CAJ | 학술논문

目的探讨经胸壁多普勒超声测量上腔静脉流速随呼吸变异度对机械通气患者容量反应性的评估作用.方法采用前瞻性队列研究方法,选择2011年4月至2013年4月收治于首都医科大学附属北京同仁医院重症医学科接受机械通气、并存在组织灌注不足的重症患者.于30 min内静脉输注林格液500 mL进行容量负荷试验,按扩容前脉压差变异度(PPV)将患者分为有反应组(PPV≥13％)和无反应组(PPV＜13％).测量扩容前后同一呼吸周期中上腔静脉流速(A、S、D峰)最大值及最小值,计算其变异度(ΔA、ΔS、ΔD),并绘制受试者工作特征曲线(ROC曲线),评估上腔静脉流速对容量反应的价值.结果共27例患者入选,有反应组14例,无反应组13例.有反应组患者扩容后上腔静脉A、S、D峰流速(cm/s)较扩容前明显增快(A峰:34.6±2.2比31.3±2.1,t =-2.493,P=0.027;S峰:39.1±1.3比35.3±2.1,t=-2.564,P=0.024;D峰:28.1±1.2比23.3±1.4,t=-4.995,P=0.000);而扩容后ΔA、ΔS、ΔD无明显变化.ΔA、ΔS、ΔD与PPV呈正相关(r1=0.040,P1=0.854;r2=0.350,P2=0.074;r3=0.749,P3=0.000).S峰的ROC曲线下面积(AUC)0.36[95％可信区间(95％CI)0.11 ～0.52],ΔS的AUC达0.68(95％CI 0.47 ～ 0.89);D峰的AUC 0.41(95％CI 0.19 ～ 0.63),ΔD的AUC高达0.95(95％CI为0.86～ 1.00),说明上腔静脉峰流速随呼吸变异度预测容量反应的准确性优于单纯峰流速.以ΔS≥20.7％为截点,敏感度为78.6％,特异度为61.5％;以ΔD≥12.7％为截点,敏感度为92.0％,特异度为92.3％.结论经胸壁多普勒超声测量上腔静脉峰流速随呼吸变异度可用于机械通气患者容量反应性的评估.
목적 탐토경흉벽다보륵초성측량상강정맥류속수호흡변이도대궤계통기환자용량반응성적평고작용.방법 채용전첨성대렬연구방법,선택2011년4월지2013년4월수치우수도의과대학부속북경동인의원중증의학과접수궤계통기、병존재조직관주불족적중증환자.우30 min내정맥수주림격액500 mL진행용량부하시험,안확용전맥압차변이도(PPV)장환자분위유반응조(PPV≥13％)화무반응조(PPV＜13％).측량확용전후동일호흡주기중상강정맥류속(A、S、D봉)최대치급최소치,계산기변이도(ΔA、ΔS、ΔD),병회제수시자공작특정곡선(ROC곡선),평고상강정맥류속대용량반응적개치.결과 공27례환자입선,유반응조14례,무반응조13례.유반응조환자확용후상강정맥A、S、D봉류속(cm/s)교확용전명현증쾌(A봉:34.6±2.2비31.3±2.1,t =-2.493,P=0.027;S봉:39.1±1.3비35.3±2.1,t=-2.564,P=0.024;D봉:28.1±1.2비23.3±1.4,t=-4.995,P=0.000);이확용후ΔA、ΔS、ΔD무명현변화.ΔA、ΔS、ΔD여PPV정정상관(r1=0.040,P1=0.854;r2=0.350,P2=0.074;r3=0.749,P3=0.000).S봉적ROC곡선하면적(AUC)0.36[95％가신구간(95％CI)0.11 ～0.52],ΔS적AUC체0.68(95％CI 0.47 ～ 0.89);D봉적AUC 0.41(95％CI 0.19 ～ 0.63),ΔD적AUC고체0.95(95％CI위0.86～ 1.00),설명상강정맥봉류속수호흡변이도예측용량반응적준학성우우단순봉류속.이ΔS≥20.7％위절점,민감도위78.6％,특이도위61.5％;이ΔD≥12.7％위절점,민감도위92.0％,특이도위92.3％.결론 경흉벽다보륵초성측량상강정맥봉류속수호흡변이도가용우궤계통기환자용량반응성적평고.
Objective To approach the evaluative effect of respiratory variation of superior vena cava peak flow velocity measured using transthoracic echocardiography (TTE) on fluid responsiveness in patients with mechanical ventilation.Methods A prospective cohort study was conducted.All mechanical ventilated critically ill patients whose fluid therapy was planned due to hypovolemia in Department of Critical Care Medicine of Beijing Tongren Hospital of Capital Medical University from April 2011 to April 2013 were enrolled.Volume expansion was performed with 500 mL Linger solution within 30 minutes.Patients were classified as responders if pulse pressure variation (PPV) increased ≥ 13％ before volume expansion.The respiratory variation in superior vena cava peak velocity was calculated as the difference between maximum and minimum values of velocity in peak A,peak S and peak D over a single respiratory circle,and their variations (ΔA,ΔS,ΔD) were also calculated.The receiver operating characteristic curve (ROC curve) was plotted to assess the evaluative effect of respiratory variation of superior vena cava peak velocity on fluid responsiveness.Results Twenty-seven patients were enrolled in this study.Volume expansion increased PPV ≥ 13％ happened in 14 patients (responders).The velocity of superior vena cava in peak A,peak S,peak D was significantly increased after volume expansion compared with that before volume expansion in responders [peak A (cm/s):34.6 ± 2.2 vs.31.3 ±2.1,t=-2.493,P=0.027; peak S (cm/s):39.1 ± 1.3 vs.35.3 ±2.1,t=-2.564,P=0.024; peak D (cm/s):28.1 ± 1.2 vs.23.3 ± 1.4,t=-4.995,P=0.000],but there was no significant difference in ΔA,ΔS and ΔD between before and after volume expansion.The ΔA,ΔS and ΔD were positively correlated with PPV (r＝0.040,P=0.854; r=0.350,P=0.074; r=0.749,P=0.000).The area under ROC curve (AUC) of peak S was 0.36 [95％ confidence interval (95％CI):0.11-0.52],but the AUC of ΔS was 0.68 (95％CI 0.47-0.89),the AUC of peak D was 0.41 (95％CI 0.19-0.63),but the AUC of ΔD was 0.95 (95％CI 0.86-1.00),so the aberration rate of superior vena cava in respiration was better than the flow rate in superior vena cava.When the cut-off value of ΔS was 20.7％ for predicting fluid responsiveness,the sensitivity was 78.6％ and the specificity was 61.5％.When the cut-off value of ΔD was 12.7％ for predicting fluid responsiveness,the sensitivity was 92.0％ and the specificity was 92.3％.Conclusion Respiratory variations in superior vena cava peak velocity measured by TTE could assess fluid responsiveness in patients with mechanical ventilation.