Variations in the bifurcation level of the abdominal aorta, formation level of the inferior vena cava, and insertion level of the left renal vein into the inferior vena cava and their clinical importance in laparoscopic surgery

Objective: It is important to minimize the risk of major vascular injury during pneumoperitoneumestablishment in laparoscopic surgeries for patients with unusual variations in the levels of theabdominal aorta, the inferior vena cava (IVC), and the left renal vein, which will decrease the morbidityand mortality. The study aims to assess the variations regarding the bifurcation level of the abdominalaorta, formation level of the IVC, and insertion level of the left renal vein into the IVC.Methods: This retrospective study was conducted on 100 patients (50 males and 50 females) referred tothe Department of Radiology, Jordan University Hospital for abdomino-pelvic CT with intra-venouscontrast from January 2018 to December 2019. The three vessels were determined on the axial plane,the coronal plane, and the midsagittal plane. The central vertebral body height as well as the distance ofthe level of the point of interest to the upper end plate of the vertebrae were measured. Afterwards, theresults were classified into the following categories, upper end plate, lower end plate, intervertebral disc,upper half, and lower half of the vertebra.Results: The aortic bifurcation was mainly found at the level of the L4 vertebral body (65, 65%). In theremaining cases, the bifurcation was found to be variably located spanning from L3 in 11 (11%) cases to3 (3%) cases at L5. As for the iliocaval junction, the most common site was also at the level of L4 with41 (41%) cases followed by 39 (39%) cases at the level of L5, and 20 (20%) cases at the intervertebral discof L4/L5. The left renal vein most commonly joined the IVC at the level of L1 with 62 (62%) cases followedby 20 (20%) cases at the intervertebral disc T12/L1. There was wide variation in its entry to the IVCspanning from 4 (4%) cases at T12/L1 to 1 (1%) case at L4.Conclusion: The anatomical variation of the major vessels can be found in the normal population.Therefore, sufficient investigation of the anatomical position of these vessels is essential for patientsbefore laparoscopic surgery.

Optimizing the value of measuring inferior vena cava diameter in shocked patients

Point-of-care ultrasound has been increasingly used in evaluating shocked patients including the measurement of inferior vena cava(IVC) diameter. Operators should standardize their technique in scanning IVC. Relativechanges are more important than absolute numbers. We advise using the longitudinal view(B mode) to evaluate the gross collapsibility, and the M mode to measure the IVC diameter. Combining the collapsibility and diameter size will increase the value of IVC measurement. This approach has been very useful in the resuscitation of shocked patients, monitoring their fluid demands, and predicting recurrence of shock. Pitfalls in measuring IVC diameter include increased intra-thoracic pressure by mechanical ventilation or increased right atrial pressure by pulmonary embolism or heart failure. The IVC diameter is not useful in cases of increased intra-abdominal pressure(abdominal compartment syndrome) or direct pressure on the IVC. The IVC diameter should be combined with focused echocardiography and correlated with the clinical picture as a whole to be useful.

Meta-Analysis of Ventilated versus Spontaneously Breathing Patients in Predicting Fluid Responsiveness by Inferior Vena Cava Variation

Purpose: Respiratory variation in inferior vena cava (ΔIVC) has been extensively studied in predicting fluid responsiveness, but the results are conflicting. We performed a systemic review and meta-analysis of studies aiming at investigating the diagnostic accuracy of ΔIVC in predicting fluid responsiveness. Methods: MEDLINE, EMBASE, Cochrane Database and Web of Science were screened for relevant original and review articles from inception to July 2016. The meta-analysis determined the pooled sensitivity, specificity, diagnostic odds ratio (DOR) and area under the ROC curve (AUROC). In addition, subgroup analyses were performed in mechanically ventilated patients and spontaneously breathing patients. Results: A total of 20 studies involving 635 patients were included. Cutoff values of ΔIVC varied from 12% to 42%, the pooled sensitivity and specificity was 0.68 (0.62 - 0.75) and 0.80 (0.75 - 0.85), respectively. The DOR was 14.2 (6.0 - 33.6) and the AUROC was 0.86 (0.78 - 0.93). Subgroup analysis showed better diagnostic performance in patients on mechanical ventilation than in spontaneously breathing patients with higher sensitivity (0.75 vs. 0.56), specificity (0.82 vs. 0.78), DOR (22.9 vs. 7.9) and AUROC (0.90 vs. 0.80). The best threshold of ΔIVC in patients on mechanical ventilation was IVC distensibility index (ΔIVC ≥17% ±4%), compared to IVC collapsibility index (ΔcIVC ≥33% ±12%) in spontaneously breathing patients. Conclusion: ΔIVC is not an accurate predictor of fluid responsiveness in patients with acute circulatory failure. In patients on mechanical ventilation, the predicting ability of ΔIVC was moderate with acceptable sensitivity and specificity;in spontaneously breathing patients, the specificity remains acceptable but its sensitivity is poor.

Utility of the Inferior Vena Cava Diameter as a Marker of Dry Weight in Nonoliguric Hemodialyzed Patients

We have previously reported that the maximal inferior vena cava(IVC) diameter during quiet expiration(IVCe) measured by ultrasonography correlates well with the amount of body fluid, especially the circulating blood volume[1] and proposed using the criteria of IVC diameter to determine dry weight(DW) in anuric hemodialyzed (HD) patients: standard IVCe of pre-and post-HD are (14.9±0.4) and (8.2±0.3) mm, respectively[2]. However, the same post-HD IVC criterion should not be applied to nonoliguric HD patients because it could result in rapid deterioration of residual renal function due to forced dehydration. Although the biochemical DW marker plasma atrial natriuretic peptide (ANP) is useful to evaluate hypervolemia but not hypovolemia,both hyper-and hypovolemia can be detected by IVC measurement.……

The Inferior Vena Cava Diameter as a Marker of Dry Weight in Chronic Hemodialyzed Patients(续)

The IVC diameters in HD patients Since BW and stature as well as gender and age were not considered to be determinant factors of the IVC diameters, these factors were not accounted for in evaluating the IVC diameters in HD patients. The IVC diameters of stable anuric HD patients are shown in Table 2. In agreement with our previous observation [7-9] ,the reduction of BW from (51.7±12.6) to (49.3±12.6)kg by ultrafiltration during HD resulted in a significant (P<0.0001)reduction of the IVCe and IVCi from (14.9 ± 3.2) to (6.8±1.9)mm and (5.2±4.2) to (0.1±0.3) mm,respectively. Thus,CI values before and at the end of HD were calculated as (0.68±0.24) and (0.98±0. 05), respectively (P<0.0001). ……

Deep vein thrombosis in patient with left-sided inferior vena cava draining into the hemiazygos vein: A case report

BACKGROUND Abnormalities of the inferior vena cava(IVC)are uncommon,and in many cases they are asymptomatic.Even so,it is vital that clinicians be aware of such anomalies prior to surgery in affected individuals.In the present report,we describe a rare anatomical variation of the IVC.CASE SUMMARY A 66-year-old male was admitted to the hospital due to deep vein thrombosis of the right lower extremity.Upon contrast-enhanced computed tomography imaging,we found that this patient presented with a case of left-sided IVC draining into the hemiazygos vein,while his hepatic vein was directly draining into the atrium.CONCLUSION Cases of left-sided IVC can increase patient susceptibility to thromboembolism owing to the resultant changes in blood flow and/or associated vascular compression.

Effect of inferior vena cava respiratory variability-guided fluid therapy after laparoscopic hepatectomy:a randomized controlled clinical trial

Background:After major liver resection,the volume status of patients is still undetermined.However,few concerns have been raised about postoperative fluid management.We aimed to compare gut function recovery and short-term prognosis of the patients after laparoscopic liver resection(LLR)with or without inferior vena cava(IVC)respiratory variability-directed fluid therapy in the anesthesia intensive care unit(AICU).Methods:This randomized controlled clinical trial enrolled 70 patients undergoing LLR.The IVC respiratory variability was used to optimize fluid management of the intervention group in AICU,while the standard practice of fluid management was used for the control group.The primary outcome was the time to flatus after surgery.The secondary outcomes included other indicators of gut function recovery after surgery,postoperative length of hospital stay(LOS),liver and kidney function,the severity of oxidative stress,and the incidence of severe complications associated with hepatectomy.Results:Compared with patients receiving standard fluid management,patients in the intervention group had a shorter time to anal exhaust after surgery(1.5±0.6 days vs.2.0±0.8 days)and lower C-reactive protein activity(21.4[95%confidence interval(CI):11.9-36.7]mg/L vs.44.8[95%CI:26.9-63.1]mg/L)24 h after surgery.There were no significant differences in the time to defecation,serum concentrations of D-lactic acid,malondialdehyde,renal function,and frequency of severe postoperative complications as well as the LOS between the groups.Conclusion:Postoperative IVC respiratory variability-directed fluid therapy in AICU was facilitated in bowel movement but elicited a negligible beneficial effect on the short-term prognosis of patients undergoing LLR.Trial Registration:ChiCTR-INR-17013093.

床旁超声在儿童脓毒性休克液体复苏中的应用价值

目的探讨床旁超声在脓毒性休克患儿液体复苏中的临床价值。方法选取2021年12月至2023年1月收治河北医科大学附属河北省儿童医院重症医学一科诊断为脓毒性休克的患儿50例,采用随机数字表法分为常规组和超声组,每组25例。患儿入院后均给予抗感染、呼吸支持等对症治疗。2组均给予初始液体复苏(20 mL/kg醋酸钠林格液)。常规组在初始液体复苏后按照指南(早期目标导向治疗6 h目标)继续液体复苏;超声组在初始液体复苏后根据超声测下腔静脉内径及肺部超声检查指导后续液体复苏。比较2组液体复苏6、12 h后心率、平均动血压(mean arterial pressure,MAP)及中心静脉血氧饱和度(Systemic central venous oxygen saturation,ScvO_(2))指标变化,并比较2组患儿24 h液体入量及血管药物评分、液体复苏12、24、48 h氧合指数变化、肺水肿发生例数及28 d病死率。结果液体复苏6、12后2组患儿的心率、MAP、ScvO_(2)指标比较,差异无统计学意义(P>0.05)。超声组24 h液体总入量少于常规组,差异有统计学意义(P<0.05),24 h血管活性药物评分低于常规组,但差异无统计学意义(P>0.05)。液体复苏12 h超声组氧合指数高于常规组,但差异无统计学意义(P>0.05),液体复苏24、48 h超声组患儿的氧合指数明显高于常规组,差异有统计学意义(P<0.05)。超声组液体复苏期间发生肺水肿的例数少于常规组,差异有统计学意义(P<0.05);2组患儿的28 d病死率比较,差异无统计学意义(P>0.05)。结论床旁超声测下腔静脉内径联合肺部超声可以指导儿童脓毒性休克的液体管理,减少液体入量,优化容量状态,改善血流动力指标,降低肺水肿发生的风险,因超声具有无创性,在儿科临床应用更广泛,益于儿童。

肺超声技术在血液透析患者容量评估中的临床应用

目的探讨肺超声B线在血液透析患者容量状态评估中的应用价值。方法选取2022年1月至2023年6月该院透析中心93例维持性血液透析患者,使用超声分别测量透析前后B线数量、下腔静脉直径(IVCD),比较透析前后两者的变化,并分析透析前后B线数量与IVCD的相关性。同时选取其中62例合并高血压患者,分别采用传统临床评估法和肺超声B线评估法以调整透析干体重,比较2组患者透析后B线数量、干体重下降程度、血压、透析低血压发生率的差异。结果透析后B线数量及IVCD、体重均低于透析前,差异有统计学意义(P<0.05);透析前B线数量与IVCD呈正相关(r=0.536,P<0.05)。相比传统评估组,肺超声B线组患者的血压下降程度、干体重下降幅度更大,透析低血压发生率更低,差异均有统计学意义(P<0.05)。结论在血液透析患者中,应用肺超声B线检测进行容量评估具有较好的临床价值。

下腔静脉变异度联合SVV指导下的目标导向液体治疗在腹腔镜肠癌根治术麻醉管理中的应用

目的 探讨下腔静脉变异度联合每搏量变异度(SVV)指导下的目标导向液体治疗在腹腔镜肠癌根治术患者麻醉管理中的应用效果。方法 选取2021年7月至2022年6月择期行腹腔镜下肠癌根治术患者60例,按照不同目标导向液体治疗分为常规补液组(对照组)和SVV组(观察组)各30例。比较两组术中液体出入量、不同时间点血流动力学和视神经鞘直径(ONSD)、术前及术后实验室指标水平[C反应蛋白(CRP)、下腔静脉变异度、纤维蛋白原(FIB)、血浆血栓素B2(TXB2)],术前及术后1、3 d认知功能。结果 观察组总入量、胶体量低于对照组(P<0.05),两组晶体量比较差异无统计学意义(P>0.05)。两组部分时间点血流动力学和ONSD差异有统计学意义(P<0.05)。术前和术后1 d实验室指标水平差异有统计学意义,且观察组CRP、FIB水平低于对照组,下腔静脉变异度高于对照组(P<0.05)。术前及术后3 d,两组认知功能差异无统计学意义(P>0.05),术后1 d观察组认知功能评分高于对照组(P<0.05)。结论 下腔静脉变异度联合SVV指导下的目标导向液体治疗应用于腹腔镜肠癌根治术患者麻醉管理中,能够优化术中液体管理,减少外科应激,维持患者内环境稳定,降低术后短期认知功能损害程度,于患者术后康复有益。

脓毒症休克患者腹内压和下腔静脉呼吸变异度对预测患者容量反应性的价值研究

目的:探究脓毒症休克患者腹内压、下腔静脉呼吸变异度(IVC-RVI)对预测患者容量反应性的价值研究。方法:选择86例脓毒症休克患者为研究对象,根据液体复苏后容量反应性情况分为无反应组(n=59)和反应组(n=27)。监测患者液体复苏前及复苏后6 h腹内压、IVC-RVI,分析其对容量反应性的影响。结果:两组患者的年龄、性别、合并基础疾病、感染部位、急性生理学与慢性健康状况评分Ⅱ(APACHEII)、收缩压(SBP)及心率(HR)均无统计学差异(P>0.05);两组患者复苏前腹内压比较,差异无统计学意义(P>0.05);液体复苏后6 h,两组患者腹内压均升高,且无反应组腹内压及复苏前后腹内压差值均高于反应组(P<0.05)。无反应组IVC-RVI低于反应组(P<0.05)。Logistic回归分析显示,IVC-RVI、复苏后6 h腹内压为脓毒症休克患者容量反应性的独立影响因素(P<0.05)。受试者工作特征曲线分析显示,复苏后6 h腹内压、IVC-RVI预测脓毒症休克患者无容量反应性的截断值分别为9.860 mmHg、16.95%,敏感度分别为78.00%、50.00%,特异度分别为82.00%、50.00%,曲线下面积(AUC)分别为0.782、0.722(P<0.05)。两个指标联合预测的价值最高(P<0.05),AUC为0.817(95%CI:0.725~0.909),敏感度、特异度分别为84.00%、78.00%。结论:腹内压偏高、IVC-RVI偏低是导致脓毒症休克患者液体复苏后无容量反应性的影响因素,临床治疗中可据此合理制定液体复苏方案,以提高治疗效果,降低并发症风险。

下腔静脉变异指导液体复苏对创伤失血性休克患者血栓弹力图、炎症因子的影响及预后相关分析

目的探讨基于B超的下腔静脉变异指导液体复苏模式对创伤失血性休克患者血栓弹力图、炎症因子的影响及不同液体复苏模式与患者预后的联系。方法选取2020年1月—2022年6月我院收治的创伤失血性休克患者104例,依据随机数表法将其分为对照组和观察组,每组52例。对照组接受常规限制性液体复苏,观察组接受基于B超的下腔静脉变异指导液体复苏。比较两组患者临床资料、血栓弹力图指标[凝血反应时间(R),血凝块形成时间(K)、血凝块最大强度]、炎症因子[肿瘤坏死因子α(TNF-α)、白介素-6(IL-6)、IL-10]差异。根据104例患者28 d内死亡、多器官功能障碍综合征、急性呼吸窘迫综合征发生情况分为为预后不良组(n=23)和预后良好组(n=81)。采用二元Logistics回归分析影响预后的因素,探究不同液体复苏模式与预后的联系。结果与对照组比较,观察组患者输液量、输血量、ICU住院时间更少(P<0.05);干预1 h,R、K更低,血凝块最大强度更大(P<0.05);干预1 h,TNF-α、IL-6、IL-10更低(P<0.05)。与预后良好组相比,预后不良组患者发病至入院时间≥6 h、限制性液体复苏占比更大,休克指数、ISS评分更高(P<0.05)。以发病至入院时间(<6 h=1,≥6 h=0)、液体复苏模式(下腔静脉变异指导=1,限制性液体复苏=0)、休克指数、ISS评分为自变量,预后(预后不良=1,预后良好=0)为因变量,二元Logistics回归分析显示液体复苏模式、发病至入院时间、ISS评分是影响预后不良的因素(P<0.05)。结论基于B超的下腔静脉变异指导液体复苏可提升患者康复与治疗效率,改善血栓弹力图、炎症反应,是改善预后的保护性因素。

超声检测下腔静脉和锁骨下静脉内径变异在预测全身麻醉诱导后低血压中的价值

目的:分析超声检测下腔静脉(IVC)和锁骨下静脉(SCV)内径变异在预测全麻诱导后低血压(PIH)中的价值。方法:回顾性选取2021年5月—2023年5月在咸宁市第一人民医院行全麻手术的204例患者作为研究对象,根据是否发生PIH将其分为研究组(发生PIH,86例)和对照组(未发生PIH,118例)。对两组患者的基础资料、麻醉诱导前血压、麻醉诱导药物用量进行对比。比较IVC内径的最大值(IVCmax)和最小值(IVCmin)、SCV内径的最大值(SCVmax)和最小值(SCVmin),并计算IVC塌陷指数(IVCCI)和SCV塌陷指数(SCVCI)。采用受试者工作特征(ROC)曲线分析IVC、SCV内径及变异对全麻PIH的预测价值。结果:两组基础资料、麻醉诱导前血压指标和麻醉诱导药物用量比较,差异均无统计学意义(P>0.05)。研究组IVCmax、IVCmin、SCVmax、SCVmin水平均低于对照组,IVCCI、SCVCI水平均高于对照组,差异均有统计学意义(P<0.05)。受试者操作特征(ROC)曲线分析结果显示,麻醉诱导前IVCmax、IVCmin、SCVmax、SCVmin、IVCCI、SCVCI水平预测PIH的ROC曲线下面积(area under curve,AUC)分别为0.674、0.675、0.618、0.707、0.895、0.905,其中,SCVCI的AUC和cut-off值下的敏感度均为最高,分别为0.905、65.12%。结论:全麻PIH患者可表现为IVC和SCV内径缩小及IVCCI、SCVCI等内径变异指标的增高,采用血管超声技术检测上述变异指标可辅助预测PIH风险。

下腔静脉呼吸变异指数对老年全麻宫颈癌根治术患者发生低血压的预测价值

目的 探讨下腔静脉呼吸变异指数(IVC-RVI)对老年全麻宫颈癌根治术患者发生低血压的预测价值。方法 回顾性分析2020年9月至2023年5月江苏省连云港市第一人民医院行全麻宫颈癌根治术治疗的107例老年宫颈癌患者的临床资料。根据术后48 h内是否发生低血压分为低血压组、非低血压组。比较两组临床资料,分析影响老年全麻宫颈癌根治术患者发生低血压的相关因素;IVC-RVI对老年全麻宫颈癌根治术患者发生低血压的预测价值采用受试者操作特征曲线。结果 107例行老年全麻宫颈癌根治术的患者中有36例(33.64%)发生低血压。低血压组合并高血压占比、肺毛细血管楔压、中心静脉压、IVC-RVI高于非低血压组,术前使用血管收缩性药物占比低于非低血压组(P<0.05)。合并高血压、IVC-RVI是老年全麻宫颈癌根治术患者低血压发生的危险因素(OR=2.881、3.235,P<0.05),术前使用血管收缩性药物是保护因素(OR=0.334,P<0.05)。IVC-RVI预测老年全麻宫颈癌根治术患者低血压发生的灵敏度、特异度及曲线下面积分别为88.89%、87.32%、0.869。结论 超声IVC-RVI对老年全麻宫颈癌根治术患者发生低血压的预测价值较高。

混合静脉-动脉血二氧化碳分压差联合下腔静脉直径指导脓毒性休克患者液体复苏的临床研究

目的:探讨混合静脉-动脉血二氧化碳分压差(Pcv-aCO_(2))联合下腔静脉直径(IVCD)指导脓毒性休克(SS)患者液体复苏的临床效果。方法:选取2022年1月—2023年6月新余市人民医院收治的83例SS患者,按随机数字表法分为对照组(n=42)、观察组(n=41);对照组行3 h集束化液体复苏,观察组于Pcv-aCO_(2)联合IVCD指导下行液体复苏;比较两组复苏相关指标、6 h复苏达标率与乳酸清除率、复苏6 h与24 h液体总入量、机械通气时间与急性肺水肿发生率。结果:复苏6、24 h,观察组中心静脉压(CVP)、平均动脉压(MAP)、中心静脉血氧饱和度(ScvO_(2))均高于对照组,乳酸(Lac)均低于对照组,差异均有统计学意义(P<0.05)。观察组6 h复苏达标率与乳酸清除率均高于对照组,差异均有统计学意义(P<0.05);复苏6、24 h,观察组液体总入量均少于对照组,差异均有统计学意义(P<0.05);观察组机械通气时间短于对照组,急性肺水肿发生率低于对照组,差异均有统计学意义(P<0.05)。结论:Pcv-aCO_(2)联合IVCD指导SS患者行液体复苏可提高复苏达标率,减少液体总入量,缩短机械通气时间,且可降低急性肺水肿发生率。

心脏超声结合下腔静脉内径呼吸变异度在预测ICU脓毒症患者容量反应性的临床研究

目的:探究心脏超声结合下腔静脉内径呼吸变异度预测重症监护室(ICU)脓毒症患者容量反应性的临床价值。方法:将2021年1月~2023年5月于我院接受治疗的60例ICU脓毒症患者纳入研究。根据患者入院时的容量负荷检查结果进行分组,将发生容量反应的患者纳入有容量反应组(19例),将未发生容量反应的患者纳入无容量反应组(41例)。对比两组患者下腔静脉内径[呼气末最大下腔内径(IVCDmax)、呼气末最小下腔内径(IVCDmin)],计算下腔静脉内径呼吸变异度(Respiratory variability of inferior vena cava,RVI);心脏超声检测指标[每搏输出量(Stroke volume,SV)、心排血量(Cardiac output,CO)、心率(Heart Rate,HR)、平均动脉压(Mean arterial pressure,MAP)];采用受试者工作特征(ROC)曲线分析RVI、心脏超声指标对ICU脓毒症患者容量反应性异常的预测价值。结果:有容量反应组IVCDmax、IVCDmin小于无容量反应组,RVI水平高于无容量反应组(P<0.05);有容量反应组患者SV、CO水平低于无容量反应组(P<0.05),两组患者HR、MAP水平差异不明显(P>0.05);经ROC分析RVI、SV、CO的有容量反应性的曲线下面积分别为0.882、0.714、0.858,敏感度分别为86.67%、84.00%、85.77%,特异性分别为86.67%、42.88%、72.22%(P<0.05)。结论:心脏超声结合下腔静脉内径呼吸变异度在预测ICU脓毒症患者容量反应性的临床价值明显,安全有效地提高临床上对ICU脓毒症患者容量反应性预测的准确性。

下腔静脉先天变异的CT表现特征分析

目的 通过回顾下腔静脉的胚胎发育特征、分析其临床CT表现,提高对下腔静脉先天变异CT表现的认识。方法 回顾性收集2015年1月至2020年10月因各种原因于本院行腹部CT平扫及增强扫描或者胸腹部联合CT检查,于门静脉期或延迟期观察下腔静脉的走形及连接,回顾性学习下腔静脉的胚胎发育特征,分析本组病例下腔静脉先天变异的类型、特征以及是否合并其他脏器畸形。结果 本组27例患者,下腔静脉肝段缺如10例,双下腔静脉8例,左位下腔静脉10例,下腔静脉异常延续12例,其中部分病例为几种变异联合存在;本组未收集到下腔静脉后输尿管病例。下腔静脉发育异常合并其他系统异常,共12例(12/27),其中6例合并先天性心脏病,另6例分别合并迷走右锁骨下动脉及夹层、永存左上腔静脉、多脾综合征、脾静脉与肠系膜上静脉汇合异常;其他15例下腔静脉异常是因其他原因行CT检查偶然发现。结论 识别下腔静脉变异对临床操作及治疗具有重要意义;因此,对影像诊断医生而言下腔静脉的观察与评价应该成为日常诊断工作中的基本组成部分。

下腔静脉扩张指数指导目标导向液体治疗对老年患者全膝关节置换术后并发症的影响

目的探讨下腔静脉扩张指数(IVC-DI)指导的目标导向液体治疗(GDFT)对老年患者全膝关节置换术术后并发症的影响。方法选择2019年3月到2021年8月行全膝关节置换术的老年患者120例,男29例,女91例,年龄65~85岁,BMI 18~30 kg/m^(2),ASAⅠ—Ⅲ级。采用随机分组法分为三组:经胸IVC-DI监测组(I组)、每搏量变异度(SVV)监测组(S组)和血压监测组(C组),每组40例。I组IVC-DI>18%时,补充胶体液250 ml;若IVC-DI≤18%,而MAP低于基础值的80%,给予升压药物。S组SVV>13%时,补充胶体液250 ml;若SVV≤13%,而MAP低于基础值的80%,给予升压药物。C组MAP低于基础值的80%时,补充胶体液250 ml,当胶体液量达20 ml/kg时血压仍未改善,给予升压药物。记录麻醉药物用量、出血量、晶体和胶体输注量、总输注量、升压药物使用和输血情况。记录术后6 h、1、2、3 d活动(抬腿屈膝)时VAS疼痛评分。记录手术时间、术后首次下床活动时间、首次肛门排气时间、术后48 h内镇痛泵总按压次数和有效按压次数、恶心呕吐、切口感染、入ICU情况、术后住院时间。记录术后30 d并发症发生情况。结果与C组比较,I组和S组晶体输注量明显增多(P<0.05),胶体输注量和总输注量明显减少(P<0.05),升压药物使用率明显升高(P<0.05)。与术后6 h比较,术后1、2、3 d三组活动时VAS疼痛评分明显升高(P<0.05)。与I组比较,术后3 d S组和C组活动时VAS疼痛评分明显升高(P<0.05)。与C组比较,I组和S组术后首次肛门排气时间明显缩短(P<0.05),总并发症发生率明显降低(P<0.05)。三组手术时间、术后首次下床活动时间、镇痛泵总按压次数和有效按压次数、恶心呕吐、切口感染、入ICU率、术后住院时间、术后30 d并发症发生率差异无统计学意义。结论与常规监测比较,IVC-DI指导目标导向液体治疗可通过减少术后并发症加快老年患者全膝关节置换术后康复。

IVC-RVI联合血清炎症因子水平预测脓毒症休克患者容量反应性的价值

目的 探讨下腔静脉内径呼吸变异度(IVC-RVI)联合血清炎症因子水平预测脓毒症休克患者容量反应性的临床价值。方法 选取锦州市中心医院2019年6月—2021年6月120例脓毒症休克患者作为研究对象,根据容量负荷试验将患者分为有反应组(n=52)和无反应组(n=68)。于容量负荷试验前采用超声测定患者吸气末下腔静脉最大内径(D_(max))、呼气末下腔静脉最小内径(D_(min)),计算IVC-RVI。于患者入院时测定血清炎症因子[白介素-6(IL-6)、C反应蛋白(CRP)、肿瘤坏死因子-α(TNF-α)]。借助ROC分析D_(max)、D_(min)、IVC-RVI、IL-6、CRP、TNF-α对脓毒症休克患者有容量反应性的预测价值,通过一致性分析,评估D_(max)、D_(min)、IVC-RVI联合IL-6、CRP、TNF-α对脓毒症休克患者有容量反应性的预测价值。结果 有反应组D_(max)、D_(min)显著低于无反应组,IVC-RVI显著高于无反应组,比较差异有统计学意义(P<0.05)。有反应组血清IL-6、CRP、TNF-α水平均显著低于无反应组,比较差异有统计学意义(P<0.05)。经ROC分析,D_(_(max))、D_(min)、IVC-RVI、IL-6、CRP、TNF-α预测脓毒症休克患者有容量反应性的曲线下面积分别为0.836、0.846、0.804、0.903、0.877、0.756,均有P<0.05。经一致性分析,120例脓毒症休克患者中联合预测阳性51例,敏感度为0.981,特异性为0.971,准确率为0.975,Kappa为0.949。结论 IVC-RVI和血清炎症因子水平均可用于脓毒症休克患者容量反应性预测中,且联合检测可获得更好的敏感度、特异性。

严重脓毒症患者液体复苏中ScvO_(2)、乳酸清除率与超声测算IVC-RVI的相关性及对预后的预测价值

目的:探讨严重脓毒症患者液体复苏中中心静脉血氧饱和度(ScvO_(2))、乳酸清除率与超声测算下腔静脉呼吸变异度(IVC-RVI)的相关性,以期为临床早期制定干预方案提供参考。方法:选取2020年12月至2022年12月四川省自贡市第一人民医院60例严重脓毒症患者,对所有患者根据早期目标导向治疗(EGDT)方案按6 h脓毒症集束化治疗行液体复苏,监测ScvO_(2)、乳酸清除率,并经超声检查测算IVC-RVI,分析ScvO_(2)、乳酸清除率及IVC-RVI与EGDT治疗达标的关系,比较不同预后患者复苏后6 h、12 h及24 h ScvO_(2)、乳酸清除率及IVC-RVI,分析其对预后评估价值。结果:EGDT治疗未达标组复苏后6 h ScvO_(2)、乳酸清除率均低于达标组,IVC-RVI高于达标组(P<0.05);复苏后6 h ScvO_(2)、乳酸清除率低水平组患者EGDT治疗不达标风险分别是高水平组的7.500倍、4.667倍;IVC-RVI高水平组患者EGDT治疗不达标风险是低水平组的3.250倍;死亡组患者复苏后6 h、12 h及24 h ScvO_(2)、乳酸清除率均低于生存组患者,IVC-RVI高于生存组患者(P<0.05);复苏后6 h、12 h及24 h ScvO_(2)、乳酸清除率、IVC-RVI联合预测AUC分别为0.856、0.892、0.933,明显较各时间点单个指标大,且复苏后24 h联合预测AUC>复苏后12 h>复苏后6 h(P<0.05);严重脓毒症患者复苏后6 h、12 h及24 h ScvO_(2)、乳酸清除率均与IVC-RVI呈负相关关系(P<0.05)。结论:严重脓毒症患者液体复苏中ScvO_(2)、乳酸清除率及IVC-RVI对于液体复苏疗效具有较高评估价值,可为临床早期预测预后提供依据,以针对性展开后续治疗,提高患者生存率。