超声下腔静脉预测容量反应性和容量状态的临床应用

The clinical pplication of ultrasound inferior vena cava in prediction of volume responsiveness and volume status

目的 观察超声下腔静脉(IVC)预测容量反应性和容量状态的能力。方法 选取2017年2~12月在中国人民解放军联勤保障部队第九〇〇医院行择期手术的全麻患者140例。麻醉诱导前超声测量IVC呼吸周期的最大直径(dIVC_(max))和塌陷指数(cIVC),观察麻醉诱导后补液前后每搏输出量(SV)的变化判断是否存在容量反应性。根据机械通气下补液前超声测量IVC呼吸周期的最大直径(dIVC_(max))和扩张指数(dIVC),以及同一时间的每搏变异度(SVV)值判定患者的容量状态。若SVV>12%,250 mL胶体液在15 min内输注完毕,SV增加≥10%,则归为容量反应性阳性组,反之为阴性组。机械通气下补液前若SVV≤12%,归为容量状态充足组,反之为容量不足组。记录患者于入手术室时(T1)、插管前即刻(T_2)、插管成功即刻(T_3)、插管后1 min(T_4)、补液前(T_5)、补液后(T_6)的SBP、DBP、HR;记录T_2~T_6的SV、SVV。采用受试者特征(ROC)曲线分析超声IVC预测容量状态和容量反应性的能力,以及运用灰色区域法来确定超声IVC的可疑范围。结果 容量反应性:容量反应性阳性组插管后1 min(T_4)、补液前(T_5)的SV明显均低于阴性组,差异具有统计学意义(P<0.05);容量反应阳性组和阴性组不同时间的SBP、DBP、HR、SV、SVV存在时间效应(P<0.05);且两组不同时间点的SV存在交互效应(P<0.05);cIVC和dIVC_(max)的曲线下面积(AUC)分别为0.86和0.71,最佳截止点分别为41%和1.8 cm;灰色区域范围分别为38%~43%和1.7~1.9 cm。容量状态:麻醉诱导后,容量充足组患者的SBP、SV均明显高于容量不足组,SVV明显低于容量不足组,差异有统计学意义(P<0.05);两组不同时间的SBP、DBP、HR、SV存在时间效应(P<0.05);两组不同时间点的SVV存在组间、时间及交互效应(P<0.05);dIVC的AUC为0.85,dIVC_(max)的AUC为0.75,最佳截止点分别是12%和1.9 cm;灰色区域范围分别是12%~16%和1.7~2.0 cm。结论 麻醉诱导前超声测量下腔静脉有助于预测机体的容量反应性和容量状态,而且cIVC预测容量反应性的能力胜于dIVCmax,dIVC预测容量状态的能力胜于dIVCmax。

Objective To predict volume responsiveness and volume status by observing the ultrasound inferior vena cava(IVC).Meth-ods A total of 140 patients undergoing elective surgery under general anesthesia at the 900th Hospital of the Joint Service Support Force of the Chinese People's Liberation Army from February to December 2017 were selected.Before anesthesia induction,the maximum diameter(dI-VCmax)and collapse index(cIVC)of the IVC respiratory cycle were measured by ultrasound,and the changes in stroke output(SV)before and after fluid infusion after anesthesia induction were observed to determine whether there was volume responsiveness.The volume status of the patient was determined based on the maximum diameter(dIVCmax)and dilation index(dIVC)of the IVC respiratory cycle measured by ultra-sound before fluid replacement under mechanical ventilation,as well as the stroke variability(SVV)value at the same time.If SVV>12%,250 mL of colloidal solution was infused within 15 minutes,and SV increased by≥10%,it was classified as a volumetric reactivity positive group,and vice versa.If SVV≤12%before fluid replacement under mechanical ventilation,it was classified as the group with sufficient capacity,and vice versa,it was classified as the group with insufficient capacity.Record the SBP,DBP,and HR of the patients were recorded at the time of admission to the operating room(T1),immediately before intubation(T2),immediately after successful intubation(T3),1 minute after intuba-tion(T4),before fluid replacement(T5),and after fluid replacement(T6);Record SV and SVV of T2 to T6 were recorded.The ability of ultra-sound IVC to predict volume status and volume responsiveness was analyzed using subject characteristic(ROC)curves,and the gray area method was used to determine the suspicious range of ultrasound IVC.Results Volume reactivity:SV in the positive volume reactivity group was significantly lower than that in the negative group at 1 min(T4)after intubation and before fluid replacement(T5),with a statistically sig-nificant difference(P<0.05);There was a time effect on SBP,DBP,HR,SV,and SVV in the positive and negative volumetric reaction groups at different times points(P<0.05);There was an interaction effect between SV at different time points in the two groups(P<0.05);The area under curve(AUC)of cIVC and dIVCmax was 0.86 and 0.71,respectively,with the optimal cutoff points of 41%and 1.8 cm,respectively;The gray area ranged from 38%to 43%and from 1.7 to 1.9 cm,respectively.Volume status:After anesthesia induction,the SBP and SV of patients in the volume sufficient group were significantly higher than those in the volume insufficient group,and the SVV was significantly lower than that in the volume insufficient group,with a statistically significant difference(P<0.05);There was a time effect on SBP,DBP,HR,SV at different times points in the two groups(P<0.05);There were inter group,time,and interaction effects on SVV at different time points in the two groups(P<0.05);The AUC of dIVC was 0.85,and the AUC of dIVCmax was 0.75.The optimal cutoff points are 12%and 1.9 cm,respectively;The gray area ranged from 12%to 16%and from 1.7 to 2.0 cm,respectively.Conclusions Ultrasound measurement of the inferior vena cava before an-esthesia induction can help predict the volume responsiveness and volume status of the body,and the ability of cIVC to predict volume respon-siveness is better than that of dIVCmax,and the ability of dIVC to predict volume status is better than that of dIVCmax.