超声监测联合被动抬腿试验评估容量反应性

The ultrasonic monitoring coupled with passive leg raising test for evaluation of fluid responsiveness in critical patients

目的探讨床旁经胸壁超声（TTE）监测被动抬腿试验（PLR）前后主动脉流速-时间积分变异率（AVTI）和每搏量变异率（ASV）预测患者容量反应性的价值。方法前瞻性选取2014年10月至2015年10月安徽医科大学附属第二医院收治的患者42例，监测患者的心率（HR）、平均动脉压（MAP）、中心静脉压（CVP），VTI和sV等血流动力学指标。行PLR后再次监测上述各指标。行PICCO监测SVI，然后行容量负荷试验，以容量负荷试验后SVI增加≥15％将全组病例分为容量反应（＋）组和容量反应（-）组，统计分析TTE监测PLR前后AVTI和ASV预测容量反应性的价值。结果42例患者容量反应（＋）22例，容量反应（-）组20例。两组患者基本临床资料比较差异无统计学意义。容量反应（＋）组患者HR、CVP在PLR前后差异无统计学意义（P〉0．05），MAP、VTI和SV在PLR后有显著升高（P〈0．05）；容量反应（-）组患者MAP、SV在PLR前后差异无统计学意义（P〉0．05），而HR、CVP和VTI在PLR后有显著升高（P〈0．05）；容量反应（＋）组患者PLR前后ΔVTI和ΔSV值明显高于容量反应（-）组（P〈0．05）；以PICCO监测容量负荷试验后SVI上升≥15％为标准，行PLR前后ΔVTI预测容量反应性的ROC曲线下面积为0．750（95％CI：0．593～0．907，P〈0．01），以ΔVTI15．6％为阈值，其灵敏度为63．6％，特异度为95．0％；ΔSV预测容量反应性的ROC曲线下面积为0．844（95％CI：0．716～0．972，P〈0．01），以ΔSV10．5％为阈值，其灵敏度为81．8％，特异度为85．0％。结论TTE监测PLR前后ΔVTI、ΔSV可用于预测自主呼吸状态下危重患者的容量反应性。

Objective To explore the value of predicting fluid responsiveness using velocity time index variation （ΔVTI） and stroke volume variation （ΔSV） before and after passive leg raising （PLR） monitored by bedside temporary test equipment （TTE）. Methods A cohort of 42 patients supported with mechanical ventilation in our hospital admitted from October 2014 to October 2015 were prospectively selected. The hemodynamic variables including heart rate （HR） , mean arterial pressure （MAP） , central venous pressure （CVP）, VTI, SV and other parameters were monitored before and after after undergoing PLR. Fluid resuscitation volume expansion test was carried out after stroke volume index （SVI） monitored by pulse indicator continuous cardiac output monitoring （PICCO）. Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to presence or absence of SVI ≥ 15% after fluid resuscitation volume expansion. Results Of 42 patients, 22 belonged to fluid responsiveness positive group, 20 got into fluid responsiveness negative group. There were no significant differences in basic clinical data between two groups. Before and after PLR, there were no distinct changes in HR and CVP （P 〉 0. 05 ）, while MAP, VTI and SV increased significantly （ P 〈 0. 05 ） after PLR in fluid responsiveness positive group. Contrarily, there were no noticeable changes in MAP and SV after PLR （P 〉 0. 05 ）, but HR, CVP and VTI increased significantly （ P 〈 0. 05 ） in fluid responsiveness negative group. The degrees of ΔVTI and ΔSV in fluid responsiveness positive group were much higher than those in fluid responsiveness negative group （P 〈 0.05）. According to SVI ≥15% monitored by PICCO after fluid resuscitation volume expansion test as a standard, the area under the ROC （AUC） of ΔVTI between pre- PLR and post-PLR was 0. 75 （95% CI： 0. 593 - 0. 907, P 〈 0. 01 ）, the sensitivity and specificity were 63.6% and 95% respectively using ΔVTI 15.6% as threshold value. The AUC of ΔSV was 0. 844 （95% CI： 0. 716 -0. 972, P 〈0. 01 ）, the sensitivity and specificity were 81.8% and 85.0% respectively using ΔSV 10. 5% as threshold value. Conclusion ΔVTI and ΔSV monitored by TTE before and after PLR could be employed for predicting fluid responsiveness of critical patients under the status of spontaneous respiration. Their value for prediction of critical patients could be further improved by combined employment of these two indexes of variation.