超声测量下腔静脉参数对高龄患者术中容量治疗的指导价值

Ultrasound Measurement of Respiratory Variability Index of Inferior Vena Cava for the Perioperative Volume Load Prediction in Elderly Patients with General Anesthesia

目的探讨超声定量检测下腔静脉内径呼吸变异度(respiratory variability index of inferior vena cava,IVC-RVI)对高龄外科手术患者全身麻醉围术期容量治疗的临床指导价值。方法选择90例在海南医学院第二附属医院择期行外科手术治疗的高龄患者,根据术中患者中心静脉压(central venous pressure,CVP)分为:低容量组(共28例,CVP≤5 cmH2O)(1 cmH2O=0.098 kPa)、正常容量组(共30例,5 cmH2O<CVP<12 cmH2O)和高容量组(共32例,CVP≥12 cmH2O)。在术前30 min(T0)、术中1h(T1)、手术结束前30 min(T2)、拔管前10 min(T3)和拔管后30 min(T4)5个时间点行超声检测,比较三组IVC-RVI、平均动脉压(mean arterial pressure,MAP)、中心静脉压(central venous pressure,CVP)等指标。应用Pearson相关性检验分析IVC-RVI与MAP和CVP的相关性。应用多元Logistic回归分析判断与高龄患者低血压发生相关的危险因素。绘制受试者工作特征曲线(receiver operating characteristic curve,ROC)评估下腔静脉参数对高龄患者术中麻醉容量治疗疗效的指导价值。结果T0时三组患者IVC-RVI与CVP值比较无差异(P>0.05);T1与T2时正常容量组IVC-RVI高于高容量组,且低于低容量组(P<0.05),而正常容量组CVP值低于高容量组,但高于低容量组(P<0.05);T3与T4时间点三组IVC-RVI与CVP值比较无差异(P>0.05)。Pearson相关分析显示术中1 h患者IVC-RVI分别与MAP及CVP呈负相关(r=-0.825,P=0.025;r=-0.912,P=0.009)。多元Logistic回归分析显示,IVC-RVI为外科手术全身麻醉高龄患者容量负荷相关保护因素(OR=0.453,P=0.022),而CVP为危险因素(OR=2.872,P=0.020)。ROC曲线显示,IVC-RVI截断值为57.2%,评估高龄患者术中麻醉发生低血压的AUC为0.854,敏感度为88.5%,特异度为79.2%。结论高龄手术患者术中超声检测IVC-RVI对评估全身麻醉围术期容量负荷和指导液体输入有较好的应用价值。

Objective To analyze the quantitative measurement of respiratory variability index of inferior vena cava(IVC-RVI)by transthoracic Doppler ultrasound for systemic volume evaluation and guidance of fluid input in elderly patients undergoing elective surgery during the perioperative period of general anesthesia.Methods There were 90 elderly patients with general anesthesia of our hospital collected for the perspective study.All elderly patients were divided into three groups according to the patients'central venous pressure(CVP)value,including the low volume group(28 cases,CVP≤5 cmH2O)(1 cmH2O=0.098 kPa),the normal volume group(30 cases,5 cmH2O<CVP<12 cmH2O)and the high volume group(32 cases,CVP≥12 cmH2O).The index of respiratory variability index of inferior vena cava(IVC-RVI),mean arterial pressure(MAP),central venous pressure(CVP)of elderly patients in three groups were collected by ultrasonography at 30 min pre-operation(T0),1h peri-operation(T1),30 min before the end of operation(T2),10 min pre-extubation(T3)and 30 min post-extubation(T4).The correlations of IVC-RVI to MAP and CVP were confirmed by Pearson linear correlation analysis.The risk factors of occurrence of hypotension of elderly patients with general anesthesia to the clinical indexes were confirmed by multivariate Logistic analysis.The diagnostic value of the IVC-RVI to the occurrence of hypotension of the elderly patients with general anesthesia was analyzed by receiver operating characteristic curves(ROC).Results There was no difference among three groups of the levels of IVC-RVI and CVP at the time-point of T0(P>0.05).At the time-points of T1 and T2,the levels of IVC-RVI in the normal volume group were higher than that of the high volume group,but lower than that of the low volume group(P<0.05);the levels of CVP of the normal volume group were lower than that of the high volume group,but higher than that of the low volume group(P<0.05).There was no different in the levels of IVC-RVI and CVP at the time-points of T3 and T4 among three groups(P>0.05).The negative correlations of IVC-RVI to MAP and CVP were confirmed by Pearson linear correlation analysis(r=-0.825,P=0.025;r=-0.912,P=0.009).Multivariate Logistic analysis showed that the IVC-RVI was the protective factor for the occurrence of hypotension of elderly patients with general anesthesia(OR=0.453,P=0.022),and the CVP was the risk factors(OR=2.872,P=0.020).When the cut-off point of IVC-RVI level was 57.2%,the AUC of predictions to the occurrence of hypotension of elderly patients with general anesthesia was 0.854 with the sensitivity of 88.5%and specificity of 79.2%.Conclusion It proves that the evaluation of IVC-RVI with ultrasound in elderly general anesthesia patients has good value in detection of volume load and in guidance of perioperative fluid input.