超声测量上腔静脉血流评估机械通气患者容量反应性  

The assessment of ultrasonic measurement of superior vena cava blood flow for the volume responsiveness of patients with mechanical ventilation

作　　者：郭喆[1] 何伟[1] 侯静[1] 李彤[1] 周华[1] 许媛[1] 席修明[1] 

机构地区：[1]首都医科大学附属北京同仁医院重症医学科,100730

出　　处：《中华危重病急救医学》2014年第9期624-628,共5页Chinese Critical Care Medicine

基　　金：国家科技支撑计划项目（2012BAI11B05）

摘　　要：目的 探讨经胸壁多普勒超声测量上腔静脉流速随呼吸变异度对机械通气患者容量反应性的评估作用.方法 采用前瞻性队列研究方法,选择2011年4月至2013年4月收治于首都医科大学附属北京同仁医院重症医学科接受机械通气、并存在组织灌注不足的重症患者.于30 min内静脉输注林格液500 mL进行容量负荷试验,按扩容前脉压差变异度（PPV）将患者分为有反应组（PPV≥13％）和无反应组（PPV＜13％）.测量扩容前后同一呼吸周期中上腔静脉流速（A、S、D峰）最大值及最小值,计算其变异度（ΔA、ΔS、ΔD）,并绘制受试者工作特征曲线（ROC曲线）,评估上腔静脉流速对容量反应的价值.结果 共27例患者入选,有反应组14例,无反应组13例.有反应组患者扩容后上腔静脉A、S、D峰流速（cm/s）较扩容前明显增快（A峰：34.6±2.2比31.3±2.1,t =-2.493,P=0.027;S峰：39.1±1.3比35.3±2.1,t=-2.564,P=0.024;D峰：28.1±1.2比23.3±1.4,t=-4.995,P=0.000）;而扩容后ΔA、ΔS、ΔD无明显变化.ΔA、ΔS、ΔD与PPV呈正相关（r1=0.040,P1=0.854;r2=0.350,P2=0.074;r3=0.749,P3=0.000）.S峰的ROC曲线下面积（AUC）0.36[95％可信区间（95％CI）0.11 ～0.52],ΔS的AUC达0.68（95％CI 0.47 ～ 0.89）;D峰的AUC 0.41（95％CI 0.19 ～ 0.63）,ΔD的AUC高达0.95（95％CI为0.86～ 1.00）,说明上腔静脉峰流速随呼吸变异度预测容量反应的准确性优于单纯峰流速.以ΔS≥20.7％为截点,敏感度为78.6％,特异度为61.5％;以ΔD≥12.7％为截点,敏感度为92.0％,特异度为92.3％.结论 经胸壁多普勒超声测量上腔静脉峰流速随呼吸变异度可用于机械通气患者容量反应性的评估.Objective To approach the evaluative effect of respiratory variation of superior vena cava peak flow velocity measured using transthoracic echocardiography （TTE） on fluid responsiveness in patients with mechanical ventilation.Methods A prospective cohort study was conducted.All mechanical ventilated critically ill patients whose fluid therapy was planned due to hypovolemia in Department of Critical Care Medicine of Beijing Tongren Hospital of Capital Medical University from April 2011 to April 2013 were enrolled.Volume expansion was performed with 500 mL Linger solution within 30 minutes.Patients were classified as responders if pulse pressure variation （PPV） increased ≥ 13% before volume expansion.The respiratory variation in superior vena cava peak velocity was calculated as the difference between maximum and minimum values of velocity in peak A,peak S and peak D over a single respiratory circle,and their variations （ΔA,ΔS,ΔD） were also calculated.The receiver operating characteristic curve （ROC curve） was plotted to assess the evaluative effect of respiratory variation of superior vena cava peak velocity on fluid responsiveness.Results Twenty-seven patients were enrolled in this study.Volume expansion increased PPV ≥ 13% happened in 14 patients （responders）.The velocity of superior vena cava in peak A,peak S,peak D was significantly increased after volume expansion compared with that before volume expansion in responders [peak A （cm/s）：34.6 ± 2.2 vs.31.3 ±2.1,t=-2.493,P=0.027; peak S （cm/s）：39.1 ± 1.3 vs.35.3 ±2.1,t=-2.564,P=0.024; peak D （cm/s）：28.1 ± 1.2 vs.23.3 ± 1.4,t=-4.995,P=0.000],but there was no significant difference in ΔA,ΔS and ΔD between before and after volume expansion.The ΔA,ΔS and ΔD were positively correlated with PPV （r=0.040,P=0.854; r=0.350,P=0.074; r=0.749,P=0.000）.The area under ROC curve （AUC） of peak S was 0.36 [95% confidence interval （95%CI）：0.11-0.52],but the AUC of ΔS was 0.68 （95%CI 0.47-0.89）,the AUC of p

关 键 词：机械通气 容量反应性 上腔静脉流速 经胸壁多普勒超声 

分 类 号：R459.7[医药卫生—急诊医学]