超声监测下腔静脉变异度联合肺复张评估机械通气患者急性循环衰竭容量反应性的应用价值

Application value of ultrasound monitoring of inferior vena cava variability combined with lung recruitment maneuver in evaluating volumetric responsiveness in acute circulatory failure patients with mechanical ventilation

目的探讨超声监测下腔静脉变异度(ΔIVC)联合肺复张在机械通气患者急性循环衰竭容量反应性评估中的应用价值。方法选取我院重症监护病房收治的急性循环衰竭且需机械通气的患者53例,依次完成肺复张和容量负荷试验,应用脉搏指示剂连续心排血量监测仪分别测量患者肺复张前、肺复张时平均动脉压(MAP)、中心静脉压(CVP)、每搏变异度(SVV)、全心舒张末容积指数(GEDI)、心脏指数和肺复张后心脏指数变化率(ΔCILRM),以及容量负荷试验后心脏指数变化率(ΔCIVE)等血流动力学参数;应用超声测量肺复张时下腔静脉直径并计算ΔIVC。将患者分为有反应组(ΔCIVE≥15%)28例和无反应组(ΔCIVE<15%)25例,比较两组上述参数的差异;分析上述血流动力学参数与ΔIVC的相关性;绘制受试者工作特征(ROC)曲线分析各参数预测容量反应性的效能。结果两组肺复张时SVV均高于肺复张前,肺复张前和肺复张时有反应组SVV均高于无反应组,肺复张时有反应组下腔静脉直径差值(ΔDIVC)和ΔIVC均高于无反应组,差异均有统计学意义(均P<0.05)。相关性分析显示,肺复张时MAP与ΔIVC呈负相关(r=-0.279,P=0.043),SVV、ΔCILRM、ΔCIVE与ΔIVC均呈正相关(r=0.409、0.807、0.800,P=0.002、0.000、0.000),ΔCILRM与ΔCIVE呈正相关(r=0.894,P=0.000),CVP、GEDI与ΔIVC无相关性。ROC曲线分析显示,肺复张时SVV、ΔIVC和ΔDIVC预测容量反应性的曲线下面积分别为0.891、0.770、0.747,当SVV截断值为14.5%,其敏感性为60.7%,特异性为100%;当ΔIVC截断值为12.9%,其敏感性为78.6%,特异性为72.0%;当ΔDIVC截断值为0.25 cm,其敏感性为46.4%,特异性为88.0%。结论应用超声监测ΔIVC联合肺复张可较准确地预测机械通气患者急性循环衰竭的容量反应性,具有重要的临床价值。

Objective To investigate the application value of ultrasound monitoring of inferior vena cava variability(ΔIVC)combined with lung recruitment maneuver in evaluating volume responsiveness in acute circulatory failure patients with mechanical ventilation.Methods Fifty-three patients with acute circulation failure requiring mechanical ventilation in intensive care unit of our hospital were enrolled.Lung recruitment maneuver and volume expansion(VE)were performed successively.The hemodynamic parameters including mean arterial pressure(MAP),central venous pressure(CVP),stroke volume variation(SVV),global end-diastolic volume index(GEDI),cardiac index(CI)before and during lung recruitment maneuver and the variation ratio in cardiac index after lung recruitment maneuver(ΔCILRM)were measured by pulse indicator continuous cardiac output monitor.ΔIVC and infenior vena cave diameter during lung recruitment maneuver were calculated by ultrasound.The patients were divided into the reaction group(ΔCIVE≥15%,28 cases)and non-reaction group(ΔCIVE<15%,25 cases),the differences of the above hemodynamic parameters between the two groups were compared.The correlations between the above hemodynamic parameters andΔIVC were analyzed.The receiver operation characteristic(ROC)curve was drawn and the efficacy of each parameter in predicting the volume responsiveness was analyzed.Results Both in reaction group and nonreaction group,SVV at the time of lung recruitment maneuver was higher than that before lung recruitment maneuver(P<0.05).SVV of the reaction group was significantly higher than that of the non-reaction group before and during lung recruitment maneuver(both P<0.05).ΔDIVC andΔIVC of the reaction group were significantly higher than those of the non-reaction group during lung recruitment maneuver(both P<0.05).During lung recruitment maneuver,MAP was negatively correlated withΔIVC(r=-0.279,P=0.043),and SVV,ΔCILRM,ΔCIVE were positively correlated withΔIVC(r=0.409,0.807,0.800,P=0.002,0.000,0.000),ΔCILRM was positively correlated withΔCIVE(r=0.894,P<0.05),while CVP and GEDI were no correlation withΔIVC.ROC curve analysis showed that the area under the curve of SVV,ΔIVC andΔDIVC during lung recruitment maneuver for predicting volumetric responsiveness were 0.891,0.770,0.747,respectively.When the cut-off value of SVV was 14.5%,the sensitivity was 60.7%,and the specificity was 100%.When the cut-off value ofΔIVC was 12.9%,the sensitivity was 78.6%,and the specificity was 72.0%.When the cut-off value ofΔDIVC was 0.25 cm,the sensitivity was 46.4%,and the specificity was 88.0%.Conclusion Ultrasound monitoring ofΔIVC combined with lung recruitment maneuver could accurately predict volume responsiveness in acute circulation failure patients with mechanical ventilation,which has important clinical value.