中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
9期
729-734
,共6页
司向%黄牧云%陈娟%欧阳彬%陈敏英%蔡常洁%吴健峰%刘紫锰%刘勇军%黄顺伟%黎丽芬%管向东
司嚮%黃牧雲%陳娟%歐暘彬%陳敏英%蔡常潔%吳健峰%劉紫錳%劉勇軍%黃順偉%黎麗芬%管嚮東
사향%황목운%진연%구양빈%진민영%채상길%오건봉%류자맹%류용군%황순위%려려분%관향동
脓毒症%心功能不全%被动抬腿试验%液体反应性
膿毒癥%心功能不全%被動抬腿試驗%液體反應性
농독증%심공능불전%피동태퇴시험%액체반응성
Sepsis%Cardiac dysfunction%Passive leg raising test%Fluid responsiveness
目的：探讨被动抬腿试验（PLR）在脓毒症合并心功能不全患者中对液体反应性的预测价值。方法采用前瞻性观察性队列研究方法，选择2013年9月至2014年7月中山大学附属第一医院外科重症监护中心连续收治的38例行机械通气的脓毒症合并心功能不全患者，分别于PLR前（床头抬高45°、患者半卧位）、PLR时（患者仰卧位，下肢抬高45°）、容量负荷试验（VE）前（恢复半卧位）和VE时（30 min内输注250 mL 5%人血白蛋白）4个阶段记录血流动力学指标；根据VE后每搏量变化（ΔSVVE）是否≥15%分为对液体复苏有反应组和液体无反应组。对各血流动力学指标变化值之间进行线性相关分析，并通过受试者工作特征曲线（ROC）评价PLR前后各项血流动力学指标变化预测患者液体反应性的价值。结果38例患者中25例为有反应组，13例为无反应组。两组基线资料及初始半卧位时的血流动力学指标差异均无统计学意义。有反应组实施PLR后引起的SV及心排血量（CO）变化（ΔSVPLR、ΔCOPLR）较无反应组明显升高〔ΔSVPLR：（14.7±5.7）%比（6.4±5.3）%，t＝4.304，P＝0.000；ΔCOPLR：（11.2±7.5）%比（3.4±2.3）%，t＝3.454，P＝0.001〕，而PLR引起的收缩压、平均动脉压、脉搏压、心率的变化（ΔSBPPLR、ΔMAPPLR、ΔPPPLR、ΔHRPLR）在两组之间差异无统计学意义；有反应组ΔSVVE较无反应组明显升高〔（20.8±5.5）%比（5.0±3.7）%，t＝8.347， P＝0.000〕。相关性分析显示，ΔSVPLR与ΔSVVE呈显著正相关（r＝0.593，P＝0.000），ΔCOPLR与ΔSVVE呈显著正相关（r＝0.494，P＝0.002）。以ΔSVPLR≥8.1%预测患者液体反应性的ROC曲线下面积（AUC）为0.860±0.062（P＝0.000），敏感度为92.0%，特异度为70.0%；以ΔCOPLR≥5.6%预测患者液体反应性的AUC为0.840±0.070（P＝0.001），敏感度为84.0%，特异度为76.9%；以ΔMAPPLR≥6.9%预测患者液体反应性的AUC为0.662±0.089，敏感度为68.0%，特异度为76.9%；以ΔSBPPLR≥6.4%预测患者液体反应性的AUC为0.628±0.098，敏感度为76.0%，特异度为61.5%；以ΔPPPLR≥6.2%预测患者液体反应性的AUC为0.502±0.094，敏感度为56.0%，特异度为53.8%；以PLR后HR降低超过1.7%预测患者液体反应性的AUC为0.457±0.100，敏感度为56.0%，特异度为46.2%。结论在脓毒症合并心功能不全患者中，PLR引起的SV及CO变化能准确预测液体反应性，而其引起的HR、 MAP、 SBP及PP的变化均不能有效预测液体反应性。
目的：探討被動抬腿試驗（PLR）在膿毒癥閤併心功能不全患者中對液體反應性的預測價值。方法採用前瞻性觀察性隊列研究方法，選擇2013年9月至2014年7月中山大學附屬第一醫院外科重癥鑑護中心連續收治的38例行機械通氣的膿毒癥閤併心功能不全患者，分彆于PLR前（床頭抬高45°、患者半臥位）、PLR時（患者仰臥位，下肢抬高45°）、容量負荷試驗（VE）前（恢複半臥位）和VE時（30 min內輸註250 mL 5%人血白蛋白）4箇階段記錄血流動力學指標；根據VE後每搏量變化（ΔSVVE）是否≥15%分為對液體複囌有反應組和液體無反應組。對各血流動力學指標變化值之間進行線性相關分析，併通過受試者工作特徵麯線（ROC）評價PLR前後各項血流動力學指標變化預測患者液體反應性的價值。結果38例患者中25例為有反應組，13例為無反應組。兩組基線資料及初始半臥位時的血流動力學指標差異均無統計學意義。有反應組實施PLR後引起的SV及心排血量（CO）變化（ΔSVPLR、ΔCOPLR）較無反應組明顯升高〔ΔSVPLR：（14.7±5.7）%比（6.4±5.3）%，t＝4.304，P＝0.000；ΔCOPLR：（11.2±7.5）%比（3.4±2.3）%，t＝3.454，P＝0.001〕，而PLR引起的收縮壓、平均動脈壓、脈搏壓、心率的變化（ΔSBPPLR、ΔMAPPLR、ΔPPPLR、ΔHRPLR）在兩組之間差異無統計學意義；有反應組ΔSVVE較無反應組明顯升高〔（20.8±5.5）%比（5.0±3.7）%，t＝8.347， P＝0.000〕。相關性分析顯示，ΔSVPLR與ΔSVVE呈顯著正相關（r＝0.593，P＝0.000），ΔCOPLR與ΔSVVE呈顯著正相關（r＝0.494，P＝0.002）。以ΔSVPLR≥8.1%預測患者液體反應性的ROC麯線下麵積（AUC）為0.860±0.062（P＝0.000），敏感度為92.0%，特異度為70.0%；以ΔCOPLR≥5.6%預測患者液體反應性的AUC為0.840±0.070（P＝0.001），敏感度為84.0%，特異度為76.9%；以ΔMAPPLR≥6.9%預測患者液體反應性的AUC為0.662±0.089，敏感度為68.0%，特異度為76.9%；以ΔSBPPLR≥6.4%預測患者液體反應性的AUC為0.628±0.098，敏感度為76.0%，特異度為61.5%；以ΔPPPLR≥6.2%預測患者液體反應性的AUC為0.502±0.094，敏感度為56.0%，特異度為53.8%；以PLR後HR降低超過1.7%預測患者液體反應性的AUC為0.457±0.100，敏感度為56.0%，特異度為46.2%。結論在膿毒癥閤併心功能不全患者中，PLR引起的SV及CO變化能準確預測液體反應性，而其引起的HR、 MAP、 SBP及PP的變化均不能有效預測液體反應性。
목적：탐토피동태퇴시험（PLR）재농독증합병심공능불전환자중대액체반응성적예측개치。방법채용전첨성관찰성대렬연구방법，선택2013년9월지2014년7월중산대학부속제일의원외과중증감호중심련속수치적38례행궤계통기적농독증합병심공능불전환자，분별우PLR전（상두태고45°、환자반와위）、PLR시（환자앙와위，하지태고45°）、용량부하시험（VE）전（회복반와위）화VE시（30 min내수주250 mL 5%인혈백단백）4개계단기록혈류동역학지표；근거VE후매박량변화（ΔSVVE）시부≥15%분위대액체복소유반응조화액체무반응조。대각혈류동역학지표변화치지간진행선성상관분석，병통과수시자공작특정곡선（ROC）평개PLR전후각항혈류동역학지표변화예측환자액체반응성적개치。결과38례환자중25례위유반응조，13례위무반응조。량조기선자료급초시반와위시적혈류동역학지표차이균무통계학의의。유반응조실시PLR후인기적SV급심배혈량（CO）변화（ΔSVPLR、ΔCOPLR）교무반응조명현승고〔ΔSVPLR：（14.7±5.7）%비（6.4±5.3）%，t＝4.304，P＝0.000；ΔCOPLR：（11.2±7.5）%비（3.4±2.3）%，t＝3.454，P＝0.001〕，이PLR인기적수축압、평균동맥압、맥박압、심솔적변화（ΔSBPPLR、ΔMAPPLR、ΔPPPLR、ΔHRPLR）재량조지간차이무통계학의의；유반응조ΔSVVE교무반응조명현승고〔（20.8±5.5）%비（5.0±3.7）%，t＝8.347， P＝0.000〕。상관성분석현시，ΔSVPLR여ΔSVVE정현저정상관（r＝0.593，P＝0.000），ΔCOPLR여ΔSVVE정현저정상관（r＝0.494，P＝0.002）。이ΔSVPLR≥8.1%예측환자액체반응성적ROC곡선하면적（AUC）위0.860±0.062（P＝0.000），민감도위92.0%，특이도위70.0%；이ΔCOPLR≥5.6%예측환자액체반응성적AUC위0.840±0.070（P＝0.001），민감도위84.0%，특이도위76.9%；이ΔMAPPLR≥6.9%예측환자액체반응성적AUC위0.662±0.089，민감도위68.0%，특이도위76.9%；이ΔSBPPLR≥6.4%예측환자액체반응성적AUC위0.628±0.098，민감도위76.0%，특이도위61.5%；이ΔPPPLR≥6.2%예측환자액체반응성적AUC위0.502±0.094，민감도위56.0%，특이도위53.8%；이PLR후HR강저초과1.7%예측환자액체반응성적AUC위0.457±0.100，민감도위56.0%，특이도위46.2%。결론재농독증합병심공능불전환자중，PLR인기적SV급CO변화능준학예측액체반응성，이기인기적HR、 MAP、 SBP급PP적변화균불능유효예측액체반응성。
ObjectiveTo assess the value of passive leg raising (PLR) test in predicting fluid responsiveness in patients with sepsis-induced cardiac dysfunction.Methods A prospective observational cohort study was conducted. Thirty-eight patients under mechanical ventilation suffering from sepsis-induced cardiac dysfunction admitted to Department of Surgical Intensive Care Unit of First Affiliated Hospital of Sun Yat-Sen University from September 2013 to July 2014 were enrolled. The patients were studied in four phases: before PLR (semi-recumbent position with the trunk in 45°), PLR (the lower limbs were raised to a 45° angle while the trunk was in a supine position), before volume expansion (VE, return to the semi-recumbent position), and VE with infusing of 250 mL 5% albumin within 30 minutes. Hemodynamic parameters were recorded in every phase. The patients were classified into two groups according to their response to VE: responders (at least a 15% increase in stroke volume,ΔSVVE≥15%), and non-responders. The correlations among all changes in hemodynamic parameters were analyzed by linear correlation analysis, and the receiver operating characteristic curve (ROC) was plotted to assess the value of hemodynamic parameters before and after PLR in predicting fluid responsiveness.Results Of 38 patients, 25 patients were responders, and 13 non-responders. There was no significant difference in the baseline and hemodynamic parameters at semi-recumbent position between the two groups. The changes in SV and cardiac output (CO) after PLR (ΔSVPLR andΔCOPLR) were significantly higher in responders than those of non-responders [ΔSVPLR: (14.7±5.7)%vs. (6.4±5.3)%,t = 4.304,P = 0.000;ΔCOPLR: (11.2±7.5)% vs. (3.4±2.3)%,t = 3.454,P = 0.001], but there was no significant difference in the changes in systolic blood pressure, mean arterial pressure, pulse pressure, and heart rate after PLR (ΔSBPPLR,ΔMAPPLR,ΔPPPLR andΔHRPLR) between two groups.ΔSVVE in responders was significantly higher than that of the non-responders [(20.8±5.5) % vs. (5.0±3.7) %,t = 8.347,P = 0.000]. It was shown by correlation analysis thatΔSVPLR was positively correlated withΔSVVE (r = 0.593,P = 0.000),ΔCOPLR was positively correlated withΔSVVE (r = 0.494,P = 0.002). The area under ROC curve (AUC) ofΔSVPLR≥8.1% for predicting fluid responsiveness was 0.860±0.062 (P = 0.000), with sensitivity of 92.0% and specificity of 70.0%; the AUC ofΔCOPLR≥5.6% for predicting fluid responsiveness was 0.840±0.070 (P = 0.000), with sensitivity of 84.0%and specificity of 76.9%; the AUC ofΔMAPPLR≥6.9% for predicting fluid responsiveness was 0.662±0.089, with sensitivity of 68.0% and specificity of 76.9%; the AUC ofΔSBPPLR≥6.4% for predicting fluid responsiveness was 0.628±0.098, with sensitivity of 76.0% and specificity of 61.5%; the AUC ofΔPPPLR≥6.2% for predicting fluid responsiveness was 0.502±0.094, with sensitivity of 56.0% and specificity of 53.8%; the AUC ofΔHRPLR≥-1.7%for predicting fluid responsiveness was 0.457±0.100, with sensitivity of 56.0% and specificity of 46.2%.Conclusion In patients with sepsis-induced cardiac dysfunction, changes in SV and CO induced by PLR are accurate indices for predicting fluid responsiveness, but the changes in HR, MAP, SBP and PP cannot predict the fluid responsiveness.
