MostCare/PRAM仪监测下心脏不停跳冠状动脉旁路移植术患者的呼气末屏气试验容量反应性的应用研究

Volume responsiveness in end-expiratory occlusion test by PRAM/MostCare device in off-pump coronary artery bypass grafting patients

目的探讨MostCare/PRAM监测下补液试验(volume expansion,VE)验证的呼气末屏气试验(end-expiratory occlusion,EEO)的容量反应性在心脏不停跳冠状动脉旁路移植术患者中的诊断效能。方法40例行心脏不停跳冠状动脉旁路移植手术患者,应用MostCare/PRAM监测仪监测EEO和VE成组配对试验78组,将VE试验阳性50次和阴性28次对应的EEO试验分为有反应组50次和无反应组28次。记录VE及EEO试验开始后30 s(T1)和试验结束后30 s(T2)、1 min(T3)、1.5 min(T4)、2 min(T5)每博输出量(stroke volume,SV)等血流动力学指标变化率。以VE为金标准,绘制ROC曲线,评估EEO试验容量反应性在心脏不停跳冠状动脉旁路移植术患者中的诊断效能。结果EEO试验有反应组T1时SV变化率[6.59(3.85,9.56)%]明显低于VE阳性组[25.85(17.76,37.13)%](P<0.05);有反应组SVEEO-T1变化率、SVEEO-T2变化率、SVEEO-T3变化率高于无反应组(P<0.05),SVEEO-T4变化率和SVEEO-T5变化率与无反应组比较差异无统计学意义(P>0.05)。中心静脉压VE-基础值、每博量变异率VE-基础值、脉压变异率VE-基础值及SVEEO-T1变化率、SVEEO-T2变化率、SVEEO-T3变化率、SVEEO-T4变化率和SVEEO-T5变化率在心脏不停跳冠状动脉旁路移植术患者中诊断效能的AUC依次为0.368、0.664、0.717、0.852、0.755、0.703、0.637、0.554;SVEEO-T1变化率的AUC最大,其容量反应性的最佳截断值为3.75%时,灵敏度为76.00%,特异度为82.14%。结论低容量状态下冠状动脉旁路移植手术患者围手术期的EEO试验引起的容量效应明显小于VE;MostCare/PRAM监测下EEO容量反应性效应局限在EEO试验开始30 s内,试验结束后30 s及1、1.5、2 min的效应明显低下。

Objective To explore the diagnostic efficacy of volume responsiveness in end-expiratory occlusion(EEO)test verified by volume expansion(VE)test under the MostCare/PRAM continuous non-invasive cardiac output monitoring system in patients undergoing off-pump coronary artery bypass grafting(OPCABG).Methods Forty patients undergoing OPCABG received 78 sets of EEO and VE tests under MostCare/PRAM device.These patients were divided into responders group in 50 EEO tests and non-responders group in 28 EEO tests according to the results of paired 50 positive VE tests and 28 negative VE tests,respectively.The hemodynamic data of VE and EEO tests as stroke volume(SV)were recorded at T1(30 s after the beginning of EEO test),as well as T2,T3,T4 and T5(30 s,1 min,1.5 min and 2 min after the end of EEO test).ROC was used to evaluate the diagnostic efficacy of volume responsiveness in EEO on OPCABG by the golden standard of VE tests.Results The increase change rate of SV was lower at T1 in EEO responders group(6.59(3.85,9.56)%)than that in positive VE tests patients(25.85(17.76,37.13)%)(P<0.05).The increase change rate of SV was higher in EEO responders group at T1,T2 and T3 than that in non-responders group(P<0.05).And there was no significant difference in the increase change rate of SV between EEO responders group and non-responders group at T4 and T5(P>0.05).The AUC of central venous pressure,stroke volume variation,pulse pressure variation,and the increase change rates of SV at T1,T2,T3,T4 and T5 was 0.368,0.664,0.717,0.852,0.755,0.703,0.637 and 0.554 for the diagnostic efficacy on OPCABG,respectively.When the optimal cut-off of volume responsiveness was 3.75%,the AUC for the increase change rate of SV at T1 in EEO test was the greatest,with a sensitivity of 76.00%and a specificity of 82.14%.Conclusion In perioperative period of OPCABG,EEO may cause significantly less efficacy in volume responsiveness for hypovolemia patients than VE test.It is the increase change rate of SV in 30 safter the beginning of EEO test that could get the optimum diagnostic efficacy in volume responsiveness for EEO tests.And the increase change rates of SV in 30 s,1 min,1.5 min and 2 min after the end of EEO tests are obviously low.