下腔静脉变异度在冠状动脉搭桥术后患者容量反应性评估中的作用  

Effect of inferior vena cava variability in the assessment of volumetric reactivity in patients with coronary artery bypass grafting

作　　者：肖继来[1] 聂帅[1] 章文豪[1] 宋晓春[1] 施乾坤[1] 赵谊[1] 徐巧莲[1] 穆心苇[1] Xiao Jilai;Nie Shuai;Zhang Wenhao;Song Xiaochun;Shi Qiankun;Zhao Yi;Xu Qiaolian;Mu Xinwei(Department of Critical Care Medicine,Nanjing Hospital Affiliated to Nanjing Medical University,Nanjing 210006,China)

机构地区：[1]南京医科大学附属南京医院重症医学科,南京210006

出　　处：《中华危重症医学杂志（电子版）》2017年第6期391-396,共6页Chinese Journal of Critical Care Medicine:Electronic Edition

基　　金：南京市卫生和计划生育委员会计划项目(YKK15099)

摘　　要：目的探讨下腔静脉变异度(IVCV)在冠状动脉搭桥术(CABG)后患者容量反应性评估中的指导意义。方法选取22例冠状动脉搭桥术后放置肺动脉漂浮导管(PAC)的机械通气患者,在入ICU病房加强监护的第1小时分别进行被动抬腿试验(PLR),将PLR后心输出量上升≥15%的患者纳入容量反应阳性组,心输出量上升<15%的患者纳入容量反应阴性组。记录两组患者PLR前后的心率、动脉血压、中心静脉压、肺动脉楔压、心输出量、右室舒张末期容积指数(EDVI)、每搏输出量等血流动力学参数及心脏超声指标包括下腔静脉内径最大值(IVCmax)、下腔静脉内径最小值(IVCmin)和IVCV水平。对两组患者的一般资料、血流动力学参数以及心脏超声指标进行比较,采用受试者工作特征曲线(ROC)评价IVCV对容量反应性的预测价值。结果两组患者年龄[(64±8)岁vs.(69±6)岁]、性别比(10/6 vs.3/3)、急性病生理学和长期健康评价(APACHE)Ⅱ评分[(11.6±2.7)分vs.(12.7±2.4)分]、体外循环时间[(52±32)min vs.(68±34)min]、机械通气时间[(11±5)h vs.(12±6)h]及住ICU时间[(1.8±1.0)d vs.(1.7±0.5)d]等方面比较,差异均无统计学意义(P均>0.05)。容量反应阳性组患者PLR前心输出量[(4.5±0.8)mL/m2 vs.(5.0±0.8)mL/m2]、每搏输出量[(56±9)mL vs.(62±11)mL]及IVCmin[(1.61±0.28)cm vs.(9±3)cm]水平较容量反应阴性组均显著降低(t=2.586、2.236、4.217,P=0.012、0.021、<0.001);而IVCV[(21±7)%vs.(68±34)%]水平比较发现,容量反应阳性组高于容量反应阴性组(t=9.242,P<0.001)。ROC曲线分析显示IVCV的曲线下面积为0.941(95%CI:0.879~1.000,P<0.001),其对CABG后患者容量反应性具有预测价值。结论 IVCV可以作为CABG后患者容量反应性预测的有效指标。Objective To investigate the significance of inferior vena cava variability(IVCV)in the evaluation of volumetric reactivity in patients with coronary artery bypass grafting(CABG).Methods Totally 22 mechanical ventilation patients with pulmonary artery catheter(PAC)after CABG were collected,and the passive leg raising(PLR)tests were carried out on them in the first hour of intensive monitoring in the ICU ward.Patients with elevated cardiac output≥15%after PLR were included in the volume-reactive positive group,while patients with elevated cardiac output<15%were included in the volume-reactive negative group.The hemodynamic parameters of heart rate,arterial blood pressure,central venous pressure,pulmonary artery wedge pressure,cardiac output,end-diastolic volume index(EDVI),stroke volume,and the echocardiographic indexes of the maximum diameter of the inferior vena cava(IVCmax),the minimum diameter of the inferior vena cava(IVCmin)and the IVCV expression were all recorded before and after PLR in both groups.The general data,hemodynamic parameters and echocardiographic indexes of the two groups were compared,and then the predictive value of IVCV to volumetric reactivity was evaluated by the receiver operating characteristic curve(ROC).Results The age[(64±8)years vs.(69±6)years],the sex ratio(10/6 vs.3/3),the acute physiology and chronic health evaluation(APACHE)Ⅱscores[(11.6±2.7)vs.(12.7±2.4)],the extracorporeal circulation time[(52±32)min vs.(68±34)min],the mechanical ventilation time[(11±5)h vs.(12±6)h]and the ICU residence time[(1.8±1.0)d vs.(1.7±0.5)d]all showed no statistically significant difference between the two groups(all P>0.05).The expressions of cardiac output[(4.5±0.8)mL/m2 vs.(5.0±0.8)mL/m2],the stroke volume[(56±9)mL vs.(62±11)mL]and the IVCmin[(1.61±0.28)cm vs.(9±3)cm]before PLR were all significantly lower in the volume-reactive positive group compared to the volume-reactive negative group(t=2.586,2.236,4.217;P=0.012,0.021,<0.001).Meanwhile,the expression of IVCV[(21±7)%vs.(

关 键 词：下腔静脉变异度 容量反应性 被动抬腿试验 冠状动脉搭桥术 

分 类 号：R654.2[医药卫生—外科学]