被动抬腿试验对脓毒症合并心功能不全患者液体反应性的预测价值  

The value of passive leg raising test in predicting fluid responsiveness in Patients with sepsis-induced cardiac dysfunction

作　　者：司向[1] 黄牧云 陈娟[1] 欧阳彬[1] 陈敏英[1] 蔡常洁[1] 吴健峰[1] 刘紫锰[1] 刘勇军[1] 黄顺伟[1] 黎丽芬 管向东[1] 

机构地区：[1]中山大学附属第一医院SICU,广东广州510080

出　　处：《中华危重病急救医学》2015年第9期729-734,共6页Chinese Critical Care Medicine

基　　金：广东省重大科技专项资助（2012A080204018）;国家临床重点专科建设项目（2011-872）

摘　　要：目的探讨被动抬腿试验（PLR）在脓毒症合并心功能不全患者中对液体反应性的预测价值。方法采用前瞻性观察性队列研究方法，选择2013年9月至2014年7月中山大学附属第一医院外科重症监护中心连续收治的38例行机械通气的脓毒症合并心功能不全患者，分别于PLR前（床头抬高450、患者半卧位）、PLR时（患者仰卧位，下肢抬高45°）、容量负荷试验（VE）前（恢复半卧位）和VE时（30min内输注250mL 5％人血白蛋白）4个阶段记录血流动力学指标；根据VE后每搏量变化（△SV VE）是否≥15％分为对液体复苏有反应组和液体无反应组。对各血流动力学指标变化值之间进行线性相关分析，并通过受试者工作特征曲线（ROC）评价PLR前后各项血流动力学指标变化预测患者液体反应性的价值。结果38例患者中25例为有反应组，13例为无反应组。两组基线资料及初始半卧位时的血流动力学指标差异均无统计学意义。有反应组实施PLR后引起的SV及心排血量（CO）变化（△SVPLR、△COPLR）较无反应组明显升高（△SVPLR=（14．7±5．7）％比（6．4±5．3）％，t=4．304，P=0．000；△COPLR：（11．2±7．5）％比（3．4±2．3）％，t=3．454，P=0．001]，而PLR引起的收缩压、平均动脉压、脉搏压、心率的变化（△SBP PLR、△MAP PLR、△PP PLR、△HRPLR）在两组之间差异无统计学意义；有反应组△SV VE较无反应组明显升高[（20．8±5．5）％比（5．0±3．7）％，t=8．347，P=0．000]。相关性分析显示，△SV PLR与△SV VE呈显著正相关（r=0．593，P=0．000），△COPLR与△SV VE呈显著正相关（r=0．494，P=0．002）。以△SV PLR≥8．1％预测患者液体反应性的ROC曲线下面积（AUC）为0．860±0．062（P=0．000），敏感度为92．0％，特异度为70．0％；以△CO PLR≥5．6％预测患者液体反应性的AUC为0．840±0．070（P=O．001），敏感�Objective To assess the value of passive leg raising （PLR） test in predicting fluid responsiveness in patients with sepsis-induced cardiac dysfunction. Methods A prospective observational cohort study was conducted. Thirty-eight patients under mechanical ventilation suffering from sepsis-induced cardiac dysfunction admitted to Department of Surgical Intensive Care Unit of First Affiliated Hospital of Sun Yat-Sen University from September 2013 to July 2014 were enrolled. The patients were studied in four phases： before PLR （semirecumbent position with the trunk in 45°）, PLR （the lower limbs were raised to a 45° angle while the trunk was in a supine position）, before volume expansion （VE, return to the semi-recumbent position）, and VE with infusing of 250 mL 5% albumin within 30 minutes. Hemodynamic parameters were recorded in every phase. The patients were classified into two groups according to their response to VE： responders （at least a 15% increase in stroke volume,△SV VE ≥ 15% ）, and non-responders. The correlations among all changes in hemodynamic parameters were analyzed by linear correlation analysis, and the receiver operating characteristic curve （ROC） was plotted to assess the value of hemodynamic parameters before and after PLR in predicting fluid responsiveness. Results Of 38 patients, 25 patients were responders, and 13 non-responders. There was no significant difference in the baseline and hemodynamic parameters at semi-recumbent position between the two groups. The changes in SV and cardiac output （CO） after PLR （ △SV PLR and A COpLR） were significantly higher in responders than those of non-responders [△SV PLR： （ 14.7 ± 5.7 ）% vs. （6.4 ± 5.3）%, t = 4.304, P = 0.000; △CO PLR：（11.2 ± 7.5 ）% vs. （3.4 ± 2.3 ）%, t = 3.454, P = 0.001 ], but there was no significant difference in the changes in systolic blood pressure, mean arterial pressure, pulse pressure, and heart rate after PLR （△SBP PLR, △MAP PLR, △ PP PLR and △HR PLR

关 键 词：脓毒症 心功能不全 被动抬腿试验 液体反应性 

分 类 号：R459.7[医药卫生—急诊医学] R541.6[医药卫生—治疗学]