呼气末屏气试验联合肱动脉峰流速预测机械通气-休克患者容量反应性的价值

Value of end-expiratory occlusion tests combined with brachial artery peak velocity in predicting volume responsiveness of mechanically ventilated patients with shock

目的评价呼气末屏气(EEO)试验联合肱动脉峰流速(Vpeak-BA)能否作为判断机械通气-休克患者容量反应性的指标。方法选择2018年4月至2019年11月中国科学院大学附属肿瘤医院(浙江省肿瘤医院)重症医学科收治的行机械通气的40例休克患者,对所有入组患者序贯进行EEO试验和补液试验。记录所有患者的一般资料以及EEO试验前后和补液试验前后的左室流出道速度-时间积分(VTI)、Vpeak-BA,计算EEO试验前后的Vpeak-BA变化(△VBA-EEO)和VTI变化(△VTI-EEO)。将补液试验后VTI增加值≥15%的患者纳入有反应组(23例),否则纳入无反应组(17例)。采用受试者工作特征(ROC)曲线评价△VBA-EEO预测容量反应性的价值。结果EEO试验前,有反应组和无反应组患者Vpeak-BA[(48±4)cm/s vs.(55±5)cm/s]及VTI[(19.1±4.7)cm vs.(23.0±4.8)cm]比较,差异均有统计学意义(t=5.715、3.010,P均<0.05);有反应组患者EEO试验后Vpeak-BA[(56±6)cm/s vs.(48±4)cm/s]和VTI[(22.8±5.2)cm vs.(19.1±4.7)cm]均较EEO试验前显著升高(t=5.324、2.495,P均<0.05)。补液试验前,有反应组和无反应组患者Vpeak-BA[(48±4)cm/s vs.(54±5)cm/s]及VTI[(19.0±4.7)cm vs.(23.0±4.4)cm]比较,差异均有统计学意义(t=5.222、3.155,P均<0.05);有反应组患者补液试验后Vpeak-BA[(58±6)cm/s vs.(48±4)cm/s]、VTI[(23.5±5.0)cm vs.(19.0±4.7)cm]均较补液试验前显著升高(t=6.800、3.133,P均<0.05)。△VBA-EEO预测容量反应性的ROC曲线下面积(AUC)为0.830,95%置信区间(CI)(0.718,0.941),P<0.001;△VTI-EEO的AUC为0.887,95%CI(0.772,1.003),P<0.001。以△VBA-EEO≥12.5%为界值点,预测容量反应性的敏感度和特异度分别为82.6%和70.6%;以△VTI-EEO≥9.9%为界值点,预测容量反应性的敏感度和特异度分别为87.0%和88.2%。结论△VBA-EEO可以较准确地预测机械通气-休克患者的容量反应性,指导液体复苏治疗。

Objective To evaluate whether the brachial artery peak velocity(Vpeak-BA)induced by end-expiratory occlusion(EEO)tests can predict volume responsiveness of mechanically ventilated patients with shock.Methods From April 2018 to November 2019,40 patients with shock undergoing mechanical ventilation were selected from the Department of Critical Care Medicine,Cancer Hospital of the University of Chinese Academy of Sciences(Zhejiang Cancer Hospital).The sequential EEO and rehydration tests were performed on all enrolled patients.Their general data were recorded,as well as their left ventricle outflow tract velocity-time integral(VTI)and Vpeak-BA before and after the EEO and rehydration tests.The Vpeak-BA change(△VBA-EEO)and VTI change(△VTI-EEO)before and after the EEO test were calculated.Patients with a VTI increase of≥15% after the rehydration test were included in the response group(23 patients),otherwise they were included in the non-response group(17 patients).The receiver operating characteristic(ROC)curve was used to evaluate the value of△VBA-EEO in predicting volume responsiveness.Results Before the EEO test,the Vpeak-BA[(48±4)cm/s vs.(55±5)cm/s]and VTI[(19.1±4.7)cm vs.(23.0±4.8)cm]between the response group and non-response group were statistically significantly different(t=5.715,3.010;both P<0.05).The Vpeak-BA[(56±6)cm/s vs.(48±4)cm/s]and VTI[(22.8±5.2)cm vs.(19.1±4.7)cm]in the response group were significantly higher after the EEO test than before the EEO test(t=5.324,2.495;both P<0.05).Before the rehydration test,the Vpeak-BA[(48±4)cm/s vs.(54±5)cm/s]and VTI[(19.0±4.7)cm vs.(23.0±4.4)cm]between the response group and non-response group were statistically significantly different(t=5.222,3.155;both P<0.05).The Vpeak-BA[(58±6)cm/s vs.(48±4)cm/s]and VTI[(23.5±5.0)cm vs.(19.0±4.7)cm]in the response group were significantly higher after the rehydration test than before the rehydration test(t=6.800,3.133;both P<0.05).The area under the ROC curve(AUC)of △VBA-EEO for predicting volume responsiveness was 0.830[95% confidence interval(CI)(0.718,0.941),P<0.001],while the AUC of △VTI-EEO was 0.887[95%CI(0.772,1.003),P<0.001].Based on △VBA-EEO≥12.5%,its sensitivity and specificity of predicting volume responsiveness were 82.6%and 70.6%respectively.Furthermore,its sensitivity and specificity of predicting volume responsiveness were 87.0% and 88.2% respectively,using △VTI-EEO≥9.9% as the boundary point.Conclusion △VBA-EEO can relatively accurately predict the volume responsiveness of mechanically ventilated patients with shock and guide their fluid resuscitation therapy.