脉搏灌注变异指数评价感染性休克患者容量状态的前瞻性临床研究
맥박관주변이지수평개감염성휴극환자용량상태적전첨성림상연구
A prospective clinical study of pleth variability index in prediction of volume responsiveness in patients with septic shock
  • 万方数据
    中华危重病急救医学 중화위중병급구의학
    Chinese Critical Care Medicine
    2015年 1期 17-21 ,共5页

    卢年芳%郑瑞强%林华%於江泉%邵俊%吴晓燕%王海霞

    로년방%정서강%림화%어강천%소준%오효연%왕해하

    感染性休克%容量反应性%脉搏灌注变异指数%被动抬腿试验 感染性休剋%容量反應性%脈搏灌註變異指數%被動抬腿試驗
    감염성휴극%용량반응성%맥박관주변이지수%피동태퇴시험
    Septic shock%Fluid responsiveness%Pleth variability index%Passive leg raising
    目的 通过被动抬腿试验(PLR)评价脉搏灌注变异指数(PVI)预测感染性休克机械通气患者对容量治疗的反应.方法 采用前瞻性随机对照临床研究(RCT)方法,纳入2012年6月至2014年9月苏北人民医院重症医学科87例需行机械通气的感染性休克患者,采用脉搏指示连续心排血量监测仪(PiCCO)和PVI监测仪持续监测患者PLR前后的血流动力学参数.以PLR后心排血指数(CI)增加值(△CI)≥10％定义为容量反应阳性(有反应组),△CI＜ 10％定义为容量反应阴性(无反应组).评价两组患者PLR前后心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、每搏量变异度(SVV)、CI、PVI及其变化值(△HR、△MAP、△CVP、△SVV、△CI、△PVI)的差异,分析其与△CI的相关性.绘制受试者工作特征曲线(ROC),评价血流动力学参数预测容量反应性的价值.结果 87例感染性休克患者共进行145例次PLR,有容量反应性67例次,无容量反应性78例次.PLR前,有无反应两组间HR、MAP、CVP、CI差异均无统计学意义,但有反应组SVV、PVI明显高于无反应组[SVV:(16.9±3.1)％比(8.4±2.2)％,t=9.078,P=0.031;PVI:(20.6±4.3)％比(11.1±3.2)％,t=19.189,P=0.022].PLR后,有无反应两组患者间HR、MAP、CVP、SVV和PVI比较差异均无统计学意义,但有反应组CI明显高于无反应组(mL·s-1·m-2:78.3±6.7比60.0±8.3,t=2.902,P=0.025).有无反应两组患者间△HR、△MAP、△CVP差异均无统计学意义,但有反应组△SVV、△CI、△PVI均明显高于无反应组[△SVV:(4.6±1.5)％比(1.8±0.9)％,t=11.187,P=0.022;△CI(mL·s-1·m-2):18.3±1.7比1.7±0.5,t=3.696,P=0.014;△PVI:(6.4±1.1)％比(1.3±0.2)％,t=19.563,P=0.013].PLR前HR、MAP、CVP与△CI均无相关性,SVV、PVI与△CI呈直线相关(r=0.850,P=0.015;r=0.867,P=0.001).SVV预测容量反应性的ROC曲线下面积(AUC)为0.948,最佳临界值为12.4％时,敏感度为85.4％,特异度为86.6％;PVI预测容量反应性的AUC为0.957,最佳临界值为14.8％时,敏感度为87.5％,特异度为84.8％;均明显高于其他血流动力学指标(HR、MAP、CVP).结论 PLR下,PVI和SVV均能够有效预测感染性休克机械通气患者对容量治疗的反应性,而PVI作为一种连续、无创的功能性血流动力学指标,其准确性与有创测得的SVV相类似.
    목적 통과피동태퇴시험(PLR)평개맥박관주변이지수(PVI)예측감염성휴극궤계통기환자대용량치료적반응.방법 채용전첨성수궤대조림상연구(RCT)방법,납입2012년6월지2014년9월소북인민의원중증의학과87례수행궤계통기적감염성휴극환자,채용맥박지시련속심배혈량감측의(PiCCO)화PVI감측의지속감측환자PLR전후적혈류동역학삼수.이PLR후심배혈지수(CI)증가치(△CI)≥10％정의위용량반응양성(유반응조),△CI＜ 10％정의위용량반응음성(무반응조).평개량조환자PLR전후심솔(HR)、평균동맥압(MAP)、중심정맥압(CVP)、매박량변이도(SVV)、CI、PVI급기변화치(△HR、△MAP、△CVP、△SVV、△CI、△PVI)적차이,분석기여△CI적상관성.회제수시자공작특정곡선(ROC),평개혈류동역학삼수예측용량반응성적개치.결과 87례감염성휴극환자공진행145례차PLR,유용량반응성67례차,무용량반응성78례차.PLR전,유무반응량조간HR、MAP、CVP、CI차이균무통계학의의,단유반응조SVV、PVI명현고우무반응조[SVV:(16.9±3.1)％비(8.4±2.2)％,t=9.078,P=0.031;PVI:(20.6±4.3)％비(11.1±3.2)％,t=19.189,P=0.022].PLR후,유무반응량조환자간HR、MAP、CVP、SVV화PVI비교차이균무통계학의의,단유반응조CI명현고우무반응조(mL·s-1·m-2:78.3±6.7비60.0±8.3,t=2.902,P=0.025).유무반응량조환자간△HR、△MAP、△CVP차이균무통계학의의,단유반응조△SVV、△CI、△PVI균명현고우무반응조[△SVV:(4.6±1.5)％비(1.8±0.9)％,t=11.187,P=0.022;△CI(mL·s-1·m-2):18.3±1.7비1.7±0.5,t=3.696,P=0.014;△PVI:(6.4±1.1)％비(1.3±0.2)％,t=19.563,P=0.013].PLR전HR、MAP、CVP여△CI균무상관성,SVV、PVI여△CI정직선상관(r=0.850,P=0.015;r=0.867,P=0.001).SVV예측용량반응성적ROC곡선하면적(AUC)위0.948,최가림계치위12.4％시,민감도위85.4％,특이도위86.6％;PVI예측용량반응성적AUC위0.957,최가림계치위14.8％시,민감도위87.5％,특이도위84.8％;균명현고우기타혈류동역학지표(HR、MAP、CVP).결론 PLR하,PVI화SVV균능구유효예측감염성휴극궤계통기환자대용량치료적반응성,이PVI작위일충련속、무창적공능성혈류동역학지표,기준학성여유창측득적SVV상유사.
    Objective To evaluate the role ofpleth variability index (PVI) by passive leg raising (PLR) test in volume responsiveness and volume status prediction in patients with septic shock.Methods A prospective randomized controlled trial (RCT) was conducted.Eighty-seven patients suffering from septic shock undergoing mechanical ventilation in Department of Critical Care Medicine of Subei People's Hospital from June 2012 to September 2014 were enrolled.The hemodynamic changes before and after PLR were monitored by pulse indicated continuous cardiac output (PiCCO) and PVI monitoring.Responsive group:positive fluid response was defined as an increase in cardiac index (CI) ≥ 10％ after PLR.Unresponsive group:negative fluid response was defined as an increase in CI ＜ 10％ after PLR.The hemodynamic parameters,including heart rate (HR),mean arterial pressure (MAP),central venous pressure (CVP),stroke volume variation (SVV),CI and PVI,and the changes in cardiac parameters (△ HR,△ MAP,△ CVP,△ SVV,△ CI,and △ PVI) before and after PLR were determined.The relations between hemodynamic parameters and their changes with △ CI were analyzed by the Pearson analysis.The role of the parameters for volume responsiveness prediction was evaluated by receiver operating characteristic (ROC) curves.Results 145 PLRs in 87 patients with septic shock were conducted,with 67 in responsive group and 78 in unresponsive group.There were no statistically significant differences in HR,MAP,CVP and CI before PLR between the responsive and unresponsive groups.SVV and PVI in responsive group were significantly higher than those in the unresponsive group [SVV:(16.9± 3.1)％ vs.(8.4±2.2) ％,t =9.078,P =0.031; PVI:(20.6±4.3)％ vs.(11.1 ±3.2)％,t =19.189,P =0.022].There were no statistically significant differences in HR,MAP,CVP,SVV,and PVI after PLR between the responsive group and unresponsive group.CI in the responsive group was significantly higher than that in the unresponsive group (mL·s-1·m-2:78.3±6.7 vs.60.0±8.3,t =2.902,P =0.025).There were no statistically significant differences in △HR,△MAP,△ CVP between responsive group and unresponsive group.△ SVV,△ CI and △ PVI in responsive group were significantly higher than those in the unresponsive group [△ SVV:(4.6 ± 1.5)％ vs.(1.8 ± 0.9)％,t =11.187,P =0.022;△ CI (mL·s-1·m-2):18.3 ± 1.7 vs.1.7 ± 0.5,t =3.696,P =0.014; △ PVI:(6.4 ± 1.1)％ vs.(1.3 ± 0.2)％,t =19.563,P =0.013].No significant correlation between HR,MAP or CVP before PLR and △ CI was found.SVV (r =0.850,P =0.015) and PVI (r =0.867,P =0.001) before PLR were correlated with △ CI.It was shown by ROC curve that the area under ROC curve (AUC) for SVV fluid responsiveness prediction was 0.948,and cut-off of SVV was 12.4％,the sensitivity was 85.4％,and specificity was 86.6％.The AUC for PVI fluid responsiveness prediction was 0.957,and cut-off was 14.8％,the sensitivity was 87.5％,and specificity was 84.8％.It was higher than other hemodynamic parameters (HR,MAP,CVP).Conclusions PVI and SVV can better predict fluid responsiveness in mechanically ventilating patients with septic shock after PLR.PVI as a new continuous,noninvasive and functional hemodynamic parameter has the same accuracy as SVV.
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