肱动脉峰流速变异度和下腔静脉呼吸变异度 对容量反应性的评估作用  

Measurement of brachial artery velocity variation and inferior vena cava variability to estimate fluid responsiveness

作　　者：朱炜华[1] 万林骏[1] 万晓红[1] 王刚[1] 苏关仙[1] 廖庚进[1] 黄青青[1] 

机构地区：[1]昆明医科大学第二附属医院重症医学科,云南昆明650101

出　　处：《中华危重病急救医学》2016年第8期713-717,共5页Chinese Critical Care Medicine

基　　金：云南省卫生科技内设研究机构项目（2011WS0104）

摘　　要：目的：探讨肱动脉峰流速变异度（ΔVpeakbrach）、下腔静脉呼吸变异度（VIVC）对重症患者容量反应性判断的准确性和可行性。方法采用单中心前瞻性观察性研究方法，选取2013年6月至2015年8月昆明医科大学第二附属医院重症医学科收治的有自主呼吸行机械通气严重脓毒症或脓毒性休克患者。应用床旁便携式超声仪测量肱动脉峰流速、吸气末及呼气末下腔静脉直径，计算ΔVpeakbrach和VIVC；分别于容量负荷试验（VE）前后记录患者血流动力学参数；采用脉搏指示连续心排血量监测技术（PiCCO）测量每搏量（SV），以VE试验后SV增加值（ΔSV）≥15%作为有容量反应性的标准将患者分为有反应组和无反应组。根据受试者工作特征曲线（ROC）确定ΔVpeakbrach和VIVC判断容量反应性的敏感度和特异度。结果共纳入58例患者，有容量反应组32例，无反应组26例。两组患者性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、血管活性药物使用剂量、呼吸机参数以及感染部位等比较差异均无统计学意义。与VE试验前比较，有反应组VE试验后心率（HR）下降（次/min：95±18比103±21）、收缩压（SBP）上升〔mmHg（1mmHg＝0.133kPa）：92±8比80±7〕，无反应组VE试验后中心静脉压（CVP）上升（mmHg：11±4比8±3，均P＜0.05）。有反应组ΔVpeakbrach〔（15.4±4.3）%比（11.2±3.5）%〕和VIVC〔（18.6±4.1）%比（14.3±3.6）%〕均明显高于无反应组（均P＜0.05）。ΔVpeakbrach评估容量反应性的ROC曲线下面积（AUC）为0.816，以≥13.3%为临界点时敏感度为71.9%，特异度为80.8%；VIVC评估容量反应性的AUC为0.733，以≥19.25%为临界点时敏感度为53.1%，特异度为88.5%。结论ΔVpeakbrach和VIVC可以作为临床判断重症患者容量反应性的指标。Objective To investigate the accuracy and feasibility of brachial artery peak velocity variation （ΔVpeakbrach） and inferior vena cava variability （VIVC） as indicators of fluid responsiveness in critically ill patients. Methods A single-center prospective observation was conducted. The patients on mechanical ventilation with spontaneously breathing admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from June 2013 to August 2015 were enrolled. The patients were diagnosed as severe sepsis or sepsis shock. The peak velocity in brachial artery and diameter of the inferior vena cava at the end of inspiration and expiration was measured by bedside portable ultrasonic machine, and then ΔVpeakbrach and VIVC were calculated. The hemodynamic parameters were collected at baseline and after volume expansion （VE）. The stroke volume （SV） was measured by pulse-indicated continuous cardiac output （PiCCO）. Patients were classified as responders or non-responders according to the variation of SV （ΔSV） increased ≥ 15% or not after VE. Receiver operating characteristic curve （ROC） was plotted to evaluate the sensitivity and specificity of ΔVpeakbrach and VIVC in predicting volume responsiveness. Results Among 58 patients after VE, 32 patients were defined as responders and the rest 26 were defined as non-responders.There were no differences in gender, age, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score, dose of vasoactive agent, ventilator parameters and infection site. Compared with baseline hemodynamic parameters, heart rate （HR） was decreased （bpm： 95±18 vs. 103±21）, and systolic blood pressure （SBP） was increased [mmHg （1 mmHg = 0.133 kPa）： 92±8 vs. 80±7] after VE in responders; central venous pressure （CVP） was increased after VE in non-responders （mmHg： 11±4 vs. 8±3, all P 〈 0.05）. The ΔVpeakbrach [（15.4±4.3）% vs. （11.2±3.5）%] and VIVC [（18.6±4.1）% vs. �

关 键 词：肱动脉峰流速变异度 下腔静脉呼吸变异度 脓毒症 容量反应性 

分 类 号：R459.7[医药卫生—急诊医学]