中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2014年
9期
620-623
,共4页
每搏量变异度%血流动力学监测%容量反应性%被动抬腿试验%液体管理
每搏量變異度%血流動力學鑑測%容量反應性%被動抬腿試驗%液體管理
매박량변이도%혈류동역학감측%용량반응성%피동태퇴시험%액체관리
Stroke volume variation%Hemodynamic monitoring%Volume responsiveness%Passive leg-raising test%Fluid management
目的 探讨依据外周动脉心排血量监测(APCO)容量反应指标对重症患者实施液体管理的临床意义.方法 采用回顾性队列研究方法,选择2012年6月1日至2013年12月31日收入吉林大学第一医院重症监护病房(ICU)的重症患者.当患者急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分≥15分,心率＞100次/min,无法准确判断前负荷况和心功能状态时,应用APCO监测患者的血流动力学参数,联合应用每搏量变异度(SVV)和被动抬腿试验(PLR)对患者进行液体管理.记录实施液体管理策略前后患者的心率、SVV、血乳酸、中心静脉压(CVP),以及治疗效果.当心率下降和(或)每搏量(SV)增加≥10％,同时伴有血乳酸和SVV下降判定为有效,不符合上述标准者则判定为无效.结果 共纳入68例患者.①液体管理策略实施前:CVP＞ 12 cmH2O(1 cmH2O=0.098 kPa)40例,5～ 12 cmH2O 16例,＜5 cmH2O 12例;SVV＞ 13％ 35例,＜13％9例,PLR阳性18例,PLR阴性6例,提示前负荷不足者(SVV＞13％和PLR阳性)占77.9％(53/68).②实施液体管理策略4h后有效49例,无效19例,有效率为72.06％(49/68);液体管理策略实施12h后,有效56例,无效12例,有效率为82.35％(56/68).③有效组液体管理策略实施后心率、SVV、血乳酸均较实施前显著下降[实施4h的心率(次/min):112.45±13.35比129.55±15.49,SVV:(15.47±6.32)％比(21.20±7.40)％,血乳酸(mmol/L):4.16±3.12比6.21 ±4.11;实施12h的心率(次/min):110.02±13.92比129.61±14.93,SVV:(14.61±5.52)％比(20.66±7.40)％,血乳酸(mmol/L):3.35±2.26比6.11 ±4.02,P＜0.05或P＜0.01];无效组液体管理策略实施后上述指标无显著变化[实施4h的心率(次/min):119.53±11.68比125.79±11.58,SVV:(16.95±6.48)％比(18.47±4.96)％,血乳酸(mmol/L):5.55±3.80比6.54±3.72;实施12h的心率(次/min):115.92±11.71比123.40±11.59,SVV:(17.17±6.09)％比(19.42±8.25)％,血乳酸(mmol/L):6.33±3.40比7.21±3.81,均P＞ 0.05].CVP仅有效组实施12h时较实施前显著升高(cmH2O:12.88±3.38比11.27±4.97,P＜0.05).结论 经APCO监测的SVV是一个能很好代表容量反应的指标,可以作为临床实施液体管理的重要参考依据.
目的 探討依據外週動脈心排血量鑑測(APCO)容量反應指標對重癥患者實施液體管理的臨床意義.方法 採用迴顧性隊列研究方法,選擇2012年6月1日至2013年12月31日收入吉林大學第一醫院重癥鑑護病房(ICU)的重癥患者.噹患者急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分≥15分,心率＞100次/min,無法準確判斷前負荷況和心功能狀態時,應用APCO鑑測患者的血流動力學參數,聯閤應用每搏量變異度(SVV)和被動抬腿試驗(PLR)對患者進行液體管理.記錄實施液體管理策略前後患者的心率、SVV、血乳痠、中心靜脈壓(CVP),以及治療效果.噹心率下降和(或)每搏量(SV)增加≥10％,同時伴有血乳痠和SVV下降判定為有效,不符閤上述標準者則判定為無效.結果 共納入68例患者.①液體管理策略實施前:CVP＞ 12 cmH2O(1 cmH2O=0.098 kPa)40例,5～ 12 cmH2O 16例,＜5 cmH2O 12例;SVV＞ 13％ 35例,＜13％9例,PLR暘性18例,PLR陰性6例,提示前負荷不足者(SVV＞13％和PLR暘性)佔77.9％(53/68).②實施液體管理策略4h後有效49例,無效19例,有效率為72.06％(49/68);液體管理策略實施12h後,有效56例,無效12例,有效率為82.35％(56/68).③有效組液體管理策略實施後心率、SVV、血乳痠均較實施前顯著下降[實施4h的心率(次/min):112.45±13.35比129.55±15.49,SVV:(15.47±6.32)％比(21.20±7.40)％,血乳痠(mmol/L):4.16±3.12比6.21 ±4.11;實施12h的心率(次/min):110.02±13.92比129.61±14.93,SVV:(14.61±5.52)％比(20.66±7.40)％,血乳痠(mmol/L):3.35±2.26比6.11 ±4.02,P＜0.05或P＜0.01];無效組液體管理策略實施後上述指標無顯著變化[實施4h的心率(次/min):119.53±11.68比125.79±11.58,SVV:(16.95±6.48)％比(18.47±4.96)％,血乳痠(mmol/L):5.55±3.80比6.54±3.72;實施12h的心率(次/min):115.92±11.71比123.40±11.59,SVV:(17.17±6.09)％比(19.42±8.25)％,血乳痠(mmol/L):6.33±3.40比7.21±3.81,均P＞ 0.05].CVP僅有效組實施12h時較實施前顯著升高(cmH2O:12.88±3.38比11.27±4.97,P＜0.05).結論 經APCO鑑測的SVV是一箇能很好代錶容量反應的指標,可以作為臨床實施液體管理的重要參攷依據.
목적 탐토의거외주동맥심배혈량감측(APCO)용량반응지표대중증환자실시액체관리적림상의의.방법 채용회고성대렬연구방법,선택2012년6월1일지2013년12월31일수입길림대학제일의원중증감호병방(ICU)적중증환자.당환자급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분≥15분,심솔＞100차/min,무법준학판단전부하황화심공능상태시,응용APCO감측환자적혈류동역학삼수,연합응용매박량변이도(SVV)화피동태퇴시험(PLR)대환자진행액체관리.기록실시액체관리책략전후환자적심솔、SVV、혈유산、중심정맥압(CVP),이급치료효과.당심솔하강화(혹)매박량(SV)증가≥10％,동시반유혈유산화SVV하강판정위유효,불부합상술표준자칙판정위무효.결과 공납입68례환자.①액체관리책략실시전:CVP＞ 12 cmH2O(1 cmH2O=0.098 kPa)40례,5～ 12 cmH2O 16례,＜5 cmH2O 12례;SVV＞ 13％ 35례,＜13％9례,PLR양성18례,PLR음성6례,제시전부하불족자(SVV＞13％화PLR양성)점77.9％(53/68).②실시액체관리책략4h후유효49례,무효19례,유효솔위72.06％(49/68);액체관리책략실시12h후,유효56례,무효12례,유효솔위82.35％(56/68).③유효조액체관리책략실시후심솔、SVV、혈유산균교실시전현저하강[실시4h적심솔(차/min):112.45±13.35비129.55±15.49,SVV:(15.47±6.32)％비(21.20±7.40)％,혈유산(mmol/L):4.16±3.12비6.21 ±4.11;실시12h적심솔(차/min):110.02±13.92비129.61±14.93,SVV:(14.61±5.52)％비(20.66±7.40)％,혈유산(mmol/L):3.35±2.26비6.11 ±4.02,P＜0.05혹P＜0.01];무효조액체관리책략실시후상술지표무현저변화[실시4h적심솔(차/min):119.53±11.68비125.79±11.58,SVV:(16.95±6.48)％비(18.47±4.96)％,혈유산(mmol/L):5.55±3.80비6.54±3.72;실시12h적심솔(차/min):115.92±11.71비123.40±11.59,SVV:(17.17±6.09)％비(19.42±8.25)％,혈유산(mmol/L):6.33±3.40비7.21±3.81,균P＞ 0.05].CVP부유효조실시12h시교실시전현저승고(cmH2O:12.88±3.38비11.27±4.97,P＜0.05).결론 경APCO감측적SVV시일개능흔호대표용량반응적지표,가이작위림상실시액체관리적중요삼고의거.
Objective To discuss the clinical significance of fluid management of severe patients according to arterial pressure-based cardiac output (APCO) monitoring volume responsiveness index.Methods A retrospective cohort study was conducted.The severe patients were selected from the intensive care unit (ICU) of the First Hospital of Jilin University from June 1st,2012 to December 31st,2013.The hemodynamic parameters were monitored by APCO,and the fluid resuscitation was managed by stroke volume variation (SVV) and passive leg-raising test (PLR) when the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score ≥ 15,heart rate ＞ 100 bpm with the result that the preload and heart function could not be evaluated.The heart rate,SVV,lactic acid (Lac) and central venous pressure (CVP) and curative effect were recorded before and after carrying out fluid management strategy.The criteria of clinical effective was defined as heart rate decreased and (or) stroke volume (SV) increased ≥ 10％,accompanied by blood Lac and SVV decreased,other than,the cases did not meet above criteria were considered ineffective.Results Sixty-eight patients were enrolled in the study.① Before carrying out fluid management strategy:40 cases with CVP＞ 12 cmH2O (1 cmH2O=0.098 kPa),and 16 cases with 5-12 cmH2O,12 with ＜5 cmH2O.SVV＞13％ in 35 cases,SVV ＜ 13％ in 9 cases.PLR positive in 18 cases,and PLR negative in 6 cases.It was implicated that the patients with poor preload (SVV ＞ 13％ and PLR positive) accounted by 77.9％ (53/68).② There were 49 effective cases and 19 ineffective cases 4 hours after carrying out fluid management strategy,and the effective rate was 72.06％ (49/68).While there were 56 effective cases and 12 ineffective cases after 12 hours,and the total effective rate was 82.35％ (56/68).③ In effective group,heart rate,SVV,Lac after fluid management strategy were significantly lower than those before fluid management strategy [4 hours after fluid management strategy:heart rate (bpm) 112.45 ± 13.53 vs.129.55 ± 15.49,SVV (15.47 ± 6.32)％ vs.(21.20 ± 7.40)％,Lac (mmol/L) 4.16 ± 3.12 vs.6.21 ± 4.11 ; 12 hours after fluid management strategy:heart rate (bpm) 110.02 ± 13.92 vs.129.61 ± 14.93,SVV (14.61 ± 15.52)％ vs.(20.66 ± 7.40)％,Lac (mmol/L) 3.35 ± 2.26 vs.6.11 ± 4.02,P＜0.05 or P＜0.01],while there was no significant difference in those markers between before and after fluid management strategy in ineffective group [4 hours after fluid management strategy:heart rate (bpm) 119.53 ± 11.68 vs.125.79 ± 11.58,SVV (16.95 ±6.48)％ vs.(18.47 ±4.96)％,Lac (mmol/L) 5.55 ± 3.80 比 6.54 ± 3.72 ; 12 hours after fluid management strategy:heart rate (bpm) 115.92 ± 11.71 vs.123.40 ± 11.59,SVV (17.17 ± 6.09)％ vs.(19.42 ± 8.25)％,Lac (mmol/L) 6.33 ± 3.40 vs.7.21 ± 3.81,all P＞ 0.05].CVP only at 12 hours after fluid management strategy in effective group was significantly higher than that before fluid management strategy (cmH2O:12.88 ± 3.38 vs.11.27 ± 4.97,P＜0.05).Conclusion SVV monitored by APCO is a good indicator of volume responsiveness index,which can be used as an important reference combined with PLR for fluid management of severe patients.
