被动抬腿试验联合无创心排血量监测系统预测容量反应性的临床研究

目的 评价被动抬腿试验联合无创心排血量监测系统(USCOM)预测自主呼吸患者的容量反应性.方法 采用前瞻性、观察性队列研究设计方法,选择33例有自主呼吸且需补液的患者,先后进行被动抬腿试验和容量负荷试验,在每个试验前后分别采用经胸超声心动图(TTE)和USCOM测量每搏量(SV).根据对容量负荷试验的反应(以容量负荷试验后SVTTE增加≥15%者为有反应)将患者分为有反应组和无反应组.观察试验后SV的变化(△SV)及其相关性.结果 33例患者共行容量负荷试验36例次,有反应组24例次,无反应组12例次.两组一般资料及初始床头抬高45°时的血流动力学指标无明显差异.被动抬腿试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(21.7±13.2)%比(4.8±9.4)%,△SVUSCOM:(23.5±13.0)%比(4.6±8.9)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.792,P＜0.01).容量负荷试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(27.3±14.1)%比(7.2±8.4)%,△SVUSCOM:(25.4±13.8)%比(6.7±8.6)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.855,P＜0.01).用△SVTTE≥15%预测容量反应性,其敏感性为100.0%[95%可信区间(95%CI)85.0～100.0],特异性为83.3%(95%CI 68.4～98.2);而用△SVUSCOM≥15%预测容量反应性,其敏感性为83.3%(95%CI 66.1～100.0),特异性为94.4%(95%CI 83.9～100.0).被动抬腿试验后△SVTTE与△SVUSCOM的受试者工作特征曲线下面积比较差异无统计学意义(0.95±0.04比0.93±0.05,P＞0.05).结论 用USCOM测量被动抬腿试验后的△SV可反映自主呼吸患者液体治疗时的容量反应性,用以指导患者的液体治疗.

Abstract：

Objective To investigate whether passive leg raising(PLR)combined with ultrasonic cardiac output monitoring system(USCOM)could be used to predict the hemodynamic response to volume expansion(VE)in patients with spontaneous respiration. Methods The study was performed with prospective, cohort study method. Thirty-three patients with spontaneous breathing activity who were admitted to the intensive care unit(ICU)from October 2009 to April 2010 were included. Measurements of stroke volume(SV)were obtained with transthoracic echocardiography(TTE)and USCOM. Patients were considered to be responders to VE if SVTTE increased≥ 15%. Based on the responsiveness of VE, all the patients were divided into responders and non-responders. The change in SV(△SV)after the experiment and its correlation were observed. Results A total of 36 fluid load tests in 33 patients were evaluated resulting in 24 responders and 12 non-responders. There was no significant difference between two groups in the clinical data and hemodynamics parameters at incipient stage when head side of bed was raised for 45°. After PLR,the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(21.7±13.2)% vs.(4.8±9.4)%, △SVUSCOM:(23.5±13.0)% vs.(4.6±8.9)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r = 0. 792, P＜0. 01). After VE, the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(27.3±14.1)% vs.(7.2±8.4)%, △SVUSCOM:(25.4±13.8)% vs.(6.7±8.6)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r= 0. 855, P＜0. 01). The △SVTTE≥ 15%during PLR was predictive of response to VE with a sensitivity of 100. 0%[95% confidence interval (95%CI)85.0 - 100. 0]and a specificity of 83. 3%(95%CI 68.4 - 98. 2). The △SVUSCOM≥15% during PLR was predictive of response to VE with a sensitivity of 83.3%(95%CI 66. 1 - 100. 0)and a specificity of 94.4%(95%CI 83. 9 - 100. 0). There was no difference between the area under the receiver operating characteristic(ROC)curve for PLR-induced △SVTTE and △SVUSCOM(0. 95±0. 04 vs. 0. 93±0. 05, P＞0. 05).Conclusion PLR combined with USCOM can predict the hemodynamic response to VE in spontaneously breathing patients, and the procedure can be used to guide fluid therapy in spontaneously breathing patients.     

血管外肺水指数在脓毒症相关性ALI/ARDS患者液体管理中的意义

Objective The management of fluid infusion is crucial in severe sepsis/septic shock patients.The correlation of extravascular lung water index(EVLWI) versus oxygenation index ( PaO2/FiO2 ) and EVLWI versus intrathoracic blood volume index(ITBVI) were analysed in this present study. Method Totally 24 patients,admitted to the Intensive Care Unit of Second Affiliated Hospital of Zhejiang University, College of Medicine and diagnosed as severe sepsis/septic shock with acute lung injury and/or acute respiratory distress syndrome,were enrolled. ITBVI and EVLWI were detected with PiCCO technique. Correlation of EVLWI and PaO2/FiO2, ITBVI and EVLWI were analysed,respectively. Simple correlation and simple linear regression were used for statistical analysis. Results Significant negative correlation was found of EVLWI and PaO2/FiO2 ( r = - 0. 45, P ＜ 0.01).EVLWT = 14 mL/kg was defined as the cutoff value for the subgroup analysis. No correlation was found between EVLWI and PaO2/FiO2 in the subgroup with EVLWI≤ 14 mL/kg ( r = 0. 12, P = 0.243), but in the subgroup with EVLWI ＞ 14 mL/kg, significant negative correlation was found ( r = - 0. 47, P ＜ 0. 01 ). When EVLWI was higher than 14 mL/kg,EVLW should be decreased to improve oxygenation and other aspects should be taken into account. No significant correlation was found between ITBVI and EVLWI. A ITBVI value 1000 mL/m2 was also defined as the cutoff value for the subgroup analysis. No significant correlation was found in the subgroup with ITBVI≤ 1000 mL/m2( r = 0.13, P = 0.17), while significant positive correlation was found in the subgroup with ITBVI ＞ 1000 mL/m2. This result suggested that in patients of severe sepsis/septic shock with ALI/ARDS, when the blood volume is high, ITBV should be decreased to improve the oxygenation,however,it is not useful in the situation of high pulmonary vascular permeability. Conclusions Extravascular lung water has a important role in the fluid management in patients of severe sepsis/septic shock with ALI/ARDS.     

每搏量变异度预测严重感染和感染性休克患者容量反应性的价值

目的 研究每搏量变异度(stroke volume variation,SW)预测严重感染和感染性休克机械通气患者容量反应性的价值.方法 前瞻观察性研究,对2009年1月至2010年3月北京大学深圳医院ICU严重感染和感染性休克机械通气患者28例进行容量负荷试验.超声心输出量监测仪无创监测心脏指数(cardiac index,CI)、每搏输出量指数(stroke volume index,SVI)、外周血管阻力(systemic vascular resistance,SVR)、SVV等血流动力学指标.根据容量负荷试验前后CI增加值是否大于12%分为有反应组和无反应组,组间比较应用两独立样本t检验;容量负荷试验前后比较应用配对t检验;受试者工作特征曲线评价SVV、中心静脉压(central venous pressure,CVP)以及容量负荷试验前后CVP变化值(△CVP)预测容量反应性的价值.结果 容量负荷试验前,有反应组SW高于无反应组[(18.2±4.7)%和(12.7±4.2)%,P=0.003];而CVP两组差异无统计学意义[(10.2±4.0)cmH2O和(10.8±4.8)cmH2O,P＞0.05].容量负荷试验后,有反应组△CVP低于无反应组[(2.9±3.1)cmH2O和(5.3±2.7)cmH2O,P=0.037].SVV、CVP和△CVP的曲线下面积(AUC)分别是0.836(95%CI:0.680～0.992,P=0.003)、0.549(95%CI:0.329～0.768,P=0.662)和0.762(95%CI:0.570～0.953,P=0.019).SVV为15.5%时预测容量反应性的敏感度和特异度分别是84.6%和80%.结论 SVV预测严重感染和感染性休克机械通气患者的容量反应性具有良好价值,明显优于CVP、△CVP等传统指标.     

无创超声心输出量监测技术联合被动抬腿试验评估心脏术后患者容量反应性的作用

目的 探讨无创超声心输出量监测技术(USCOM)联合被动抬腿试验(PLR)评估心脏术后患者容量反应性的作用.方法 2010-02～2010-06心脏瓣膜置换术后需要扩容的患者纳入本研究,按四个阶段进行:半卧位;躯体仰卧位,下肢抬高45°进行PLR;回到半卧位;30 min内静脉输注500 mL 6%羟乙基淀粉进行扩容.通过USCOM连续进行心输出量(CO)和每搏输出量(SV)监测.根据扩容后SV的变化值(ΔSV)是否 ≥15% 分为反应组和无反应组.受试者工作特征曲线评价PLR所致ΔSV预测容量反应性的价值.结果 80例需要扩容的患者纳入本研究,9例因不能得到满意的USCOM多普勒信号被排除,32例(45.1%)患者ΔSV≥15%为反应组.PLR所致ΔSV曲线下面积(AUC)是0.84±0.05,ΔSV≥15%预测容量反应性的敏感度和特异度分别为56%和100%,阳性预测值和阴性预测者分别是65%和100%.结论 通过USCOM监测PLR所致ΔSV对评估心脏术后患者容量反应性具有一定的指导意义.     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

Objective To investigate the effect of early goal-directed therapy (EGDT) on treatment of critical patients with severe sepsis/septic shock.Methods A multi-center, prospective, randomized,controlled study was deployed.Totally 314 critical patients, from eight comprehensive hospitals in Zhejiang Province admitted during January, 2005 to January, 2008, suffering from severe sepsis/septic shock were randomized into conventional treatment group (n=151) and EGDT group (n = 163), the patients of the former underwent fluid resuscitation guided by central venous pressure (CVP), systolic blood pressure (SBP) or mean artery pressure (MAP) and urinary output (UO), and the latter guided by CVP, SBP orMAP and UO plus central venous oxygen saturation (ScvO2).The patients were treated with fluid, blood transfusions and cardiac stimulants in a period of 6 hours after enrollment to reach the goal.The difference of 28-day survival rate and intensive care unit (ICU) mortality (primary end points), the length of ICU stay,the duration of mechanical ventilation, duration of antibiotics treatment, incidence of newly occurredinfection, and severity scores (secondary end points) were compared between two groups.Results Finally,a total of 303 patients were eligible to enter this study, with 157 patients in EGDT group and 146 patients in conventional treatment group.In comparison with conventional treatment group, the 28-day survival rate of EGDT group was increased by 17.7% (75.2% vs.57.5%, P=0.001) and the ICU mortality of EGDT group was decreased by 15.7% (35.0% vs.50.7%, P=0.035), the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score (14.4±8.5 vs.18.0±7.1, P=0.043), multiple organ dysfunction syndrome (MODS) score (5.8±3.1 vs.8.9±3.7, P=0.014) and sepsis-related organ failure assessment (SOFA) score (5.6 ± 2.9 vs.10.4 ± 3.7, P = 0.001) were significantly decreased in EGDT group.Meanwhile, a significant shortening of duration of using antibiotics was also found [(13.4±10.0) days vs.(19.7 ± 13.5) days, P = 0.004], with a lowering of incidence of occurrence of new infection (37.6% vs.53.4%, P=0.014).There were no differences in other parameters for secondary end points.Conclusion EGDT improves 28-day survival rate and clinical scores, and it shows beneficial effects on outcome of critical patients with severe sepsis/septic shock.     

危重病严重脓毒症/脓毒性休克患者早期规范化液体复苏治疗——多中心、前瞻性、随机、对照研究

Objective To investigate the effect of early goal-directed therapy (EGDT) on treatment of critical patients with severe sepsis/septic shock.Methods A multi-center, prospective, randomized,controlled study was deployed.Totally 314 critical patients, from eight comprehensive hospitals in Zhejiang Province admitted during January, 2005 to January, 2008, suffering from severe sepsis/septic shock were randomized into conventional treatment group (n=151) and EGDT group (n = 163), the patients of the former underwent fluid resuscitation guided by central venous pressure (CVP), systolic blood pressure (SBP) or mean artery pressure (MAP) and urinary output (UO), and the latter guided by CVP, SBP orMAP and UO plus central venous oxygen saturation (ScvO2).The patients were treated with fluid, blood transfusions and cardiac stimulants in a period of 6 hours after enrollment to reach the goal.The difference of 28-day survival rate and intensive care unit (ICU) mortality (primary end points), the length of ICU stay,the duration of mechanical ventilation, duration of antibiotics treatment, incidence of newly occurredinfection, and severity scores (secondary end points) were compared between two groups.Results Finally,a total of 303 patients were eligible to enter this study, with 157 patients in EGDT group and 146 patients in conventional treatment group.In comparison with conventional treatment group, the 28-day survival rate of EGDT group was increased by 17.7% (75.2% vs.57.5%, P=0.001) and the ICU mortality of EGDT group was decreased by 15.7% (35.0% vs.50.7%, P=0.035), the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score (14.4±8.5 vs.18.0±7.1, P=0.043), multiple organ dysfunction syndrome (MODS) score (5.8±3.1 vs.8.9±3.7, P=0.014) and sepsis-related organ failure assessment (SOFA) score (5.6 ± 2.9 vs.10.4 ± 3.7, P = 0.001) were significantly decreased in EGDT group.Meanwhile, a significant shortening of duration of using antibiotics was also found [(13.4±10.0) days vs.(19.7 ± 13.5) days, P = 0.004], with a lowering of incidence of occurrence of new infection (37.6% vs.53.4%, P=0.014).There were no differences in other parameters for secondary end points.Conclusion EGDT improves 28-day survival rate and clinical scores, and it shows beneficial effects on outcome of critical patients with severe sepsis/septic shock.     

严重脓毒症和脓毒性休克的急诊集束化治疗依从性调查分析

目的 调查严重脓毒症和脓毒性休克在急诊患者中的发生率以及针对严重脓毒症和脓毒性休克早期集束化治疗的依从性.方法 选择2009年5月至6月由救护车送至上海交通大学医学院附属瑞金医院急诊科的患者为调查对象,统计严重脓毒症和脓毒性休克的发生率,对符合诊断标准的患者分别统计早期复苏集束化治疗各项指标完成的依从性.结果 共纳入急诊就诊患者917例,其中符合严重脓毒症和脓毒性休克诊断标准者96例,发生率为10.47%.在符合诊断标准的患者中,早期复苏集束化治疗、使用抗菌药物前留取病原学标本、2 h内放置深静脉导管并监测中心静脉压(CVP)与中心静脉血氧饱和度(ScvO2)、3 h内使用广谱抗菌药物、6 h内早期目标导向治疗(EGDT)达标、12 h内乳酸下降或原乳酸≤2 mmol/L的依从性分别为1.04%、3.12%、2.08%、83.33%、1.04%、23.96%,急诊内科各指标的依从性依次为1.19%、3.57%、2.38%、83.33%、1.19%、26.19%,急诊外科各指标的依从性依次为0、0、0、83.33%、0、8.33%,急诊内、外科依从性比较差异均无统计学意义(均P＞0.05).结论 严重脓毒症和脓毒性休克在急诊就诊患者中占相当比例,但医师的认识不足;早期集束化治疗依从性较低,需加大指南的教育及执行程度.

Abstract：

Objective To evaluate the occurrence of severe sepsis and septic shock and the rate of compliance with sepsis bundle in patients with severe sepsis and septic shock in emergency department.Methods A prospective study was conducted on consecutive adult patients who were sent to Emergency Department of Ruijin Hospital, Shanghai Jiaotong University School of Medicine by ambulance from May to June in 2009. The occurrence of severe sepsis and septic shock, and the number of the patients in whom who met the criteria of compliance with sepsis bundle were analyzed. Results Nine hundred and seventeen patients who were sent to the emergency department by ambulance in that period were enrolled in the study.The number of patients with severe sepsis and septic shock was 96. The incidence of severe sepsis and septic shock was 10.47%. Among these patients, the number of patients in whom the sepsis bundle was complied,i.e. sepsis bundle, appropriate cultures were taken before antimicrobial therapy, placement of central venous catheter and monitoring of central venous pressure(CVP)as well as central venous oxygen saturation (ScvO2)within 2 hours, antibiotic therapy within 3 hours, early goal-directed therapy(EGDT)within 6 hours, and lactate clearance in 12 hours reached 1.04%, 3. 12%, 2.08%, 83. 33%, 1.04%, 23.96%.The results were 1.19%, 3. 57%, 2.38%, 83.33%, 1.19%, 26.19% and 0, 0, 0, 83.33%, 0, 8. 33% in medical and surgical emergency department respectively. There was no statistical difference between the two divisions(all P＞0. 05). Conclusion The incidence of severe sepsis and septic shock was high in emergency department, but the rate of recognition of it and the compliance with sepsis bundle were inadequate. It is urgently necessary to enhance the learning and implementation of the guideline.     

The correlation between the apolipoprotein E genetic polymorphisms and sepsis in children Liu北大核心CSCD

Objective To study the correlation between apolipoprotein E (APOE) genetic polymorphisms and sepsis in Chinese children. Methods The inpatients suffered with sepsis were enrolled as septic group and the healthy children from child health division were enrolled as control group. The study of APOE genotypes were carried out by polymerase chain reactions followed a high-resolution melting curve analysis. SPSS 16.0 statistical software was used for data analysis. Mann-Whitney U test was used to compare the age between the groups. Hardy-Weinberg equilibrium was tested using the Pearson χ2 -test. The χ2 -test was used to compare gender and the genotype distribution between the groups. The odd ratio (OR) was calculated together with its 95% confidence interval (CI). Potential confounding effects of variables were corrected using a multivariate unconditional logistic regression model. All statistical tests were two-sided and P < 0.05 indicates statistically significance. Results Among a total of 285 children collected from March 2011 to June 2012, there were 88 patients with sepsis and 197 healthy children. In the septic group, 15 septic patients were complicated with central nervous system infection. Four apolipoprotein E genotypes were identified to be ϵ3/ϵ3, ϵ2/ϵ3, ϵ3/ϵ4, and ϵ2/ϵ4. The percentage of each genotype found in patients of the septic group and the control group was 64.4% vs. 73.1% (ϵ3/ϵ3); 16.8% vs. 10.7% (ϵ2/ϵ3); 18.8% vs. 14.7% (ϵ3/ϵ4); 0% vs. 1.5% (ϵ2/ϵ4), respectively. The number of patients with the genotype ϵ3/ϵ3 among septic patients was significantly lower than that among the control individuals (P = 0.047, 1 -β =0.334, OR =0.585, adjusted OR = 0.559). The number of patients with the genotype ϵ3/ϵ3 among the septic patients with central nervous system infection was 33.3%, which was also significantly lower than that among the septic patients without CNS infection (67.1%). (P = 0.014, 1-β = 0.685, OR = 0.245, adjusted OR = 0.275). Conclusions Apolipoprotein E genetic polymorphisms were associated with the occurrence of sepsis and central nervous system complications in children. The susceptibility of children with genotype ϵ3/ϵ3 to sepsis and central nerve system infection complications is significantly lower than that of children with other genotypes.     

Prognostic value of CD4~+CD25~+ Tregs as a valuable biomarker for patients with sepsis in ICU

BACKGROUND: Sepsis is a common complication ofinfections, burns, traumas, surgeries, poisonings, and post-cardiopulmonary resuscitation. The present study aimed to investigate prognostic value of CD4+CD25+ regulatory T cells(Treg) in peripheral blood of patients with sepsis.METHODS: Periphery blood from 28 patients diagnosed with sepsis was collected on day 1 and 7 after hospitalization in the ICU of Shanghai Changzheng Hospital between December 2013 to April 2014. The blood was used for analyses of Treg ratio using flow cytometry and for analyses of blood routine test, C-reactive protein(CRP), bilirubin, procalcitonin(PCT), and coagulation. APACHE II and sequential organ failure assessment(SOFA) scores were also investigated. The results were compared between two outcome groups of survival or death to evaluate prognostic value for sepsis.RESULTS: The patients had an average age of 60.36±15.03 years, APACHE II score 16.68±7.00, and SOFA score 7.18±3.78. Among the 28 patients, 12 had severe trauma(42.9%), 10 had septic shock(35.7%), and 9(32.2%) died. The median ratio of Tregs was 2.10%(0.80%, 3.10%) in the survival group vs. 1.80%(1.15%, 3.65%) in the death group(Z=–0.148, P=0.883) on day 1; however it was signifi cantly changed to 0.90%(0.30%, 2.80%) vs. 5.70%(2.60%, 8.30%)(Z=–2.905, P=0.004).CONCLUSION: With better prospects for clinical application, dynamic monitoring of Tregs ratio in peripheral blood has potential value in predicting prognosis of sepsis.     

被动抬腿试验联合脉搏灌注指数变异预测容量反应性的研究

目的 探讨被动抬腿试验联合脉搏灌注指数变异(PVI)预测机体容量反应的准确性.方法 选择2012年5月至2013年5月需进行补液的患者46例,监测患者的心率、收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、中心静脉压(CVP)、PVI、心指数(CI)、心输出量(CO)、每博量变异(SVV)等血流动力学指标.行被动抬腿试验(PLR),以PLR试验后CI增加百分比(△CI)≥15％为对容量治疗有反应组,否则为无反应组.结果 46例患者共进行52例次PLR.其中有反应组27例次,无反应组25例次.有反应组患者CI、CO、SVV、PVI在PLR后显著高于PLR前(P＜0.05);而HR、SBP、DBP、MAP、CVP在PLR前后无显著变化(P＞0.05).有反应组患者PLR前的基础SVV和PVI值[(20.44±4.45)％和(20.89±7.41)％]明显高于无反应组[(10.00±1.41)％和(10.71±2.69)％],两者之间比较差异具有统计学著意义(P＜0.01);基础CVP明显低于无反应组.而两组HR、SBP、DBP、MAP、CI、CO的基础值比较则差异无统计学意义(P＞0.05);PLR前的PVI预测容量反应性的ROC曲线下面积为0.796,以PVI≥13.5％评价容量反应性,其灵敏度为76.5％,特异度为66.7％.SVV预测容量反应性的AUC值为0.996;当SVV≥13.5％,其预测容量有反应的敏感性为94.1％,特异性为100％.在PLR前后CO的变化预测容量反应性的AUC值为0.984.当△CO≥0.62时,其预测容量反应性的敏感性为76.5％,特异性为100％.结论 PLR联合PVI可反映机体的容量状况,预测机体对液体治疗的反应性,可作为一种无创的方法指导容量治疗.     

主动脉峰值流速变异度联合被动抬腿试验评估重症急性胰腺炎休克患者容量反应性

目的探讨主动脉峰值流速变异度（?Vpeak_AO）联合被动抬腿试验（PLR）在重症急性胰腺炎（SAP）休克患者容量反应性中的预测价值。 方法选取2017年8月至2020年8月北京大学人民医院收治的SAP休克患者134例。记录患者临床资料，对患者进行PLR和容量负荷试验（VE），利用床旁超声仪器检测PLR和VE前后血流动力学及超声指标的变化。根据VE后每搏量（SV）变化值（?SV）是否≥15%将患者分为有反应组和无反应组。采用Pearson相关法分析?SV-VE与?Vpeak_AO-PLR的相关性。利用ROC曲线分析?Vpeak_AO联合PLR在SAP休克患者容量反应性评估中的预测价值。 结果PLR前，有反应组SV、Vpeak_AO均低于无反应组，差异均有统计学意义（P均=0.000）。PLR和VE后，有反应组SV、Vpeak_AO均高于PLR前，差异均有统计学意义（P均＜0.05）。PLR和VE后，有反应组?SV、?Vpeak_AO均高于无反应组，差异均有统计学意义（P均=0.000）。Pearson相关性分析显示，?Vpeak_AO-PLR与?SV-VE呈正相关（r=0.769，P＜0.05）。?Vpeak_AO-PLR预测SAP休克患者容量反应性的ROC曲线下面积为0.924（95%CI：0.879~0.969），临界值为10.9%时，敏感度为86.3%，特异度为88.5%。 结论?Vpeak_AO联合PLR在SAP休克患者容量反应性评估中具有良好的预测价值，对临床应用具有积极意义。     

肝颈返流试验对感染性休克患者容量反应性的评估

目的探讨肝颈返流试验（HRT）评估感染性休克患者容量反应性中的临床应用价值。 方法采用前瞻性队列研究评估感染性休克患者的容量反应性,以脉搏指示持续心排量测定（PiCCO）联合容量负荷试验（VE）获取的心输出量变异度（ΔCO_VE）为金标准,将ΔCO_VE≥15%定义为液体反应阳性,反之为液体反应阴性。所有患者进行HRT和VE,获取心率、平均动脉压（MAP）、中心静脉压（CVP）、心输出量（CO）及每搏输出量（SV）等血液动力学参数,其中包括HRT 15 s和60 s的数据,并与ΔCO_VE相比,获得相关性指标。以受试者工作特征曲线（ROC）分析HRT后ΔCO_HRT、ΔSV_HRT对容量反应性的评估价值。 结果60例感染性休克患者中,液体反应阳性组36例,液体反应阴性组24例,2组患者一般临床资料比较无统计学意义。与HRT前基线值1相比较,液体反应阳性组中HRT后15 s血液动力学参数CVP、CO、SV显著增加［CVP：（8.9±2.1）cmH₂O vs（7.8±1.9）cmH₂O,CO：（3.7±0.7）L/min vs（3.4±0.7）L/min,SV：（30.2±6.2）ml vs（27.2±6.7）ml,P<0.05］,而液体反应阴性组无显著变化（P>0.05）。HRT 15 s与60 s相比,心率、MAP、CVP、CO及SV差异均无统计学意义。VE试验中,液体反应阳性组VE后MAP、CVP、CO及SV较补液前基线值2有所增加［MAP：（75.7±7.3）mmHg vs（72.0±7.6）mmHg,CVP：（9.1±1.5）cmH₂O vs （8.0±1.8）cmH₂O,CO：（3.8±0.7）L/min vs （3.5±0.6）L/min,SV：（30.2±5.6）ml vs （27.2±6.7）ml,P<0.05］。相关性分析显示,ΔCO_HRT、ΔSV_HRT与ΔCO_VE具有相关性（r=0.82、0.83,P均<0.01）。此外,HRT中,以ΔCO_HRT=11.7%为阈值,预测容量反应性的曲线下面积为0.95±0.03（95%CI：0.903~1.00,P<0.01）,敏感度为91.7%,特异度为87.5%;以ΔSV_HRT=12.7%为阈值,预测容量反应性的曲线下面积为0.942±0.03（95%CI：0.884~0.999,P<0.01）,敏感度为83.3%,特异度为91.7%。 结论HRT利用自体输液原理判断容量反应性,是一种无创、操作便捷、较可靠的评估感染性休克患者容量反应性的新方法,值得临床推广应用。     

校正的脉搏压变异度对自主呼吸脓毒症患者液体反应性的评估

目的:研究在自主呼吸患者深吸气时潮气量（Vt DI）对脉搏压力变异度（ΔPP DI）的影响,并验证是否以Vt DI校正ΔPP DI可进一步提高预测液体反应性（fluid responsiveness,FR）的能力。 方法:前瞻性纳入2017年10月至2019年10月于武警特色医学中心和南京市高淳人民医院ICU确诊的、符合第三版国际共识诊断标准的自主呼吸的脓毒症和脓毒性休克患者,20 min内静脉输注生理盐水500 mL进行容量扩张（volume expansion,VE）,VE后每搏输出量变化率（ΔSV）≥15％为液体反应者,否则为液体无反应者。VE开始前,在平静呼吸以及深吸气时测量脉搏压力变异度（ΔPP TB和ΔPP DI）和潮气量（Vt TB和Vt DI）。采用多元线性回归分析ΔPP DI与Vt DI、ΔSV的关系,应用受试者工作特征曲线（ROC）下面积（AUC）以及灰区范围评估参数预测FR能力,并计算灰区范围误分类代价比（R）的不同而变化的情况。 结果:最终纳入31例患者,17例为液体反应者;液体反应者的ΔPP DI显著高于无反应者[（19.1±7.4）% vs（11.2±4.5）%, P=0.001]。ΔPP DI预测FR的AUC为0.832显著高于ΔPP TB的0.580（ P<0.05）。多元回归分析显示Vt DI和ΔSV均是ΔPP DI的独立影响因素（ P<0.01）;经Vt DI校正的ΔPP DI （ΔPP DI/Vt DI）的AUC显著高于单独使用ΔPP DI （ P=0.03）。采用正常液体策略时（R=1）,ΔPP DI/Vt DI的灰区范围为12.7~14.5,包含19%的患者;采用限制性液体策略时（R=2）,ΔPP DI/Vt DI灰区范围为12.8~14.5,仅包含6.5%的患者。 结论:在完全自主呼吸的脓毒症患者中,ΔPP DI预测FR具有中度的准确度,以Vt DI校正ΔPP DI后可进一步提高其预测价值。     

Passive leg raising as an indicator of fluid responsiveness in patients with severe sepsis

BACKGROUND:

In the management of critically ill patients, the assessment of volume responsiveness and the decision to administer a fluid bolus constitute a common dilemma for physicians. Static indices of cardiac preload are poor predictors of volume responsiveness. Passive leg raising (PLR) mimics an endogenous volume expansion (VE) that can be used to predict fluid responsiveness. This study was to assess the changes in stroke volume index (SVI) induced by PLR as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis.

METHODS:

This was a prospective study. Thirty-two mechanically ventilated patients with severe sepsis were admitted for VE in ICU of the First Affiliated Hospital, Zhejiang University School of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to December 2011. Patients with non-sinus rhythm or arrhythmia, parturients, and amputation of the lower limbs were excluded. Measurements of SVI were obtained in a semi-recumbent position (baseline) and during PLR by the technique of pulse indicator continuous cardiac output (PiCCO) system prior to VE. Measurements were repeated after VE (500 mL 6% hydroxyethyl starch infusion within 30 minutes) to classify patients as either volume responders or non-responders based on their changes in stroke volume index (ΔSVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between the two groups. The changes of ABPs, ABPm, CVPm, and SVI after PLR and VE were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and the change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS 17.0 software was used for statistical analysis.

RESULTS:

Among the 32 patients, 22 were responders and 10 were non-responders. After PLR among the responders, some hemodynamic variables (including ABPs, ABPd, ABPm and CVPm) were significantly elevated (101.2±17.6 vs.118.6±23.7, P=0.03; 52.8±10.7 vs. 64.8±10.7, P=0.006; 68.3±11.7 vs. 81.9±14.4, P=0.008; 6.8±3.2 vs. 11.9±4.0, P=0.001). After PLR, the area under curve (AUC) and the ROC curve of ΔSVI and ΔCVPm for predicting the responsiveness after VE were 0.882±0.061 (95%CI 0.759–1.000) and 0.805±0.079 (95%CI 0.650–0.959) when the cut-off levels of ΔSVI and ΔCVPm were 8.8% and 12.7%, the sensitivities were 72.7% and 72.7%, and the specificities were 80% and 80%.

CONCLUSION:

Changes in ΔSVI and ΔCVPm induced by PLR are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.KEY WORDS: Passive leg raising, Volume resuscitation, Hemodynamic monitoring, Stroke volume index, Central venous pressure, Severe sepsis, Fluid responsiveness, ROC curve     

呼气末正压对感染性休克患者心脏前负荷的影响

目的 探讨不同水平的呼气末正压(PEEP)对接受机械通气的感染性休克患者心脏前负荷的影响.方法 采用前瞻性、干预性的研究方法对北京协和医院MICU 15例行机械通气的感染性休克患者应用跨肺热稀释法及持续脉搏轮廓的方法进行血流动力学监测(PiCCOplus).所有患者采用容量控制通气,血流动力学稳定后,每隔1 h递增PEEP水平,PEEP从0增加20 cmH_2O(如果能耐受),根据不同的PEEP水平分为5组(0,5,10,15,20 cmH_2O).应用one-way ANOVA和Pearson's行统计分析及相关分析,观察在不同水平的PEEP对心脏前负荷的影响及其相关性.结果 15例感染性休克患者,男10例(67%),女5例(33%),年龄(67.6±19.5)岁,APACHEⅡ评分(22.1±7.5)分,基础PEEP水平(8.5±3.6)cmH_2O,基础PaO_2/FiO_2(225.6±89.2)mmHg,ICU病死率67%.随着PEEP的升高,CVP明显升高,不同水平的PEEP组差异具有统计学意义(p=0.002),而GEDI无明显变化,各组间差异无统计学意义.以PEEP0为基础值,不同PEEP水平的CVP,CI,GEDI与基础值之差为增量,发现△CI和△GEDI呈明显的正相关(r=0.6),而△CI和△CVP无明显的相关性.结论 在高PEEP存在的情况下,GEDI能够有效地评价心脏的前负荷.     

体循环平均充盈压与中心静脉压差变化对脓毒性休克患者液体反应性的评价

目的探讨体循环平均充盈压（Pmsf）与中心静脉压（CVP）差（Pmsf-CVP）变化［△（Pmsf-CVP）］评价脓毒性休克患者液体反应性的临床价值。 方法采用前瞻性观察性研究，选择2017年1至9月南京大学医学院附属鼓楼医院重症医学科收治的需要行机械通气的脓毒性休克患者。所有患者均实施容量负荷试验（VE）（20 min内输注0.9%NaCl 300 ml）。根据VE后心指数的增加值（△CI），分为有液体反应性组（≥10%）和无液体反应性组（<10%）。监测VE前后各项血流动力学参数［心率（HR）、平均动脉压（MAP）、CVP、外周血管阻力指数（SVRI）、胸腔内血容量指数（ITBVI）、血管外肺水指数（EVLWI）、每搏量变异度（SVV）、Pmsf、Pmsf-CVP、Pmsf变化（△Pmsf）、△（Pmsf-CVP）］。比较2组血流动力学指标是否存在差异，将存在差异的指标进一步通过受试者工作特征曲线（ROC）评估在容量反应性中的应用价值。 结果研究期间共纳入脓毒性休克患者20例，实施VE 26例次，其中有液体反应性17例次，无液体反应性9例次。VE前有液体反应性组患者Pmsf和Pmsf-CVP均明显低于无液体反应性组患者［（19.06±3.03）mmHg vs （23.00±5.96）mmHg，（8.29±3.92）mmHg vs （14.78±6.12）mmHg，1 mmHg=0.133 kPa］，差异均有统计学意义（t=-2.26、-3.30，均P<0.05）。有液体反应性组患者△Pmsf和△（Pmsf-CVP）均明显高于无液体反应性组患者［10.00（6.00，14.00）mmHg vs 4.00（1.00，9.50）mmHg，7.00（3.50，11.50）mmHg vs -1.00（-2.00，3.00）mmHg］，差异均有统计学意义（z=-2.57、-2.75，均P<0.05）。ROC曲线分析显示，VE前Pmsf、VE前（Pmsf-CVP）、△Pmsf和△（Pmsf-CVP）评估容量反应性的曲线下面积（AUC）分别为0.739、0.810、0.810、0.902，明显高于△CVP（AUC=0.654）。当VE前Pmsf的最佳临界值为21.98 mmHg时，敏感度为88.2%，特异度为66.7%；当VE前（Pmsf-CVP）的最佳临界值为11.48 mmHg时，敏感度为88.2%，特异度为77.8%；当△Pmsf的最佳临界值为5.5 mmHg时，敏感度为82.4%，特异度为66.7%；当△（Pmsf-CVP）的最佳临界值为3.5 mmHg时，敏感度为76.5%，特异度为100.0%。 结论VE前Pmsf、VE前（Pmsf-CVP）、△Pmsf和△（Pmsf-CVP）均能较好地评估机械通气脓毒性休克患者的液体反应性，以△（Pmsf-CVP）准确性最高。     

每搏量变异对老年严重脓毒症患者液体反应的预测

目的 评价每搏量变异(SVV)预测机械通气老年严重脓毒症患者的液体反应性.方法 采用前瞻性临床研究方法,在液体复苏过程中共对17例机械通气的老年严重脓毒症患者进行31次液体负荷试验.采用脉搏波指示剂连续心排血量(PiCCO)技术监测SVV.将液体负荷后心脏指数(CI)增加值(ΔCI)≥10%定义为液体反应阳性.观察液体负荷试验前后血流动力学及肺水指标的变化,评价SVV、中心静脉压(CVP)与ΔCI的相关性.结果 液体负荷后SVV显著降低[(6.6±2.1)%比(12.1±3.7)%,P<0.01],CVP显著增高[(12.5±3.6) mm Hg比(8.9±4.1) mm Hg,1 mm Hg=0.133 kPa,P＜0.01].直线相关分析显示,液体负荷前SVV与ΔCI显著相关(r=0.447,P=0.012),CVP与ΔCI无直线相关关系(r=0.082,P=0.674).受试者工作特征曲线(ROC曲线)分析示,液体负荷前SVV、CVP与CI的曲线下面积(AUC)分别为0.672[95%可信区间(95%CI)0.463～0.885]和0.336(95%CI 0.133～0.539).SVV为11.5%时对液体反应的敏感性为71%,特异性为67%.结论 SVV能反映机械通气状态下老年脓毒症患者液体复苏时的液体反应性,可作为指导老年严重脓毒症患者液体治疗的指标.     

胸腔内血容量指数在感染性休克患者液体管理中的应用

目的 探讨胸腔内血容量指数(ITBVI)在感染性休克患者液体管理中的应用价值.方法 采用前瞻性临床观察研究方法,将入住重症监护病房(ICU)的33例感染性休克患者分为两组.ITBVI组17例患者接受脉搏指示连续心排血量(PiCCO)监测,以ITBVI作为液体管理的指导指标;对照组16例患者以中心静脉压(CVP)作为液体管理的指导指标.对比两组患者治疗1 d和3 d时的急性生理学与慢性健康状况评分系统I(APACHE I)评分、感染相关器官功能衰竭评分系统(SOFA)评分、血管活性药物评分,以及补液72 h内两组患者的液体管理数据.结果 ①ITBVI组3 d时APACHE I、SOFA和血管活性药物评分(分)均较1 d时显著下降[21.3±6.2比25.4±7.2,6.1±3.4比9.0±3.5,5.0(0,8.0)比20.0(8.0,35.0),均P＜0.01];而对照组则均无显著变化.②虽然ITBVI组48～72 h液体出量(ml)大于对照组(2 421±868比1 721±934,P=0.039),但ITBVI组与对照组0～72 h的液体出入量和平衡量(ml)比较差异均无统计学意义(入量:9 918±137比10 529±1 331,出量:6 035±1 739比5 827±2 897,平衡量:3 882±1 889比4 703±2 813,均P＞0.05).③在快速补液试验中,ITBVI组与对照组患者除0～6 h胶体液入量[ml:250(125,500)比250(69,250)]差异无统计学意义(P＞0.05)外,其余时段液体入量(ml)ITBVI组均比对照组高[0～6 h晶体液:250(150,250)比125(105,125),6～72 h晶体液:125(125,250)比100(56,125),0～72 h晶体液:250(125,250)比125(75,125),6～72 h胶体液:125(106,250)比75(50,125),0～72 h胶体液:200(125,250)比100(50,125),均P＜0.01].结论 与以CVP指导相比,用ITBVI指导感染性休克患者的液体管理显示,3 d时患者病情较1 d改善,这种改善可能得益于对血容量状态的准确判断和适当的快速补液速度.