呼气末正压抬高试验预测感染性休克机械通气患者容量反应性的临床研究被引量：3

Clinical Study on Volume Responsiveness Predicted by Elevation of Positive End-Expiratory Pressure in Septic Shock Patients with Mechanical Ventilation

下载PDF

导出

摘要目的：评价呼气末正压（positive end-expiratory pressure, PEEP）抬高试验联合脉搏轮廓连续心输出量（pulse index continuous cardiac output, PiCCO）技术预测感染性休克患者容量反应性的价值。方法该研究采用前瞻性、观察性队列研究的设计方法，选择2013年06月～2013年12月重症医学科（ICU）的感染性休克机械通气患者。所有患者均先后进行PEEP抬高试验（PEEP由基础水平短暂抬高10 cmH2O）和容量负荷试验，并使用PiCCO持续监测PEEP抬高试验和容量负荷试验前后各项血流动力学指标的变化。根据对容量负荷试验的反应[补液后心输出量（CO）增加≥15%为有容量反应性]将患者分为有反应组和无反应组，用受试者工作特征曲线（ROC曲线）评价PEEP抬高试验预测容量反应性的价值。结果共有34例感染性休克机械通气患者纳入该研究，容量负荷试验有反应者占55.9%（19/34）。有反应组PEEP抬高试验后平均动脉压（MAP）、CO较前明显降低（47.5±6.36 vs.56.8±7.65，P＜0.05；4.97±0.55 vs.5.62±0.72，P＜0.05），而无反应组PEEP抬高试验后MAP、CO无明显变化（P＞0.05）。PEEP抬高试验后ΔMAP及ΔCO与容量负荷试验后ΔCO呈显著负相关（r=-0.75，P＜0.01；r=-0.47，P＜0.01）。PEEP抬高试验ΔMAP、ΔCO预测容量反应性的ROC曲线下面积（AUC）分别为0.846、0.782，以PEEP抬高试验ΔMAP降低≥8.1%预测容量反应性的敏感性和特异性分别为89.5%和86.7%。结论用PEEP抬高试验所引起的MAP变化能精确预测感染性休克机械通气患者的容量反应性，可用来指导液体复苏治疗。 Objective To evaluate whether haemodynamic changes during a short elevation of positive end-expiratory pressure （PEEP） would predict fluid responsiveness in septic shock patients with mechanical ventilation. Methods We performed a prospective observational study in 34 patients with septic shock on mechanical ventilation. Patients were collected in the Second Affiliated Hospital of Nantong University from June 2013 to December 2013. We assessed the following changes in haemodynamic variables during a temporary 10 cmH2O elevation of PEEP from baseline：mean arterial pressure （MAP）, central venous pressure （CVP）, heart rate （HR） and cardiac output （CO）. We defined fluid responsiveness as an increase in CO of 15%to a subsequent fluid challenge. We determined the predictive value of the measured variables by receiver operating characteristic （ROC）curve analysis. Results Thirty-four septic shock patients with mechanical ventilation were studied, nineteen patients （55.9%） responded to fluid challenge with an increase in CO of 15%or more. In responders, MAP and CO decreased significantly during PEEP elevation （56.8±7.65 vs. 47.5±6.36, P〈0.05;5.62±0.72 vs. 4.97±0.55, P〈0.05）. There was no significant change of MAP and CO in non-responders during PEEP elevation.ΔMAP andΔCO during PEEP elevation were negatively correlated withΔCO of fluid challenge, respectively （r=-0.75, P〈0.01;r=-0.47, P〈0.01）. The areas under the curve （AUC） ofΔMAP andΔCO during PEEP elevation were 0.846 and 0.782, respectively. The best predictive cut-off value forΔMAP （PEEP elevation） was-8.1%, yielding the sensitivity of 89.5%and specificity of 86.7%. Conclusion In septic shock patients with mechanical ventilation, the decrease in MAP during an elevation of PEEP may be used to predict the volume responsiveness.

作者祁峰李峰徐志华王春华桑智慧张玲玲

机构地区南通大学附属第二医院ICU

出处《中国血液流变学杂志》 CAS 2014年第2期246-249,252,共5页 Chinese Journal of Hemorheology

基金江苏省南通市科技计划项目（HS13949）

关键词呼气末正压(PEEP) 脉搏轮廓连续心输出量监测感染性休克容量反应性 septic shock volume responsiveness

分类号 R631.4 [医药卫生—外科学]

引文网络
相关文献

参考文献10

1Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence[J]. Chest, 2002, 121(6): 2000 - 2008.
2Boyd JH, Forbes J, Nakada TA, et al. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality[J]. Crit Care Med, 2011, 39(2): 259 - 265.
3Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012[J]. Crit Care Med, 2013, 41(2): 580 - 637.
4Luecke T, Pelosi P. Clinical review: Positive end-expiratory pressure and cardiac output[J]. Crit Care, 2005, 9(6): 607 - 621.
5Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference[J]. Crit Care Med, 2003, 31(4): 1250 N 1256.
6Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature[J]. Crit Care Med, 2009, 37(9): 2642 ~ 2647.
7Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict bemodynamic response to volume challenge[J]. Crit Care Med, 2007, 35(1): 64 ~ 68.
8Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill[J]. Crit Care Med, 2006, 34(5): 1402 - 1407.
9Delerme S, Renault R, Le Manach Y, et al. Variations in pulse oximetry plethysmographic waveform amplitude induced by passive leg raising in spontaneously breathing volunteers[J]. Am J Emerg Med, 2007, 25(6): 637 - 642.
10Mahjoub Y, Lejeune V, Muller L, et al. Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study[J]. Br J Anaesth, 2014, 112(4): 681 - 685.