超声监测下腔静脉参数预测椎管内麻醉后容量状态及容量反应性的价值

Predictive value of inferior vena cava ultrasonography for fluid status and responsiveness after spinal anesthesia

目的探讨超声监测下腔静脉参数预测椎管内麻醉后低血压发生的价值,并比较各参数评估椎管内麻醉后患者容量反应性的意义。方法选择2018年1月至10月广东省中医院在腰硬联合麻醉下行择期手术的患者100例。麻醉前(T1)、麻醉后10 min(T2)及麻醉后30 min(T3)应用经胸超声心动图测量每搏输出量(SV)、下腔静脉呼气末最大直径(IVCe)、吸气末最小直径(IVCi)和腹主动脉直径(Ao),计算下腔静脉塌陷指数(IVC-CI)、IVCe与Ao(IVCe/Ao)的比值。麻醉后10 min进行容量负荷试验,以容量负荷试验后SV的增加量(ΔSV)将患者分为容量治疗有反应组(ΔSV≥15%)和容量治疗无反应组(ΔSV<15%)。采用受试者工作特征(ROC)曲线评价下腔静脉参数预测椎管内麻醉后低血压发生的可靠性,及预测椎管内麻醉后容量反应性的价值。结果入组100例,脱落18例,最终纳入研究82例,其中容量治疗有反应组39例,无反应组43例。(1)容量负荷试验前,两组SBP、IVCe、IVCi、IVC-CI、IVCe/Ao差异有统计学意义(P<0.05);容量负荷试验后,有反应组以上数据接近无反应组,差异无统计学意义(P>0.05)。容量负荷试验后,有反应组SV高于无反应组,差异有统计学意义(P<0.05)。(2)容量治疗有反应组低血压发生率高于无反应组(51.28%vs 11.63%,χ~2=15.174,P<0.01)。(3)麻醉前IVCe、IVCi、IVC-CI和IVCe/Ao预测椎管内麻醉后低血压发生的AUC分别为0.78、0.79、0.70和0.84,四个参数预测椎管内麻醉后低血压的发生均有统计学意义(P<0.05)。(4)椎管内麻醉后10 min测量IVCe、IVCi、IVC-CI和IVCe/Ao,预测容量治疗有反应的AUC分别为0.62、0.71、0.70和0.72,其中IVCi、IVC-CI和IVCe/Ao三个参数预测容量治疗反应有统计学意义(P<0.05)。结论麻醉前IVCe、IVCi、IVC-CI和IVCe/Ao可预测椎管内麻醉后低血压的发生,IVCi、IVC-CI和IVCe/Ao可预测椎管内麻醉后患者的容量反应性,其中IVCe/Ao预测效能较好,是预测椎管内麻醉后低血压和评估容量反应性较为可靠的参数。

Objective To explore the value of ultrasound parameters of inferior vena cava(IVC)in predicting hypotension and the significance of each parameter in evaluating fluid responsiveness of patients after spinal anesthesia.Methods A total of 100 patients from January 2018 to October 2018 scheduled for elective surgery under combined spinal epidural anesthesia were recruited.Before anesthesia(T1),10 min after anesthesia(T2)and 30 min after anesthesia(T3),stroke volume(SV),maximum end-expiratory diameter of inferior vena cava(IVCe),minimum end-inspiratory diameter of inferior vena cava(IVCi)and aorta diameter(Ao)were measured by transthoracic echocardiography(TTE),and IVC collapsibility index(IVC-CI)and IVCe/Ao were calculated.According to the increase of SV(ΔSV)after volume loading test performed at T2,the patients were divided into the response group(ΔSV≥15%)and the non-response group(ΔSV<15%).Receiver operating characteristic(ROC)curve was used to evaluate the values of IVC parameters in predicting hypotension and volume responsiveness after spinal anesthesia.Results In 100 patients,18 were lost,and there were 39 cases in response group and 43 cases in non-response group.There were statistical differences in SBP,IVCe,IVCi,IVC-CI and IVCe/Ao before volume loading test(P<0.05)and in SV after volume loading test between two groups(P<0.05).The incidence of hypotension in the volume treatment response group was higher than that in the non-response group(51.28%vs 11.63%,χ2=15.174,P<0.01).AUC for IVCe,IVCi,IVC-CI and IVCe/Ao in predicting hypotension after intraspinal anesthesia were 0.78,0.79,0.70 and 0.84 respectively,all with statistically significant in predicting.There was a significant difference in the incidence of hypotension after anesthesia between two groups(P<0.05).AUC for IVCe,IVCi,IVC-CI and IVCe/Ao in predicting volume responsiveness 10 min after intraspinal anesthesia were 0.62,0.71,0.70 and 0.72,and IVCi,IVC-CI and IVCe/Ao were statistically significant in predicting volume responsiveness(P<0.05).Conclusion IVCe,IVCi,IVC-CI and IVCe/Ao can predict the occurrence of hypotension after intraspinal anesthesia.IVCi,IVC-CI and IVCe/Ao can predict the volume responsiveness.IVCE/Ao has better predictive effect and is a more reliable parameter for predicting hypotension and evaluating volume responsiveness after intraspinal anesthesia.