经外周动脉心排血量监测在重症患者液体管理中的应用

An application of arterial pressure-based cardiac output measurements in fluid management strategies of critically ill patients

目的 探讨依据外周动脉心排血量监测（APCO）容量反应指标对重症患者实施液体管理的临床意义.方法 采用回顾性队列研究方法,选择2012年6月1日至2013年12月31日收入吉林大学第一医院重症监护病房（ICU）的重症患者.当患者急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分≥15分,心率＞100次/min,无法准确判断前负荷况和心功能状态时,应用APCO监测患者的血流动力学参数,联合应用每搏量变异度（SVV）和被动抬腿试验（PLR）对患者进行液体管理.记录实施液体管理策略前后患者的心率、SVV、血乳酸、中心静脉压（CVP）,以及治疗效果.当心率下降和（或）每搏量（SV）增加≥10％,同时伴有血乳酸和SVV下降判定为有效,不符合上述标准者则判定为无效.结果 共纳入68例患者.①液体管理策略实施前：CVP＞ 12 cmH2O（1 cmH2O=0.098 kPa）40例,5～ 12 cmH2O 16例,＜5 cmH2O 12例;SVV＞ 13％ 35例,＜13％9例,PLR阳性18例,PLR阴性6例,提示前负荷不足者（SVV＞13％和PLR阳性）占77.9％（53/68）.②实施液体管理策略4h后有效49例,无效19例,有效率为72.06％（49/68）;液体管理策略实施12h后,有效56例,无效12例,有效率为82.35％（56/68）.③有效组液体管理策略实施后心率、SVV、血乳酸均较实施前显著下降[实施4h的心率（次/min）：112.45±13.35比129.55±15.49,SVV：（15.47±6.32）％比（21.20±7.40）％,血乳酸（mmol/L）：4.16±3.12比6.21 ±4.11;实施12h的心率（次/min）：110.02±13.92比129.61±14.93,SVV：（14.61±5.52）％比（20.66±7.40）％,血乳酸（mmol/L）：3.35±2.26比6.11 ±4.02,P＜0.05或P＜0.01];无效组液体管理策略实施后上述指标无显著变化[实施4h的心率（次/min）：119.53±11.68比125.79±11.58,SVV：（16.95±6.48）％比（18.47±4.96）％,血乳酸（mmol/L）：5.55±3.80比6.54±3.72;实施12h的心率（次/min）：115.92±11.71比123.40±11.59,SVV：（17.17±6.09）％比（19.42±8.25）％,血乳酸（mmol/L）：6.33±3.40比7.21±3.81,均P＞ 0.05].CVP仅有效组实施12h时较实施前显著升高（cmH2O：12.88±3.38比11.27±4.97,P＜0.05）.结论 经APCO监测的SVV是一个能很好代表容量反应的指标,可以作为临床实施液体管理的重要参考依据.

Objective To discuss the clinical significance of fluid management of severe patients according to arterial pressure-based cardiac output （APCO） monitoring volume responsiveness index.Methods A retrospective cohort study was conducted.The severe patients were selected from the intensive care unit （ICU） of the First Hospital of Jilin University from June 1st,2012 to December 31st,2013.The hemodynamic parameters were monitored by APCO,and the fluid resuscitation was managed by stroke volume variation （SVV） and passive leg-raising test （PLR） when the acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score ≥ 15,heart rate 〉 100 bpm with the result that the preload and heart function could not be evaluated.The heart rate,SVV,lactic acid （Lac） and central venous pressure （CVP） and curative effect were recorded before and after carrying out fluid management strategy.The criteria of clinical effective was defined as heart rate decreased and （or） stroke volume （SV） increased ≥ 10%,accompanied by blood Lac and SVV decreased,other than,the cases did not meet above criteria were considered ineffective.Results Sixty-eight patients were enrolled in the study.① Before carrying out fluid management strategy：40 cases with CVP〉 12 cmH2O （1 cmH2O=0.098 kPa）,and 16 cases with 5-12 cmH2O,12 with 〈5 cmH2O.SVV〉13% in 35 cases,SVV 〈 13% in 9 cases.PLR positive in 18 cases,and PLR negative in 6 cases.It was implicated that the patients with poor preload （SVV 〉 13% and PLR positive） accounted by 77.9% （53/68）.② There were 49 effective cases and 19 ineffective cases 4 hours after carrying out fluid management strategy,and the effective rate was 72.06% （49/68）.While there were 56 effective cases and 12 ineffective cases after 12 hours,and the total effective rate was 82.35% （56/68）.③ In effective group,heart rate,SVV,Lac after fluid management strategy were significantly lower than those before fluid management strategy [4 hours after fluid management strategy：heart rate （bpm） 112.45 ± 13.53 vs.129.55 ± 15.49,SVV （15.47 ± 6.32）% vs.（21.20 ± 7.40）%,Lac （mmol/L） 4.16 ± 3.12 vs.6.21 ± 4.11 ; 12 hours after fluid management strategy：heart rate （bpm） 110.02 ± 13.92 vs.129.61 ± 14.93,SVV （14.61 ± 15.52）% vs.（20.66 ± 7.40）%,Lac （mmol/L） 3.35 ± 2.26 vs.6.11 ± 4.02,P〈0.05 or P〈0.01],while there was no significant difference in those markers between before and after fluid management strategy in ineffective group [4 hours after fluid management strategy：heart rate （bpm） 119.53 ± 11.68 vs.125.79 ± 11.58,SVV （16.95 ±6.48）% vs.（18.47 ±4.96）%,Lac （mmol/L） 5.55 ± 3.80 比 6.54 ± 3.72 ; 12 hours after fluid management strategy：heart rate （bpm） 115.92 ± 11.71 vs.123.40 ± 11.59,SVV （17.17 ± 6.09）% vs.（19.42 ± 8.25）%,Lac （mmol/L） 6.33 ± 3.40 vs.7.21 ± 3.81,all P〉 0.05].CVP only at 12 hours after fluid management strategy in effective group was significantly higher than that before fluid management strategy （cmH2O：12.88 ± 3.38 vs.11.27 ± 4.97,P〈0.05）.Conclusion SVV monitored by APCO is a good indicator of volume responsiveness index,which can be used as an important reference combined with PLR for fluid management of severe patients.