颈内静脉扩张指数预测脓毒症休克容量反应性的临床研究

Clinical study of internal jugular vein dilatation index in predicting septic shock volume responsiveness

目的探讨重症超声测量颈内静脉扩张指数(internal jugular vein dilation index,ΔIJV)联合被动抬腿试验(passive leg raising,PLR)预测脓毒性休克容量反应性中的价值。方法前瞻性选取2020年1月至2021年3月复旦大学附属金山医院急危重病中心ICU完全机械通气情况下诊断为脓毒症休克的患者为研究对象,将给予患者在30min内输入500mL晶体后,将“金标准”左心室搏出量(stroke volume,SV)提高15%为容量反应性阳性组,提高不足15%为容量反应阴性组。首先给予超声测量颈内静脉呼吸周期中最大前后径IJV_(max)、最小前后径IJV_(min),其次测量PLR前后的SV,最后给予快速输注500mL晶体后再次测量SV、IJV_(max)和IJV_(min),计算ΔIJV=(JIV_(max)-IJV_(min))/(IJV_(mean))×100%。采用Wilcoxon秩和检验比较扩容前后和PLR前后血流动力学指标;采用Spearman检验分析PLR后SV的变化率(ΔSV)和ΔUV与“金标准”的ΔSV之间相关性,通过绘制受试者功能曲线得出敏感度、特异度及相关截断值来评估ΔIJV和PLR在预测脓毒症患者容量反应性中的价值。结果研究共纳入56例患者,容量反应性试验后分为两组,有反应组为32例,无反应组为24例。扩容后ΔIJV与ΔSV呈正相关性(r=0.778,P<0.01);以ΔIJV>17.3%为阈值,其曲线下面积(area under the curve,AUC)为0.846(95%CI:0.716~0.977),敏感度为84.4%,特异度为83.3%。而PLR同ΔSV也呈正相关性(r=0.698,P<0.01),取PLR后ΔSV>15.5%为阈值,其AUC是0.895(95%CI:0.796~0.993),敏感度为96.9%,特异度为79.2%。当ΔIJV联合PLR预测容量反应性时,其AUC是0.944(95%CI:0.862~1.00),敏感度为99.8%,特异度为87.5%。结论应用床旁超声测量颈内静脉呼吸扩张指数是预测脓毒症患者容量反应性的可靠性指标,当联合PLR时可以提高预测的敏感度和特异度。

Objective To explore the value of severe ultrasound measurement of intermal jugular vein dilation index(ΔIJV)combined with passive leg raising(PLR)in predicting the volume responsiveness of septic shock.Methods Patients diagnosed with septic shock under complete mechanical ventilation in the ICU of Jinshan Hospital Affiliated to Fudan University from January 2020 to March 2021 were prospectively selected as the research objects.After 500 mL crystals were injected within 30 min,the patients having the"gold standard"left stroke volume(SV)increased by 15%were llocated to the volume response positive group,and patient having an SV increased by less than 15%to the volume response negative group.First,the maximum anterior posterior diameter(IJV_(max))and the minimum anterior posterior diameter(IJV_(min))in the respiratory cycle of internal jugular vein were measured by ultrasound,then SV before and after PLR was measured,and finally SV,IJV_(max) and IJV_(min) were measured again after rapid infusion of 500 mL crystals,and ΔIJV=(JIV_(max)-IJV_(min))/(IJV_(mean))×100%.The Wilcoxon rank-sum test was used to compare the hemodynamic indexes before and after capacity expansion and PLR.Spearman rank method was used to analyze the change rate of SV(ΔSV)after PLR and the correlation between ΔIJV and ΔSV of the"gold standard".The sensitivity,specificity and relevant cut-off values were obtained by drawing the subject function curve to evaluate the value of ΔIJV and PLR in predicting the volume responsiveness of patients with sepsis.Results A total of 56 patients were enrolled in the study,and they were divided into two groups:32 patients in the volume response positive group and 24 patients in the volume response negative group.There was a positive corelation between ΔIJV and ASV after capacity expansion(r=0.778,P<0.01).Taking ΔIJV>17.3%as the threshold,the area under the curve(AUC)was 0.846(95%CI:0.716~0.977),the sensitivity was 84.4%and the specificity was 83.3%.PLR was also positively correlated with ASV(r=0.698,P<0.01).Taking ΔSV>15.5% after PLR as the threshold,the AUC was 0.895(95%CI:0.796~0.993),the sensitivity was 96.9%,and the specificity was 79.2%.When ΔIJV combined with PLR predicted volume reactivity,the AUC was 0.944(95%CI:0.862~1.000),the sensitivity was 99.8% and the specificity was 87.5%.Conclusions The measurement of internal jugular vein respiratory dilation index by bedside ultrasound is a reliable index to predict volume responsiveness in patients with sepsis.When combined with PLR,the sensitivity and specificity of prediction can be improved.