被动直腿抬高试验在严重脓毒症患者容量判断中的作用

Clinical study of passive leg raising as an indicator of fluid responsiveness in severe septic patients

目的探讨被动直腿抬高试验（passivelegraising，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）技术分别记录在半卧位、PLR后、液体输注后（30min内快速输注6％羟乙基淀粉500m1）的血流动力学参数。根据每搏量指数变化（t,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ASVI、ACVPm对预测患者液体反应的价值。用SPSSl7．0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。液体反应阳性组PLR后ABPs、ABPm、CVPm比基线水平显著升高[（115．9±13．1）VS．（100．1±18．1），（77．8±13．0）vs．（68．1±12．4），（10．1±4．1）VS．（7．2±3．4）]，分另0为P=0．005，P=0．03，P=0．03。PLR后，ASVI和ACVPm预测液体反应阳性的ROC曲线下面积分别为0．897±0．059（95％C／=0．762-1．000）和0．819±0．081（95％C／=0．661～0．977）。分别取ASVI=10．5％和ACVPm=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．O％和80．O％。结论PLR后的ASVI和ACVPm可以作为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。

Objective To assess the value of legs passively lifted as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis. Methods Twenty-eight mechanically ventilated patients with severe sepsis admitted from May 2010 to May 2011 for volume resuscitation were collected. Patients with non-sinus rhythm or arrhythmia and parturients were excluded. Variation of hemodynamics of the patients in a semi-recumbent position, after passive leg raising （PLR） and after volume expansion （500 ml 6% hydroxyethyl starch infusion within 30 rains） was studied by using the technique of pulse indicator continuous cardiac output （PiCCO） system. The volume resuscitation were resulted into two groups, responder and non-responder, as per ASVI （stroke volume index） over 15%. HR, arterial systolic blood pressure （ABPs）, arterial diastolic blood pressure （ABPd）, mean arterial blood pressure （ABPm）,mean central venous pressure （CVPm） and cardiac index （CI） were compared between two groups. The changes of ABPs, ABPm, CVPm and SVI after PLR and after fluid resuscitation were compared with those before PLR and fluid resuscitation. The ROC curve was drawn to evaluate the value of ASVI and ACVPm in predicting volume responsiveness. SPSS 17.0 software was used for statistic analysis. Results Of 28 patients, 8 were responders and 10 were non-responders. In responders after PLR, some hemodynamic variables including ABPs, ABPm and CVPm were significantly increased [ （ 100. 1 ± 18.1 ） vs. （ 115.9 ± 13.1）, P=0.005; （68.1 ±12.4） vs. （77.8±13.0）, P=0.03 and （7.2±3.4） vs. （10.1±4.1）, P =0. 03, respectively]. After PLR, the area under curve （AUC） of the ROC curve of ASVI and ACVPm to predict the responsiveness after fluid resuscitation were 0. 897 ± 0. 059 （95 % CI 0. 762-1. 000） and 0. 819 ± 0. 081 （95% CI 0. 661-0. 977 ） , respectively. When the cut-off levels of ASVI and ACVPm were 10. 5% and 12. 7%, the sensitivities were 72. 2% and 72. 2%, the specificities were 90% and 80%. Conclusions Changes in ASVI and ACVPm induced by passive leg raising are accurate indices for predicting fluid responsiveness in mechanically ventilated atients with severe sepsis.