每搏量变异度及脉搏压变异度在小儿腹腔镜手术中预测液体反应性的价值

Clinical value of stroke volume variation and pulse pressure variation in predicting fluid responsiveness in children undergoing laparoscopic surgery

目的探讨每搏量变异度(stroke volume variation, SVV)和脉搏压变异度(pulse pressure variation, PPV)在小儿腹腔镜手术中预测液体的准确性及阈值变化。方法选择拟在全麻下行小儿腹腔镜的手术患儿40例,全麻后连续监测HR、MAP、每搏量(stroke volume, SV)、每搏量指数(stroke volume index, SVI)、SVV、PPV等血流动力学指标,手术开始后进行气腹操作,待血流动力学稳定后进行容量负荷试验,分别于麻醉后气腹前(T_0)、气腹后(T_1)和补液试验结束后即刻(T_2)记录上述血流动力学指标数值,然后以输液前后每搏量指数的差值(ΔSVI)将患者分为2组,即有反应组(R组,ΔSVI≥10%)和无反应组(NR组,ΔSVI<10%),绘制SVV和PPV判断扩容效应的ROC曲线,确定患儿在腹腔镜手术中应用SVV和PPV预测容量状况的准确性、诊断阈值。结果与T_0时刻比较,T_1时刻HR、MAP、SVV、PVV等血流动力学参数均无明显变化(P>0.05)。与T_1时刻相比较,T_2时刻SVV、PVV均明显减小,差异有统计学意义(P<0.05),而SV、SVI、CO、CI明显增大(P<0.05),其他血流动力学指标,HR、MAP变化差异无统计学意义(P>0.05)。SVV和PPV判断扩容有效的ROC曲线下面积分别为0.822和0.916,SVV的诊断阈值为14.5%,灵敏度为80.2%,特异度为85.7%;PPV的诊断阈值为15.0%,灵敏度为88.5%,特异度为93.5%。结论 SVV和PPV均可用于预测小儿在腹腔镜气腹状态下的容量状况,PPV的准确性略高于SVV,但两者的诊断阈值较正常情况下成年患者均升高。

Objective To evaluate the abilities and thresholds of stroke volume variation（SVV） and pulse pressure variation（PPV） in predicting fluid responsiveness in children undergoing laparoscopic surgery. Methods Forty children,undergoing laparoscopic surgery were studied. SVV was continuously displayed by the Mostcare monitor, haemodynamic data such as MAP, HR, SVI, SVV and PPV were recorded before and after volume expansion（HES 6%,7 ml/kg）. Fluid responsiveness was defined as the increase in SVI≥ 10%. Results Compared with T0, hemodynamic parameters such as HR, MAP, SVV and PVV did not change significantly at T1（P〈0.05）. Compared with T1, SVV and PVV were decreased significantly at T2（P〈0.05）, but SV、SVI、CO and CI were significantly increased（P〈0.05）, and other hemodynamic parameters changes such as HR and MAP had no statistical significance（P〉0.05）. The SVV threshold of 14.5% before volume expansion was able to diacriminate the responders from the non-responders with a sensitivity of 80.2%, and a specificity of 85.7%. The threshold for PPV was 15.0%, with a sensitivity of 88.5% and specificity of 93.5%. The area under the receiver operating characteristics（ROC） curves of SVV and PPV were 0.812 and 0.921. Conclusion SVV and PPV could predict fluid responsiveness in children undergoing laparoscopic surgery, but the threshold values of both are changed.