床旁经胸心脏超声在脓毒性休克患儿容量反应性评估中的应用  

Application of bedside transthoracic echocardiography in volume response assessment of children with septic shock

作　　者：周芹 任兴琼 张国英 罗小丽 卢宾 赵亚凡 肖琴 王孟 Zhou Qin;Ren Xingqiong;Zhang Guoying;Luo Xiaoli;Lu Bin;Zhao Yafan;Xiao Qin;Wang Meng(Pediatric Intensive Care Unit,Chengdu Women′s and Children′s Central Hospital,School of Medicine,University of Electronic Science and Technology of China,Chengdu 610091,China)

机构地区：[1]电子科技大学医学院附属妇女儿童医院成都市妇女儿童中心医院PICU,610091

出　　处：《中国小儿急救医学》2021年第3期176-180,共5页Chinese Pediatric Emergency Medicine

基　　金：四川省卫生健康委员会科研项目(17PJ272)。

摘　　要：目的:探讨床旁经胸超声心动图(TTE)在脓毒性休克患儿容量反应性评估中的应用价值。方法:前瞻性纳入2017年1月至2020年6月入住PICU需机械通气的脓毒性休克患儿共41例,年龄1-5岁。在完全机械通气、充分镇静镇痛、无自主呼吸情况下(潮气量8-10 mL/kg),给予患儿容量负荷试验。容量负荷前后测量患儿的心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、射血分数(EF)等一般血流动力学指标,同时无创心输出量监测仪(NICOM)和TTE测量心脏指数(CI)、每搏量指数(SVI)、每搏量变异度(SVV);此外,TTE测量主动脉流速时间积分变异度(ΔVTI )、下腔静脉变异度(ΔIVC)、下腔静脉膨胀指数(dIVC)。以ΔSVI_( NICOM)≥15%定义为有容量反应性,将患儿分为有容量反应组和无容量反应组。统计分析SVV_(TTE)、ΔVTI、ΔIVC、dIVC、ΔCVP、SVV_(NICOM)预测容量反应性的价值。 结果:(1)有容量反应组23例,无容量反应组18例。两组患儿的一般血流动力学指标HR、MAP、CVP、EF、CI_(NICOM)、CI_(TTE)无统计学差异( P>0.05)。(2)有容量反应组补液后HR、MAP、CI、SVI、CVP均较补液前改善( P<0.001),无容量反应组仅CVP在补液后明显升高,其余指标在补液后无改善( P>0.05)。(3)容量负荷前,有容量反应组的SVV_(TTE)、ΔVTI 、ΔIVC、dIVC均较无容量反应组高( P均<0.001);容量负荷后,有容量反应组的SVV_(TTE)、ΔVTI 、ΔIVC、dIVC均明显减低,无容量反应组只有ΔIVC指标在容量负荷后明显减低,SVV、ΔVTI、dIVC在容量负荷前后无统计学差异。(4)ROC曲线分析提示,SVV_(TTE)和ΔVTI的曲线下面积为0.971,以12.04%为临界值,其灵敏性0.957、特异性0.944;ΔIVC的曲线下面积0.981,以25.98%为临界值,其灵敏性0.870、特异性1.000;dIVC的曲线下面积0.980,以29.86%为临界值,其灵敏性0.870、特异性1.000;ΔCVP的曲线下面积0.778,以2.5 cmH_(2)O(1 cmH_(2)O=0.098 kPa)为临界值,其灵敏性0.913、特异性0.556;SVV_(NICObjective To investigate the value of bedside transthoracic echocardiography(TTE)in volume reactivity assessment of children with septic shock.Methods A total of 41 children aged from 1 to 5 years with septic shock requiring mechanical ventilation admitted to PICU from January 2017 to June 2020 were prospectively included.Under the condition of complete mechanical ventilation,full sedation and analgesia,and no spontaneous breathing(tidal volume 8 to 10 mL/kg),volume expansion was given to children.Hemodynamic indexs such as cardiac index(CI),stroke volume index(SVI)and stroke volume variability(SVV)were measured before and after volume expansion by noninvasive cardiac output monitoring(NICOM)and TTE.Moreover,aortic flow velocity time integral variable degrees(ΔVTI),inferior vena cava variability(ΔIVC)and inferior vena cava dilation index(dIVC)were also measured by TTE.Patients were considered to be responsive to volume expansion if SVI_(NICOM)increased≥15%.Based on the responsiveness of volume expansion,all the patients were divided into response group and non-response group.The value of SVV_(TTE),ΔVTI,ΔIVC,dIVC,ΔCVP and SVV_(NICOM)in predicting volume responsiveness were analysed.Results(1)There were 23 cases in response group and 18 cases in non-response group.Before volume expansion,there were no statistically significant differences in general hemodynamic indexes HR,MAP,CVP,EF,CI_(NICOM),and CI_(TTE)between two groups(P>0.05).(2)In response group,HR,MAP,CI,SVI and CVP were all improved after volume expansion(P<0.001).In non-response group,only CVP was significantly increased after volume expansion,while other indexes were not improved(P>0.05).(3)Before the volume expansion,SVV_(TTE),ΔVTI,ΔIVC,and dIVC in response group were higher than those in non-response group(P<0.001).After volume expansion,these indicators were significantly reduced in response group.In non-response group,onlyΔIVC significantly reduced after volume expansion.(4)The receiver-operating characteristic curve analysis showed that th

关 键 词：床旁经胸超声心动图 容量反应性 儿童 脓毒性休克 动态指标 

分 类 号：R720.597[医药卫生—急诊医学]