心脏术中肺动脉导管和食管超声监测对容量反应的敏感性及特异性分析  

The analysis of the sensitivity and specificity by pulmonary artery catheter and transesophageal echocar-diography regarding volume responsiveness in cardiac surgery

作　　者：缪娟娟[1] 史宏伟[1] 赵雅梅[1] 王振红[1] 葛亚力[1] 魏海燕[1] 

机构地区：[1]南京医科大学附属南京医院南京市第一医院麻醉科,210006

出　　处：《临床麻醉学杂志》2014年第7期629-633,共5页Journal of Clinical Anesthesiology

摘　　要：目的：比较 Swan-Ganz 肺动脉导管的肺动脉阻塞压（PAOP）、CVP、右室舒张末容量（RVEDV）和经食管超声心动图（TEE）的左室舒张末面积（LVEDA）、下腔静脉内径（IVC）对容量反应的敏感性及特异性。方法选择 ASA Ⅱ或Ⅲ级的12例择期行冠状动脉搭桥的患者作为研究对象。麻醉诱导插管后置入 Swan-Ganz 肺动脉导管并放置 TEE 探头,记录切皮前（T0）、停止心肺转流后或非心肺转流下手术血管吻合完成后20 min 即快速补液前（T1）、补液后10 min（T2）和30 min （T3）的各项数据。结果与 T1时比较,T2时 PAOP、IVC、LVEDA、经左室流出道心排血量（COLVOT ）明显增高（P 〈0.01）。T2与 T1时的差值（△值）,△CVP、△PAOP、△RVEDV 与△COLVOT无明显相关性（r=-0.2985、r=-0.0918、r=-0.2436）,△IVC、△LVEDA 与△COLVOT 呈正相关（r=0.4450、r =0.6120）。以15% COLVOT 的变化作为判断标准,CVP、PAOP、RVEDV、IVC 和LVEDA 的曲线下面积（AUC）分别为0.389（95%CI 0.035-0.743）、0.458（95%CI 0.109-0.807）、0.333（95%CI 0-0.671）、0.903（95% CI 0.701-1.000）和0.889（95% CI 0.661-1.000）。结论 PAOP、IVC、LVEDA、CO 对液体的变化较敏感,而 CVP 和 RVEDV 反应液体的变化较差,基于TEE 的 IVC 和 RVEDA 在判断 CO 增加和指导容量治疗方面更具有优势。Objective To analyze the sensitivity and specificity of several volume parameters regarding volume responsiveness.The studied volume parameters include pulmonary artery obstruc-tion pressure （PAOP）,central venous pressure （CVP）,right ventricular end-diastolic volume （RV-EDV）measured by Swan-Ganz pulmonary artery catheter and left ventricular end-diastolic area （LVEDA）,inferior vena cava diameter （IVC）measured by transesophageal echocardiography （TEE）. Methods Twelve patients with ASA Ⅱ or Ⅲ,scheduled for coronary artery bypass grafting were studied.After anesthesia induction,the TEE probe was put into the esophagus and Swan-Ganz cathe-ter was placed in right internal jugular venous.Measurements were made at the time before cutting the skin （T0 ）,20 min after divorcing from cardiopulmonary bypass or finishing vascular anastomosis in off-pump surgery（T1 ）,10 min after rapid infusion （T2 ）and 30 min after rapid infusion （T3 ）,re-spectively.Results The values of PAOP,IVC,LVEDA,COLVOT at time T2 increased significantly compared to those at time T1 （P 〈0.01）.No obvious correlation （r=-0.298 5、r=-0.091 8、r=-0.243 6）was observed between △CVP、△PAOP、△RVEDV and △COLVOT （the difference between T2 and T1 ）;Meanwhile,△IVC and △LVEDA were well correlated to △COLVOT （r= 0.445 0、r=0.612 0）.Using more than 1 5% change of COLVOT after volume expansion as definition of positive re-sponse,the areas under the receiver operating characteristic curves of CVP,PAOP,RVEDV,IVC and LVEDA were 0.389 （95% CI 0.035-0.743 ）,0.458 （95% CI 0.109-0.807 ）,0.333 （95% CI 0-0.671 ）, 0.903 （95% CI 0.701-1.000 ） and 0.889 （95% CI 0.661-1.000 ）, respectively. Conclusion PAOP,IVC,LVEDA,CO are more sensitive to the change of volume;while CVP and RVEDV have weak responses to volume changes.This indicates that IVC and RVEDA have more ad-vantage to estimate cardiac output increase and guide volume therapy.

关 键 词：经食管超声心动图 肺动脉导管 容量反应 ROC 分析 

分 类 号：R614[医药卫生—麻醉学]