被动抬腿试验结合颈总动脉峰流速变异度预测保留自主呼吸机械通气的重症脓毒症患者的容量反应性

Cephalic artery peak velocity variation during passive leg raising can predict fluid responsiveness in mechanically ventilated severe sepsis patients with spontaneous breathing

目的探讨被动抬腿试验（PLR）前后颈总动脉峰流速的变异度（ΔVpeakCA－PLR）能否有效预测保留自主呼吸机械通气的重症脓毒症患者的容量反应性。方法选取福建省立医院重症医学四科2017年1至12月收治的行机械通气且存在自主呼吸的严重脓毒症或脓毒性休克患者38例，应用床边超声机测量PLR前后颈总动脉峰流速（VpeakCA）的值，计算ΔVpeakCA－PLR，随后进行容量负荷试验（VE），超声监测每搏输出量（SV）在VE前后的变化（ΔSV－VE），以ΔSV－VE≥15%的为有容量反应性并纳入有反应组，ΔSV－VE〈15%的纳入无反应组。另外，应用受试者工作特征曲线（ROC）分析ΔVpeakCA－PLR对容量反应性的预测价值。组间差异对比采用成组t检验，相关性分析采用Pearson检验。结果共有38例患者，其中有反应组纳入22例，无反应组的16例。两组患者年龄、性别、体质指数、感染部位、感染相关器官功能衰竭评分、急性生理学与慢性健康状况评分系统评分、呼吸机参数及血管活性药物走速等基线资料具有可比性。有反应组的ΔVpeakCA－PLR较无反应组明显升高（15.7%±4.2%比6.9%±4.3%，t＝6.240，P〈0.05），且ΔVpeakCA－PLR与ΔSV－VE呈正相关（r＝0.723，P〈0.05）。ΔVpeakCA－PLR评估容量反应性的曲线下面积为0.912，以ΔVpeakCA－PLR≥12.2%时评估脓毒症患者容量反应性，敏感度为81.8%，特异度为87.5%。结论超声测量被动抬腿试验前后颈总动脉峰流速的变异度可以用于预测保留自主呼吸机械通气的重症脓毒症患者的容量反应性，指导液体复苏治疗。

ObjectiveTo explore whether cephalic artery peak velocity variation during passive leg raising （ΔVpeakCA-PLR） could effectively predict fluid responsiveness in mechanically ventilated severe sepsis patients with spontaneous breathing.MethodsTotal of 38 patients on mechanical ventilation with spontaneous breathing admitted to the Fourth Departments of Intensive Care Unit （ICU） of Fujian Provincial Hospital from January to December in 2017 were enrolled.The patients were diagnosed with severe sepsis or sepsis shock.The peak velocity in cephalic artery （VpeakCA） during PLR was measured by bedside portable ultrasonic, and then ΔVpeakCA-PLR was calculated.All patients received volume expansion （VE） test and the changes of stroke volume during VE test （ΔSV-VE） were measured.Patients were classified as responsive group or non-responsive group according to the ΔSV-VE increased ≥15% or not after VE test.Furthermore, the sensitivity and specificity of ΔVpeakCA-PLR for predicting fluid responsiveness were evaluated by receiver operating characteristic （ROC） curve.The comparisons between groups were performed with Student′s unpaired two-tailed t test, and Pearson′s test was used for the correlation analysis.ResultsAmong the patients, 22 cases responded to VE test and the rest 16 cases did not.There were no significantly differences in age, gender, body mass index, infection site, sepsis-related organ failure assessment score, acute physiology and chronic health evaluation Ⅱ score, ventilator parameters and dose of vasoactive agent between the two groups.The ΔVpeakCA-PLR in responsive group was markedly higher than that in non-responsive group （15.7%±4.2% vs 6.9%±4.3%, t=6.240, P〈0.05）, and the ΔVpeakCA-PLR in the responsive group was positively related to the ΔSV-VE （r=0.723, P〈0.05）. Furthermore, the area of ΔVpeakCA-PLR under ROC curve was 0.912.The sensitivity and specificity of ΔVpeakCA-PLR≥12.2% to predict fluid responsiveness in the patients with sepsis were 81.8% and 87.5%, respectively.ConclusionΔVpeakCA-PLR measured by bedside portable ultrasonic can predict the fluid responsiveness in mechanically ventilated severe sepsis patients with spontaneous breathing, and it can be used to guide further fluid resuscitation.