床旁即时超声测量动脉峰流速呼吸变异度评价危重症患者容量反应性的Meta分析

Diagnostic accuracy of artery peak velocity variation measured by bedside real-time ultrasound for prediction of fluid responsiveness:a Meta-analysis

目的应用系统评价的方法评估床旁即时超声测量动脉峰流速呼吸变异度(ΔVpeak)对危重症患者容量反应性的评估价值。方法检索美国国立医学图书馆PubMed数据库、荷兰医学文摘Embase数据库、Cochrane图书馆数据库、中国生物医学文献服务系统(SinoMed)、万方数据、中国知网(CNKI)和维普数据库(VIP)从建库至2019年11月发布的关于ΔVpeak判断容量反应性的相关文献。由2名研究员依据纳入和排除标准对相关文献进行筛选,并对纳入文献进行资料提取,应用诊断准确性研究质量评价量表(QUADAS)进行文献质量评价。应用Meta Dics 1.4软件对符合质量标准的文献进行Meta分析,计算合并的敏感度、特异度、阳性似然比(PLR)、阴性似然比(NLR)和诊断优势比(DOR)等,绘制合并受试者工作特征曲线(SROC)并计算SROC曲线下面积(AUC);采用χ^2检验及Spearman相关系数进行异质性分析,采用Deek检验法分析文献发表偏倚。结果共纳入31项研究,总计1854例接受床旁即时超声ΔVpeak检测的患者,包括11项国内研究、20项国外研究。用QUADAS 14个条目进行文献质量评价显示,纳入文献均为A级,说明文献整体质量较高。SROC曲线平面散点分布不呈"肩臂形",Spearman相关系数为0.062(P=0.710),认为其不存在阈值效应;异质性检验提示I^2=57.2%(P=0.001),说明各研究间存在一定异质性,且该异质性来源为非阈值效应;Meta回归分析显示,补液试验方法是造成异质性的原因〔DOR=3.87,95%可信区间(95%CI)为1.56~9.57,P=0.0048〕。根据异质性分析结果,剔除用被动抬腿试验(PLR)代替容量负荷试验的研究后,各研究间无明显异质性(I^2=10.6,P=0.2885)。应用随机效应模型进行Meta分析显示,合并DOR为23.85(95%CI为17.57~32.37),合并敏感度为0.82(95%CI为0.80~0.85),合并特异度为0.83(95%CI为0.80~0.85),合并PLR为4.17(95%CI为3.58~4.86),合并NLR为0.22(95%CI为0.18~0.28),AUC为0.9012(95%CI为0.88~0.93),Q指数为0.8325。Deek漏斗图分析结果显示,纳入研究无发表偏倚(P=0.19)。结论床旁即时超声测量ΔVpeak对患者容量反应性具有较高的评估价值,是评估休克、危重症及外科手术等需要监测容量反应性人群的可靠参数。

Objective To evaluate the diagnostic value of ultrasonic measurement of artery peak velocity variation(ΔVpeak)on predicting fluid responsiveness in critically ill patients.Methods Databases of PubMed,Embase,Cochrane Library,SinoMed,Wanfang,CNKI and VIP were retrieved from the establishment of the database to November 2019.The retrieval literatures were about the research ofΔVpeak used to judge fluid responsiveness.According to the inclusion and exclusion criteria,the relevant literatures were screened by two researchers,and the data of the included literatures were extracted.The quality of literatures was evaluated by quality assessment of diagnostic accuracy studies(QUADAS).Meta Dics 1.4 software was used to analyze the literatures that met the quality standard by Meta-analysis.The pooled sensitivity,specificity,positive likelihood ratio(PLR),negative likelihood ratio(NLR)and diagnostic odds ratio(DOR)were calculated.The summary receiver operating characteristic(SROC)curve was drawn and the area under SROC curve(AUC)was calculated.Theχ^2 test and Spearman correlation coefficient were used to analyze heterogeneity,and Deek test was used to analyze publication bias.Results A total of 1854 patients were enrolled in 31 studies,including 11 domestic studies and 20 foreign studies.Using 14 items of QUADAS to evaluate the quality of literatures,it was found that the enrolled literatures were all in Grade A,indicating that the overall quality of literatures was high.The scattered distribution of SROC curve was not"shoulder arm shape",and Spearman correlation coefficient was 0.062(P=0.710),so there was no threshold effect.The heterogeneity test showed that I^2=57.2%(P=0.001),indicating that there was a certain degree of heterogeneity among the studies,and the source of heterogeneity was non threshold effect.Meta regression analysis showed that the reason for heterogeneity was the method of volume load test[DOR=3.87,95%confidence interval(95%CI)was 1.56-9.57,P=0.0048].According to the results of heterogeneity analysis,there was no significant heterogeneity(I^2=10.6,P=0.2885)among the studies after removing the samples of the passive leg raising(PLR)instead of the volume expansion.A meta-analysis was done with random effects model.The results showed that the pooled DOR was 23.85(95%CI was 17.57 to 32.37),pooled sensitivity was 0.82(95%CI was 0.80 to 0.85),pooled specificity was 0.83(95%CI was 0.80 to 0.85),pooled PLR was 4.17(95%CI was 3.58 to 4.86),and pooled NLR was 0.22(95%CI was 0.18 to 0.28).The AUC was 0.9012(95%CI was 0.88 to 0.93),and Q index was 0.8325.The results of Deek funnel plot showed that there was no published bias in all the studies(P=0.19).Conclusions Ultrasonic measurement ofΔVpeak has a high value in predicting fluid responsiveness.It is a reliable parameter for the evaluation of shock,critical illness and surgical operation population who need to monitor the fluid responsiveness.