机械通气联合超声评估脓毒性休克患者容量反应性价值的研究

Evaluation of volume response value in patients with septic shock by mechanical ventilation combined with ultrasound

目的探讨机械通气联合超声评估脓毒性休克患者容量反应性的价值。方法采用前瞻性研究,根据制定的纳入及排除标准,纳入2016年10月至2018年2月就诊于新疆医科大学第一附属医院急诊重症监护室的脓毒性休克患者共59例。首先进行呼气末阻断试验(end-expiratory block test,EEO)和吸气末阻断试验(end-inhalation block test,EIO),然后进行容量负荷试验(volume expansion test,VE)(10 min内静滴生理盐水250 mL),VE后心脏指数(cardiac index,CI)变化值(ΔCI)≥15%为容量有反应组(37例),ΔCI<15%为容量无反应组(22例)。采用Vigileo-FloTrac系统持续监测EEO前后、EIO前后及VE前后中心静脉压(central venous pressure,CVP)、平均动脉压(mean arterial pressure,MAP)、CI、每搏变异度(stroke volume variation,SVV)等血流动力学指标的变化。超声检测下腔静脉直径(improved inferior vena cava diameter,IVCD),计算呼吸变异指数(respiratory variability index,RVI)。评价EEO、EIO前后CVP、MAP、SVV、CI、RVI的变化在预测容量反应性中的价值,以ROC曲线分析EEO、EIO中各项血流动力学指标与容量反应性的关系。结果MAP、CI在EEO、EIO及VE干预后的容量有反应组与无反应组之间比较,差异无统计学意义(P>0.05)。EEO-ΔSVV、EEO-ΔRVI、EEO-ΔCVP、EIO-ΔSVV及EIO-ΔRVI在容量有反应组与无反应组之间比较,差异有统计学意义(P<0.05)。相关性分析中EEO-ΔRVI、EIO-ΔRVI均和VE-ΔRVI有相关性(r=0.695,P<0.01;r=-0.489,P<0.01);EEO-ΔCVP和VE-ΔCVP有相关性(r=0.566,P<0.01);EEO-ΔSVV、EIO-ΔSVV均和VE-ΔSVV有相关性(r=0.842,P<0.01;r=-0.727,P<0.01);ROC曲线显示,AUCEEO-ΔSVV=0.890,95%CI:0.792~0.988,且AUCEEO-ΔSVV>AUCEEO-ΔRVI>AUCEIO-ΔSVV>AUCEIO-ΔRVI>AUCEEO-ΔCVP。结论EEO及EIO联合超声在脓毒性休克患者容量反应性的评估中有一定的临床应用价值,且SVV、RVI的评估价值优于CVP、MAP、CI。

Objective To evaluate the value of mechanical ventilation combined with ultrasound in evaluating the volume reactivity of patients with septic shock.Methods A prospective study was performed,and 59 patients with septic shock who were admitted to the Emergency Intensive Care Unit of the First Affiliated Hospital of Xinjiang Medical University from October 2016 to February 2018 were included according to the established inclusion and exclusion criteria.First,end-expiratory block test(EEO)and end-inhalation block test(EIO)were performed,followed by volume expansion test(VE)(intravenous infusion of 250 mL saline for 10 min),with cardiac index(CI)change value after VE(ΔCI)≥15%for volume-responsive group(37 cases),ΔCI<15%for volume-free group(22 cases),Vigileo-FloTrac system was used to continuously monitor EEO,EIO,and VE before and after changes in hemodynamic parameters,such as central venous pressure(CVP),mean arterial pressure(MAP),stroke volume variation(SVV),CI,and improved inferior vena cava diameter(IVCD)and respiratory variability index(RVI).The values of predicted capacity reactivity such as changes in CVP,MAP,SVV,CI,and RVI before and after EIO were evaluated,and the relationship between EEO,EIO,and capacity reactivity was analyzed by ROC curve.Results There was no significant difference between MAP and CI in the response group and non-response group after EEO,EIO and VE intervention(P>0.05).EEO-ΔSVV,EEO-ΔRVI,EEO-ΔCVP,EIO-ΔSVV and EIO-ΔRVI were compared between the reaction group and the non-reaction group,and the difference was statistically significant(P<0.05);In the correlation analysis,EEO-ΔRVI and EIO-ΔRVI were correlated with VE-ΔRVI(r=0.695,P<0.01;r=-0.489,P<0.01);EEO-ΔCVP and VE-ΔCVP were correlated(r=0.566,P<0.01);EEO-ΔSVV,EIO-ΔSVV are related to VE-ΔSVV(r=0.842,P<0.01;r=-0.727,P<0.01),and the ROC curve showed(AUCEEO-ΔSVV=0.890,95%CI:0.792-0.988),showed AUCEEO-ΔSVV>AUCEEO-ΔRVI>AUCEIO-ΔSVV>AUCEIO-ΔRVI>AUCEEO-ΔCVP.Conclusions EEO and EIO combined with ultrasound have certain clinical value in the evaluation of volume responsiveness in patients with septic shock,and the evaluation value of SVV and RVI is superior to CVP,MAP,and CI.