗脓毒症患者应用床旁超声所测左心室流出道血流速度时间积分(velocity-time integral, VTI)变异度和下腔静脉(inferior vena cava, IVC)吸气扩张率评估容量反应性的价值。方法脓毒症患者40例,随机分为VTI指导组和IVC指导组各20例。补液前2组经床旁超声测量VTI或IVC,补液后每小时测量1次,计算VTI变异度或IVC吸气扩张率,根据是否存在容量反应性指导液体复苏。补液6 h时评估2组早期目标导向治疗达标率和液体出入量,并比较2组补液前及补液6 h时心率、平均动脉压(mean arterial pressure, MAP)、中心静脉压(central venous pressure, CVP)、脉搏血氧饱和度(pulse oxygen saturation, SpO_2)、中心静脉血氧饱和度(central venous oxygen saturation, ScvO_2),以及ICU停留时间和入院28 d生存率。结果补液6 h时,VTI指导组和IVC指导组心率[(103.12±10.38)、(100.24±13.72)次/min]低于补液前[(125.13±23.53)、(123.42±24.65)次/min](P<0.05),MAP[(86.61±8.26)、(68.33±6.37)mm Hg]、CVP[(10.28±2.55)、(8.76±2.15)mm Hg]、SpO_2[(96.35±6.86)%、(95.81±5.97)%]、ScvO_2[(70.95±10.25)%、(70.05±7.18)%]较补液前[MAP:(53.20±6.77)、(52.83±7.38)mm Hg;CVP:(5.37±2.62)、(5.29±3.67)mm Hg;SpO_2:(92.51±7.33)%、(93.92±6.49)%;ScvO_2:(54.55±5.26)%、(53.73±6.12)%]增高(P<0.05);VTI指导组补液6 h时MAP、CVP高于IVC指导组(P<0.05),心率、SpO_2、ScvO_2与IVC指导组比较差异无统计学意义(P>0.05);VTI指导组液体入量[(2 336.55±519.72)mL]较IVC指导组[(3 028.29±473.68)mL]少,ICU停留时间[(9.56±2.35)d]较IVC指导组[(11.35±2.42)d]短(P<0.05),早期目标导向治疗达标率(80.0%)、入院28 d生存率(65.0%)与IVC指导组(60.0%、55.0%)比较差异无统计学意义(P>0.05)。结论床旁超声监测VTI变异度、IVC吸气扩张率均可有效评估行机械通气治疗脓毒症患者的容量反应性,但应用VTI指导可避免容量过负荷,缩短ICU停留时间。
Objective To investigate the value of left ventricular outflow tract blood flow velocity-time integral(VTI) variability and inferior vena cava(IVC) inspiratory expansion rate monitored by bedside ultrasound to the assessment of volume responsiveness in sepsis patients receiving mechanical ventilation. Methods Forty patients with sepsis were randomly divided into VTI guidance group and IVC guidance group, with 20 patients in each group. VTI variability and IVC inspiratory expansion rate were measured by bedside ultrasound before and every one hour after rehydration in both groups to guide fluid resuscitation based on the presence of volumetric reactivity. The early goal-directed therapy compliance rate and liquid inflow rate were evaluated after rehydration for 6 h, and the heart rate, mean arterial pressure(MAP), central venous pressure(CVP), pulse oxygen saturation(SpO_2) and central venous oxygen saturation(ScvO_2) before and after rehydration, as well as ICU stay and 28-day survival rate were compared. Results After rehydration for 6 h, the heart rates((103.12±10.38),(100.24±13.72) beats/min) in VTI guidance group and IVC guidance group were significantly lower than those before rehydration((125.13±23.53),(123.42±24.65) beats/min)(P<0.05), and MAP((86.61±8.26),(68.33±6.37) mm Hg), CVP((10.28±2.55),(8.76±2.15) mm Hg), SpO_2((96.35±6.86)%,(95.81±5.97)%), and ScvO_2((70.95±10.25)%,(70.05±7.18)%) were significantly higher than those before rehydration(MAP:(53.20±6.77),(52.83±7.38) mm Hg; CVP:(5.37±2.62),(5.29±3.67) mm Hg; SpO_2:(92.51±7.33)%,(93.92±6.49)%; ScvO_2:(54.55±5.26)%,(53.73±6.12)%)(P<0.05). After rehydration for 6 h, MAP and CVP in VTI guidance group were significantly higher than those in IVC guidance group(P<0.05), while the heart rate, SpO_2 and ScvO_2 showed no significant differences between two groups(P>0.05). The liquid intaking volume in VTI guidance group((2 336.55±519.72) mL) was significantly less and the ICU stay was significantly shorter((9.56±2.35)d)than that in IVC guidance group((3 028.29±473.68)mL,(11.35±2.42)d)(P<0.05),and there were no significant differences in early goal-directed therapy compliance rate and 28-day survival rate between VTI guidance group(80.0%,65.0%)and IVC guidance group(60.0%,55.0%)(P>0.05).Conclusion Bedside ultrasound monitoring of VTI variability and IVC inspiratory expansion rate can effectively assess the volume responsiveness in sepsis patients receiving mechanical ventilation,and rehydration under VTI-guidance can avoid volume overload and effectively reduce ICU stay.
Objective To investigate the value of left ventricular outflow tract blood flow velocity-time integral(VTI) variability and inferior vena cava(IVC) inspiratory expansion rate monitored by bedside ultrasound to the assessment of volume responsiveness in sepsis patients receiving mechanical ventilation. Methods Forty patients with sepsis were randomly divided into VTI guidance group and IVC guidance group, with 20 patients in each group. VTI variability and IVC inspiratory expansion rate were measured by bedside ultrasound before and every one hour after rehydration in both groups to guide fluid resuscitation based on the presence of volumetric reactivity. The early goal-directed therapy compliance rate and liquid inflow rate were evaluated after rehydration for 6 h, and the heart rate, mean arterial pressure(MAP), central venous pressure(CVP), pulse oxygen saturation(SpO_2) and central venous oxygen saturation(ScvO_2) before and after rehydration, as well as ICU stay and 28-day survival rate were compared. Results After rehydration for 6 h, the heart rates((103.12±10.38),(100.24±13.72) beats/min) in VTI guidance group and IVC guidance group were significantly lower than those before rehydration((125.13±23.53),(123.42±24.65) beats/min)(P<0.05), and MAP((86.61±8.26),(68.33±6.37) mm Hg), CVP((10.28±2.55),(8.76±2.15) mm Hg), SpO_2((96.35±6.86)%,(95.81±5.97)%), and ScvO_2((70.95±10.25)%,(70.05±7.18)%) were significantly higher than those before rehydration(MAP:(53.20±6.77),(52.83±7.38) mm Hg; CVP:(5.37±2.62),(5.29±3.67) mm Hg; SpO_2:(92.51±7.33)%,(93.92±6.49)%; ScvO_2:(54.55±5.26)%,(53.73±6.12)%)(P<0.05). After rehydration for 6 h, MAP and CVP in VTI guidance group were significantly higher than those in IVC guidance group(P<0.05), while the heart rate, SpO_2 and ScvO_2 showed no significant differences between two groups(P>0.05). The liquid intaking volume in VTI guidance group((2 336.55±519.72) mL) was significantly less and the ICU stay was significantly shorter((9.56±2.35)d)than that in IVC guidance group((3 028.29±473.68)mL,(11.35±2.42)d)(P<0.05),and there were no significant differences in early goal-directed therapy compliance rate and 28-day survival rate between VTI guidance group(80.0%,65.0%)and IVC guidance group(60.0%,55.0%)(P>0.05).Conclusion Bedside ultrasound monitoring of VTI variability and IVC inspiratory expansion rate can effectively assess the volume responsiveness in sepsis patients receiving mechanical ventilation,and rehydration under VTI-guidance can avoid volume overload and effectively reduce ICU stay.
引文
[1] 杨建旭.持续高容量血液净化治疗对脓毒症休克患者血乳酸水平影响[J].医药论坛杂志,2016,37(12):43-45.
[2] 贾建超,张文平,杨金坡,等.肺炎继发脓毒症患者血清降钙素原和C反应蛋白变化及预后因素分析[J].中华实用诊断与治疗杂志,2018,32(2):144-147.
[3] 吴桂新,田玲,周明明,等.床旁超声监测联合被动抬腿试验对重症机械通气患者容量反应性评估价值研究[J].创伤与急危重病医学,2018,6(1):21-24.
[4] LU N,XI X,JIANG L,et al.Exploring the best predictors of fluid responsiveness in patients with septic shock[J].Am J Emerg Med,2017,35(9):1258-1261.
[5] 王运,李海明,翟展艺,等.血管外肺水指数评估急性呼吸窘迫综合征患者液体管理及预后的价值[J].中华实用诊断与治疗杂志,2014,28(10):986-988.
[6] BLANCO P,AGUIAR F M,BLAIVAS M,et al.Rapid ultrasound in shock (RUSH) velocity-time integral:a proposal to expand the RUSH protocol[J].J Ultrasound Med,2015,34(9):1691-1700.
[7] HODES A,EVANS L E,ALHAZZANI W,et al.Surviving Sepsis Campaign:International Guidelines for Management of Sepsis and Septic Shock:2016[J].Crit Care Med,2017,45(3):486-552.
[8] BOU CHEBL R,ABOU DAGHER G,WUHANTU J,et al.Mitral valve velocity time integral and passive leg raise as a measure of volume responsiveness[J].Crit Ultrasound J,2018,10(1):32-34.
[9] PARE J R,MOORE C L.Defining fluid responsiveness by the velocity-time integral alone?[J].J Ultrasound Med,2016,35(2):459-460.
[10] VIEILLARD-BARON A,EVRARD B,REPESSé X,et al.Limited value of end-expiratory inferior vena cava diameter to predict fluid responsiveness impact of intra-abdominal pressure[J].Intensive Care Med,2018,44(2):197-203.
[11] DELLINGER R P,LEVY M M,RHODES A,et al.Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock,2012[J].Intensive Care Med,2013,39(2):165-228.
[12] SHOKOOHI H,BERRY G W,SHAHKOLAHI M,et al.The diagnostic utility of sonographic carotid flow time in determining volume responsiveness[J].J Crit Care,2017,38(3):231-235.
[13] RATHORE A,SINGH S,LAMSAL R,et al.Validity of pulse pressure variation (PPV) compared with stroke volume variation (SVV) in predicting fluid responsiveness[J].Turk J Anaesthesiol Reanim,2017,45(4):210-217.
[14] MIELNICKI W,DYLA A,ZAWADA T,et al.Utility of transthoracic echocardiography (TTE) in assessing fluid responsiveness in critically ill patients:a challenge for the bedside sonographer[J].Med Ultrason,2016,18(4):508-514.
[15] 王守君,王世富,翟萍,等.床旁超声心动图监测重症患者血容量及心脏功能的临床研究[J].临床超声医学杂志,2016,3(20):200-202.
[16] SOUTO MOURA T,AGUIAR ROSA S,GERMANO N,et al.The accuracy of PiCCO? in measuring cardiac output in patients under therapeutic hypothermia:comparison with transthoracic echocardiography[J].Med Intensiva,2018,42(2):92-98.
[17] ILYAS A,ISHTIAQ W,ASSAD S,et al.Correlation of IVC diameter and collapsibility index with central venous pressure in the assessment of intravascular volume in critically ill patients[J].Cureus,2017,9(2):e1025.
[18] COWIE B S,KLUGER R,REX S,et al.The relationship between superior vena cava diameter and collapsibility and central venous pressure[J].Anaesth Intensive Care,2015,43(3):357-360.
[19] KEIKHA M,SALEHI-MARZIJARANI M,SOLDOOZI NEJAT R,et al.Diagnostic accuracy of rapid ultrasound in shock (RUSH) exam;a systematic review and meta-analysis[J].Bull Emerg Trauma,2018,6(4):271-278.
[20] MERCADO P,MAIZEL J,BEYLS C,et al.Transthoracic echocardiography:an accurate and precise method for estimating cardiac output in the critically ill patient[J].Crit Care,2017,21(1):136-139.
[21] 沈珏,汪沁,刘文生,等.小剂量容量负荷试验联合经胸心脏超声评估感染性休克患者容量反应性的临床价值研究[J].浙江医学,2017,39(15):1265-1268,1296.
[2] 贾建超,张文平,杨金坡,等.肺炎继发脓毒症患者血清降钙素原和C反应蛋白变化及预后因素分析[J].中华实用诊断与治疗杂志,2018,32(2):144-147.
[3] 吴桂新,田玲,周明明,等.床旁超声监测联合被动抬腿试验对重症机械通气患者容量反应性评估价值研究[J].创伤与急危重病医学,2018,6(1):21-24.
[4] LU N,XI X,JIANG L,et al.Exploring the best predictors of fluid responsiveness in patients with septic shock[J].Am J Emerg Med,2017,35(9):1258-1261.
[5] 王运,李海明,翟展艺,等.血管外肺水指数评估急性呼吸窘迫综合征患者液体管理及预后的价值[J].中华实用诊断与治疗杂志,2014,28(10):986-988.
[6] BLANCO P,AGUIAR F M,BLAIVAS M,et al.Rapid ultrasound in shock (RUSH) velocity-time integral:a proposal to expand the RUSH protocol[J].J Ultrasound Med,2015,34(9):1691-1700.
[7] HODES A,EVANS L E,ALHAZZANI W,et al.Surviving Sepsis Campaign:International Guidelines for Management of Sepsis and Septic Shock:2016[J].Crit Care Med,2017,45(3):486-552.
[8] BOU CHEBL R,ABOU DAGHER G,WUHANTU J,et al.Mitral valve velocity time integral and passive leg raise as a measure of volume responsiveness[J].Crit Ultrasound J,2018,10(1):32-34.
[9] PARE J R,MOORE C L.Defining fluid responsiveness by the velocity-time integral alone?[J].J Ultrasound Med,2016,35(2):459-460.
[10] VIEILLARD-BARON A,EVRARD B,REPESSé X,et al.Limited value of end-expiratory inferior vena cava diameter to predict fluid responsiveness impact of intra-abdominal pressure[J].Intensive Care Med,2018,44(2):197-203.
[11] DELLINGER R P,LEVY M M,RHODES A,et al.Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock,2012[J].Intensive Care Med,2013,39(2):165-228.
[12] SHOKOOHI H,BERRY G W,SHAHKOLAHI M,et al.The diagnostic utility of sonographic carotid flow time in determining volume responsiveness[J].J Crit Care,2017,38(3):231-235.
[13] RATHORE A,SINGH S,LAMSAL R,et al.Validity of pulse pressure variation (PPV) compared with stroke volume variation (SVV) in predicting fluid responsiveness[J].Turk J Anaesthesiol Reanim,2017,45(4):210-217.
[14] MIELNICKI W,DYLA A,ZAWADA T,et al.Utility of transthoracic echocardiography (TTE) in assessing fluid responsiveness in critically ill patients:a challenge for the bedside sonographer[J].Med Ultrason,2016,18(4):508-514.
[15] 王守君,王世富,翟萍,等.床旁超声心动图监测重症患者血容量及心脏功能的临床研究[J].临床超声医学杂志,2016,3(20):200-202.
[16] SOUTO MOURA T,AGUIAR ROSA S,GERMANO N,et al.The accuracy of PiCCO? in measuring cardiac output in patients under therapeutic hypothermia:comparison with transthoracic echocardiography[J].Med Intensiva,2018,42(2):92-98.
[17] ILYAS A,ISHTIAQ W,ASSAD S,et al.Correlation of IVC diameter and collapsibility index with central venous pressure in the assessment of intravascular volume in critically ill patients[J].Cureus,2017,9(2):e1025.
[18] COWIE B S,KLUGER R,REX S,et al.The relationship between superior vena cava diameter and collapsibility and central venous pressure[J].Anaesth Intensive Care,2015,43(3):357-360.
[19] KEIKHA M,SALEHI-MARZIJARANI M,SOLDOOZI NEJAT R,et al.Diagnostic accuracy of rapid ultrasound in shock (RUSH) exam;a systematic review and meta-analysis[J].Bull Emerg Trauma,2018,6(4):271-278.
[20] MERCADO P,MAIZEL J,BEYLS C,et al.Transthoracic echocardiography:an accurate and precise method for estimating cardiac output in the critically ill patient[J].Crit Care,2017,21(1):136-139.
[21] 沈珏,汪沁,刘文生,等.小剂量容量负荷试验联合经胸心脏超声评估感染性休克患者容量反应性的临床价值研究[J].浙江医学,2017,39(15):1265-1268,1296.