重脓毒症患者容量判断中的作用.docx

1、重脓毒症患者容量判断中的作用被动直腿抬高试验在严重脓毒症患者容量判断中的作用董绉绉 方强2 【摘要】 目的 探讨被动直腿抬高试验（passive leg raising, PLR）在判断严重脓毒症的机械通气患者中血流动力学反应的作用，指导脓毒性患者的容量复苏。 方法 前瞻性研究，入选2010年5月至2011年5月浙江大学医学院附属第一医院ICU和宁波市医疗中心李惠利医院ICU符合严重脓毒症诊断标准的机械通气患者28例进行液体复苏。排除非窦性心律者、心律不齐者和产妇。用脉搏波指示剂连续心排血量（pulse indicator continuous cardiac output, PiCCO）技术

2、分别记录在半卧位、PLR后、液体输注后（30分钟内快速输注6%羟乙基淀粉500 ml）的血流动力学参数。根据每搏量指数变化（SVI）是否大于等于15%，分为液体反应阳性组和液体反应阴性组。比较两组间基线水平时心率（HR）、收缩压（ABPs）、舒张压（ABPd）、平均动脉压（ABPm）、平均中心静脉压（CVPm）和心指数（CI）的差异；比较两组患者PLR后及快速输液后ABPs、ABPm、CVPm、SVI与基线水平之间的差异；ROC曲线评价SVI、CVPm对预测患者液体反应的价值。用SPSS17.0统计软件包进行统计分析。 结果 28例患者中液体反应阳性组18例，液体反应阴性组10例。液体反应阳性

3、组PLR后ABPs、ABPm、CVPm比基线水平显著升高（115.913.1）和（100.118.1），（77.813.0）和（68.112.4），（10.14.1）和（7.23.4），分别为P=0.005，P=0.03，P=0.03。PLR后，SVI和CVPm预测液体反应阳性的ROC曲线下面积分别为0.8970.059（95%CI=0.7621.000）和0.8190.081（95%CI=0.6610.977）。分别取SVI=10.5%和CVPm=12.7%为界值，预测患者液体反应阳性的敏感性为72.2%和72.2%，特异性为90.0%和80.0%。 结论 PLR后的SVI和CVPm可以作为

4、严重脓毒症机械通气患者的一项准确而可逆的液体反应预测指标。 【关键词】 被动直腿抬高试验；液体复苏；血流动力学监测；每搏量指数；中心静脉压；严重脓毒症；液体反应；ROC曲线Passive leg raising is predictive of fluid responsiveness in patients with severe sepsisDONG Zhou-zhou, FANG Qiang*. *Intensive care unit, First Affiliated Hospital, Zhejiang University College Of Medicine,Zhejiang

5、,310006,China.Corresponding author: FANG qiang, 310006，Tel: 1805735654, Email:fangqicu. Abstract Objective To assess the value of passive leg raising as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsisk to guide volume resuscitation. Method This was a prosp

6、ective study. Twenty eight mechanically ventilated patients with severe sepsis, admitted in ICU of First Affiliated Hospital, Zhejiang University College Of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to May 2011, were collected for volume resuscitation. Non-sinus rhy

7、thm or arrhythmia ones, parturients were excluded. Hemodynamic indices of the patients were obtained in a semi-recumbent position, then after passive leg raising, and after volume expansion (500 mL 6% hydroxyethyl starch infusion within 30 mins) by the technique of pulse indicator continuous cardiac

8、 output (PiCCO) system. The volume resuscitation were resulted into two groups according to the change in stroke volume index (SVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous press

9、ure (CVPm) and cardiac index (CI) were compared between two groups. The changes of ABPs, ABPm, CVPm, SVI after PLR and after fluid resuscitation were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of SVI and change of CVPm (CVPm) in predicting volume respons

10、iveness. SPSS l7.0 software was used for statistic. Results Among twenty eight patients included in this study, eighteen were responders and ten were non-responders. After PLR among the responders, some hemodynamic variables including (ABPs, ABPm and CVPm) were significantly elevated, (100.118.1) an

11、d (115.913.1), P=0.005; (68.112.4) and (77.813.0), P=0.03; (7.23.4) and (10.14.1), P=0.03. After PLR, the area under curve (AUC) of the ROC curve of SVI and CVPm to predict the responsiveness after fluid resuscitation were 0.8970.059 (95%CI 0.7621.000) and 0.8190.081 (95%CI 0.6610.977) when the cut-

12、off levels of SVI and CVPm were 10.5% and 12.7%, the sensitivities were 72.2% and 72.2%, the specificities were 90% and 80%. Conclusions Changes in SVI and CVPm induced by passive leg raising are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sep

13、sis. Key words Passive leg raising; Volume resuscitation; Hemodynamic monitoring; Stroke volume index; Central venous pressure; Severe sepsis; Fluid responsiveness; ROC curve 容量评估在血流动力学不稳定的危重患者的治疗过程中起着关键作用。在严重脓毒症早期，包括液体复苏在内的集束化治疗策略可以提高患者的生存率1,2，但盲目的液体复苏会加重肺水肿，甚至引起呼吸衰竭、延长机械通气时间，增高腹内压，降低生存率3。判断危重患者是否需

14、要液体负荷，主要通过评估患者的每搏量指数（stroke volume index, SVI）能否随着液体输入而增加。被动直腿抬高试验（passive leg raising, PLR）简便、安全，堪比可逆的自身容量负荷试验。我们以需要机械通气的严重脓毒症患者为对象进行前瞻性研究，采用脉搏波指示剂连续心排血量（pulse indicator continuous cardiac output, PICCO）技术作为血流动力学监测手段，先后对受试者进行PLR和液体负荷试验，分析相应的血流动力学参数变化，为评估PLR在容量判定中的临床价值提供理论依据。1 资料与方法2 1.1 临床资料：选取2010

15、年5月至2011年5月浙江大学医学院附属第一医院ICU和宁波市医疗中心李惠利医院ICU进行机械通气的严重脓毒症患者共28例，其中男23例，女5例，年龄3686岁，平均（59.714.4）岁。严重脓毒症的诊断符合2001年危重病医学会欧洲危重病医学会美国胸科医师协会（SCCMESICMACCP）对严重脓毒症和感染性休克的诊断标准4，并同时具备以下组织灌注不足临床表现中的至少一条5：收缩压50 mmHg或需要使用血管活性药物（多巴胺5 ug/kg/min或去甲肾上腺素）；尿量100次/min；皮肤出现花斑。排除非窦性心律者、心律不齐者和产妇。所有患者或家属知晓病情并签署针对临床诊治的知情同意书。1

16、.2 监测指标及方法：经右颈内静脉穿刺置入双腔静脉导管（Arrow公司，美国）监测中心静脉压（CVP）。经股动脉置入PiCCO导管（PV2014L13，Pulsion Medical Systems，德国），连接到带PiCCO模块的Philips IntelliVue MP50/70心电监护仪上。采用脉搏曲线分析及动脉热稀释法监测心输出量。热稀释法操作步骤：自静脉导管快速（5 s）注入温度低于8的生理盐水1015 ml，至少3次，取3次变异量10%的数值取平均值。实验过程中给予患者充分镇静（Ramsay评分4分），呼吸机设置为容量控制通气（CMV）模式，潮气量10 mlkg，吸入氧浓度0.50，吸呼比1:2，呼气末正压（PEEP）5 cmH2O（1