重症心肺超声评估改变临床治疗的多因素分析——1913例患者的多中心、前瞻性研究

Impact of point-of-care cardiopulmonary ultrasound on treatment change in critically ill patients:assessment of 1913 cases in a multicentric,prospective study

目的阐述重症患者的心肺超声特征,并分析其影响临床治疗的相关因素。方法2018年1-12月纳入13家医院重症医学科收治的重症患者,进入重症医学科后24 h内完成重症心肺超声评估,包括有无显著的心脏结构异常、呼吸末下腔静脉宽度、右心室收缩功能、左心室收缩和舒张功能、肺部超声评分。根据评估后治疗计划清单上的选项是否改变分为治疗改变组和治疗未改变组,通过Logistic回归模型分析影响治疗改变的相关因素,包括患者、操作者及心肺超声指标3个方面。结果共纳入1913例重症患者,1204例(62.9%)患者的治疗发生改变,其中867例(72.0%)涉及液体管理策略。组间比较表明,患者的一般情况、操作者特征和重症心肺超声指标差异有统计学意义(均P<0.05)。Logistic回归分析表明,重症超声操作者为中级和高级职称(对比初级)、部属和大学附属教学医院(对比一般综合医院)是治疗改变的危险因素(均OR值>1,P<0.05);接受机械通气、呼气末下腔静脉宽度≤1 cm(对比1~2 cm)、左室射血分数<50%(对比≥50%)和肺部超声评分>6分(对比≤6分)的患者在重症心肺超声评估后,治疗改变的可能性下降(均OR值<1,P<0.05)。结论重症心肺超声评估后,重症患者治疗措施改变的发生率为62.9%,其中72.0%的治疗改变涉及液体管理方面。呼气末下腔静脉宽度、左心室收缩功能和肺部超声评分是影响重症超声评估后治疗改变的重症心肺超声指标。

Objective To describe the features of point-of-care cardiopulmonary ultrasound(POCUS)in the critically ill patients and analyze the independent factors associated with treatment changes after POCUS assessment.Methods This was a prospective multicentric observational study from January to December 2018 in 13 intensive care units(ICU)in China.Consecutive patients admitted to the ICU were enrolled,POCUS were performed within the first 24 h of admission.The POCUS parameters included acute or chronic cardiac abnormality,diameter of inferior vena cava(IVC)at end-expiration,right ventricular systolic function,systolic and diastolic function of left ventricle(LV)and lung ultrasound score.The general features of patients and performers were recorded.Based on the treatment proposed by the performer before and after POCUS assessment,the patients were divided into treatment changed and unchanged groups.Factors associated with treatment changes were identified by multiple logistic regression analysis.Results Totally 1913 patients were enrolled including 322(16.8%)patients with shock,638(33.3%)patients with respiratory failure,139(7.3%)patients with both shock and respiratory failure and 814(42.6%)perioperative patients.POCUS had contributed to treatment changes in 1204(62.9%)patients,including 867(72.0%)cases involved fluid management.Univariate analysis showed that there were significant differences in general characteristics of patients,performers and POCUS parameters between groups(all P<0.05).Logistic regression analysis showed that independent factors of treatment changes included ministry of education or university affiliated teaching hospitals(vs.general hospitals,OR=1.891,95%CI=1.314-2.722,P<0.001 and OR=1.644,95%CI=1.152-2.347,P=0.006 separately),middle and senior title performers(vs.primary title,OR=2.112,95%CI=1.358-3.284,P=0.001,OR=3.271,95%CI=2.129-5.025,P<0.001 separately),mechanical ventilation(vs.without,OR=0.488,95%CI 0.381-0.626,P<0.001),IVC diameter≤1 cm(vs.1-2 cm,OR=0.317,95%CI 0.231-0.434,P<0.001),LV ejecting fraction<50%(vs.≥50%,OR=0.328,95%CI=0.210-0.512,P<0.001),lung ultrasound score of 6-12 and>12 points(vs.score≤6 points,OR=0.237,95%CI=0.178-0.315,P<0.001 and OR=0.619,95%CI=0.457-0.837,P=0.002 separately).Conclusions POCUS assessment contributes to treatment changes,most of which involves fluid management strategy,in 62.9%critical patients.The independent influencing factors associated with POCUS parameters includes IVC diameter at end-expiratory,LV systolic function and lung ultrasound score.The performers′title and hospital grade also have a noticeable effect.