CAJ | 학술논문

目的评价无创超声心排血量监测仪(USCOM)联合被动抬腿试验(PLR)预测有自主呼吸的脓毒性休克患儿容量反应性的价值.方法采用前瞻性、观察性队列研究设计方法,选择2011年3月至2013年6月重庆医科大学深圳儿童医院儿科重症监护病房(PICU)40例有自主呼吸且需补液的脓毒性休克患儿,先后进行PLR和容量负荷试验(VE).在每个试验前后分别用USCOM测量每搏量(SV)、心排血量(CO)、外周血管阻力指数(SVRI)等血流动力学指标.并持续监测有创动脉平均动脉压(MAP)、中心静脉压(CVP).根据VE后SV增加值(△SVVE)≥15％为有反应,将患儿分为有反应组和无反应组.用受试者工作特征曲线(ROC曲线)评价PLR预测容量反应性的价值.结果 40例患儿共行43次PLR和VE,其中有反应组25例次,无反应组18例次.两组一般资料及初始的血流动力学指标无明显差异.PLR和VE后两组SV均较试验前增加.有反应组PLR后△SV(△SVPLH)与△SVE均明显大于无反应组[(14.95±3.44)％比(8.48±3.49)％,t=6.048,P=0.000;(18.28±2 84)％比(6.57±3.83)％,t=11.530,P=0.000].相关结果分析显示,△SVPLR与△SVE呈正相关(r=0.649,P=0.000);PLR后CVP增加值(△CVPPLR)与△SVVE则无相关性(r=0.217,P=0.162).△SVPLR和△CVPPLR预测患儿的容量反应性ROC曲线下面积(AUC)及95％可信区间(95％CI)分别为0.900±0.046(95％ CI 0.809 ～ 0.991,P=0.000)和0.561±0.090(95％CI 0.385～0.737,P=0.498).以△SVPLR≥12.25％评价容量反应性的敏感度为80.0％,特异度为88.9％,以△CVPPLR≥ 15.48％的敏感度为76.0％,特异度为38.9％,△SVPLR预测容量反应性的能力优于△CVPLR.结论用USCOM测量PLR后的△SV可以反映有自主呼吸的脓毒性休克患儿的容量反应性,用以指导临床液体治疗.
목적 평개무창초성심배혈량감측의(USCOM)연합피동태퇴시험(PLR)예측유자주호흡적농독성휴극환인용량반응성적개치.방법 채용전첨성、관찰성대렬연구설계방법,선택2011년3월지2013년6월중경의과대학심수인동의원인과중증감호병방(PICU)40례유자주호흡차수보액적농독성휴극환인,선후진행PLR화용량부하시험(VE).재매개시험전후분별용USCOM측량매박량(SV)、심배혈량(CO)、외주혈관조력지수(SVRI)등혈류동역학지표.병지속감측유창동맥평균동맥압(MAP)、중심정맥압(CVP).근거VE후SV증가치(△SVVE)≥15％위유반응,장환인분위유반응조화무반응조.용수시자공작특정곡선(ROC곡선)평개PLR예측용량반응성적개치.결과 40례환인공행43차PLR화VE,기중유반응조25례차,무반응조18례차.량조일반자료급초시적혈류동역학지표무명현차이.PLR화VE후량조SV균교시험전증가.유반응조PLR후△SV(△SVPLH)여△SVE균명현대우무반응조[(14.95±3.44)％비(8.48±3.49)％,t=6.048,P=0.000;(18.28±2 84)％비(6.57±3.83)％,t=11.530,P=0.000].상관결과분석현시,△SVPLR여△SVE정정상관(r=0.649,P=0.000);PLR후CVP증가치(△CVPPLR)여△SVVE칙무상관성(r=0.217,P=0.162).△SVPLR화△CVPPLR예측환인적용량반응성ROC곡선하면적(AUC)급95％가신구간(95％CI)분별위0.900±0.046(95％ CI 0.809 ～ 0.991,P=0.000)화0.561±0.090(95％CI 0.385～0.737,P=0.498).이△SVPLR≥12.25％평개용량반응성적민감도위80.0％,특이도위88.9％,이△CVPPLR≥ 15.48％적민감도위76.0％,특이도위38.9％,△SVPLR예측용량반응성적능력우우△CVPLR.결론 용USCOM측량PLR후적△SV가이반영유자주호흡적농독성휴극환인적용량반응성,용이지도림상액체치료.
Objective To assess the ability of non-invasive ultrasonic cardiac output monitor (USCOM) combined with passive leg raising (PLR) test to predict volume responsiveness in septic shock children with spontaneous respiration.Methods Prospective and observational cohort study was performed in 40 septic shock children with spontaneous breathing admitted to pediatric intensive care unit (PICU) of Chongqing Medical University Shenzhen Children's Hospital from March 2011 to June 2013.The hemodynamic parameters including stroke volume (SV),cardiac output (CO) and systemic vascular resistance index (SVRI) were measured non-invasively by USCOM device before and after PLR and volume expansion (VE) test.And invasive mean arterial pressure (MAP) and central venous pressure (CVP) were monitored continuously.Based on the responsiveness of volume expansion [children were considered to be responders to volume expansion if SV increased (△SVVE) ≥ 15％],all the children were divided into responders and non-responders.The roles of PLR in predicting volume responsiveness were evaluated by receiver operating characteristic curve (ROC curve).Results A total of 43 PLR and VE tests in 40 children were evaluated and resulting in 25 responders and 18 non-responders.There was no significant difference between two groups in the clinical data and hemodynamics indicators at incipient stage.After PLR and VE,the SV was increased compared with that at supine position in both responder group and non-responder group.The △SV after PLR (△SVPLR) and △SVE in responder group were significantly higher than those in non-responder group [(14.95 ± 3.44)％ vs.(8.48 ± 3.49)％,t=6.048,P=0.000; (18.28 ± 2.84)％ vs.(6.57 ± 3.83)％,t=11.530,P=0.000].Correlation analysis showed that there was the positive correlation between △SVPLR and △SVVE (r=0.649,P=0.000),but CVP increased (△CVPPLR) were unrelated with △SVVE (r=0.217,P=0.162).The area under the ROC curve (AUC) of △SVPLR and △CVPPLR for PLR predicting volume responsiveness and 95％ confidence interval (95％ CI) were 0.900 ± 0.046 (95％ CI 0.809-0.991,P=0.000) and 0.561 ±0.090 (95％CI 0.385-0.737,P=0.498).The △SVPLR ≥ 12.25％ was found to predict volume responsiveness with a sensitivity of 80.0％ and specificity of 88.9％,the sensitivity and specificity of △CVPPLR≥ 15.48％ were 76.0％ and 38.9％,respectively.The capability of △SVPLR to predict volume responsiveness was better than △CVPPLR.Conclusion △SVPLR measured by USCOM can predict the volume responsiveness in septic shock children patients with spontaneous respiration and it is reliable to guide fluid therapy.