被动抬腿试验预测严重感染和感染性休克患者的容量反应性

Passive leg raising predicts volume responsiveness in patients with severe sepsis and septic shock

目的 观察被动抬腿试验（PLR）预测严重感染和感染性休克患者容量反应性的价值.方法 采用前瞻性观察性研究方法,选择2009年2月至2010年1月北京大学深圳医院重症监护病房（ICU）的30例严重感染和感染性休克患者.在患者平卧位、PLR期间和扩容后进行血流动力学监测,用超声心排血量监测仪无创监测每搏量（SV）、心排血量（CO）、外周血管阻力（SVR）等血流动力学指标,持续监测有创动脉血压、中心静脉压（CVP）.将扩容后SV增加值（△SV）≥15%定义为有容量反应性,用受试者工作特征曲线（ROC曲线）评价PLR预测容量反应性的价值.结果 扩容后有15例患者有容量反应.PLR期间无反应组和有反应组患者CVP（cm H2O,1 cm H2O=0.098 kPa）均较平卧位时增加（13.6±6.6比12.1±6.0,11.9±5.5比10.8±5.2,均P＜0.01）;有反应组PLR期间△SV明显高于无反应组[（16.6±5.5）%比（3.8±8.2）%,P=0.000];PLR期间△SV与扩容后△SV呈显著正相关（r=0.681,P=0.000）;PLR预测容量反应性的ROC曲线下面积（AUC）为0.944±0.039（P=0.000）,PLR期间△SV＞11%预测容量反应性的敏感性和特异性分别为86.7%和93.3%,阳性预测率和阴性预测率分别为92.9%和87.5%.结论 PLR能精确预测严重感染和感染性休克患者的容量反应性,可指导临床治疗.

Objective To evaluate the role of passive leg raising（PLR）test in predicting volume responsiveness in severe sepsis and septic shock patients. Methods Thirty severe sepsis and septic shock patients in intensive care unit（ICU）of Peking University Shenzhen Hospital were prospectively observed from February 2009 to January 2010. The hemodynamics including stroke volume（SV）, cardiac output （CO）and systemic vascular resistance（SVR）were measured non-invasively by ultrasonic cardiac output monitor（USCOM）device in the supine position, during PLR and after volume expansion（VE）, and invasive arterial blood pressure and central venous pressure（CVP）were monitored consecutively. Responders were defined by the appearance of an increase in SV（△SV）≥15% after VE. The role of PLR for predicting volume responsiveness was evaluated by receiver operating characteristic（ROC）curves. Results The CVP （cm H2O, 1 cm H2O=0. 098 kPa）during PLR was increased compared with that at supine position in both responder group（n= 15）and non-responder group（n= 15, 13. 6± 6. 6 vs. 12. 1 ± 6. 0, 11.9± 5.5 vs.10. 8±5.2, both P〈0. 01）. △SV was higher in responder group than in non-responder group during PLR [（16. 6±5.5）% vs.（3. 8±8. 2）%, P=0. 000]. △SV during PLR was highly correlated to △SV after VE （r=0. 681, P=0. 000）. The area under the ROC curve（AUC）for PLR predicting volume responsiveness was 0. 944±0. 039（P=0. 000）. The △SV〉11% during PLR was found to predict volume responsiveness with a sensitivity of 86. 7%, specificity of 93. 3 %, positive predictive value of 92. 9 % and negative predictive value of 87.5%. Conclusion PLR can be used generally to predict volume responsiveness accurately in severe sepsis and septic shock patients, and it can be used to direct clinical practice.