校正的脉搏压变异度对自主呼吸脓毒症患者液体反应性的评估  

Ability of adjusted pulse pressure variation in predicting fluid responsiveness in spontaneously breathing patients with sepsis

作　　者：刘阳 张鑫 李小石 周国平 李萍 于鑫 李国锋 Liu Yang;Zhang Xin;Li Xiaoshi;Zhou Guoping;Li Ping;Yu Xin;Li Guofeng(Department of Critical Care Medicine,Nanjing Gaochun People's Hospital,Nanjing 211300,China;Department of Respiratory and Critical Care Medicine,Characteristic Medical Center of Chinese People's Armed Police Force,Tianjin 300162,China)

机构地区：[1]南京市高淳人民医院重症医学科,211300 [2]武警特色医学中心呼吸与重症医学科,天津300162

出　　处：《中华急诊医学杂志》2021年第7期841-847,共7页Chinese Journal of Emergency Medicine

摘　　要：目的研究在自主呼吸患者深吸气时潮气量(Vt_(DI))对脉搏压力变异度(ΔPP_(DI))的影响,并验证是否以Vt_(DI)校正ΔPP_(DI)可进一步提高预测液体反应性(fluid responsiveness,FR)的能力。方法前瞻性纳入2017年10月至2019年10月于武警特色医学中心和南京市高淳人民医院ICU确诊的、符合第三版国际共识诊断标准的自主呼吸的脓毒症和脓毒性休克患者,20 min内静脉输注生理盐水500 mL进行容量扩张(volume expansion,VE),VE后每搏输出量变化率(ΔSV)≥15%为液体反应者,否则为液体无反应者。VE开始前,在平静呼吸以及深吸气时测量脉搏压力变异度(ΔPPTB和ΔPP_(DI))和潮气量(VtTB和Vt_(DI))。采用多元线性回归分析ΔPP_(DI)与Vt_(DI)、ΔSV的关系,应用受试者工作特征曲线(ROC)下面积(AUC)以及灰区范围评估参数预测FR能力,并计算灰区范围误分类代价比(R)的不同而变化的情况。结果最终纳入31例患者,17例为液体反应者;液体反应者的ΔPP_(DI)显著高于无反应者[(19.1±7.4)%vs(11.2±4.5)%,P=0.001]。ΔPP_(DI)预测FR的AUC为0.832显著高于ΔPPTB的0.580(P<0.05)。多元回归分析显示Vt_(DI)和ΔSV均是ΔPP_(DI)的独立影响因素(P<0.01);经Vt_(DI)校正的ΔPP_(DI)(ΔPP_(DI)/Vt_(DI))的AUC显著高于单独使用ΔPP_(DI)(P=0.03)。采用正常液体策略时(R=1),ΔPP_(DI)/Vt_(DI)的灰区范围为12.7~14.5,包含19%的患者;采用限制性液体策略时(R=2),ΔPP_(DI)/Vt_(DI)灰区范围为12.8~14.5,仅包含6.5%的患者。结论在完全自主呼吸的脓毒症患者中,ΔPP_(DI)预测FR具有中度的准确度,以Vt_(DI)校正ΔPP_(DI)后可进一步提高其预测价值。Objective To investigate the effect of tidal volume(Vt_(DI))on pulse pressure variation(ΔPP_(DI))during deep inspiration maneuvers in spontaneously breathing patients with sepsis and to test if adjustingΔPP_(DI) by Vt_(DI) can further improve its ability in predicting fluid responsiveness(FR).Methods Spontaneously breathing,nonintubated sepsis or septic shock patients who were admitted to the Intensive Care Unit of the Characteristic Medical Center of Chinese People's Armed Police Force and Nanjing Gaochun People's Hospital were prospectively enrolled from October 2017 to October 2019.Volume expansion(VE)was performed by infusing 500 mL saline over 20 min.Prior to VE,measurements including pulse pressure variation and tidal volume were obtained during quiet spontaneous breathing(ΔPPTB and VtTB,respectively)and during the deep inspiration maneuver(ΔPP_(DI) and Vt_(DI),respectively).Patients were classified as responders if stroke volume(SV)increased≥15%after VE,otherwise nonresponders.Multiple linear regression analysis was conducted to investigate the correlation ofΔPP_(DI) with Vt_(DI) and VE-induced percentage changes in SV(ΔSV).Receiver operating characteristic(ROC)curve analysis and the gray zone approach were used to assess the ability of each index to predict FR.Changes in gray zone limits according to the cost ratio(R=cost[false positive(FP)]/cost[false negative(FN)])were also evaluated.Results Of the included 31 patients,17 were responders.There was no significant difference inΔPPTB between fluid responders and non-responders(P>0.05),whereasΔPP_(DI) was significantly higher in responders than in non-responders[(19.1±7.4)%vs(11.2±4.5)%;P=0.001].The area under the ROC curve(AUC)ofΔPP_(DI) predicted FR was 0.832,sensitivity of 76.47%and specificity of 71.43%,which was significantly higher thanΔPPTB(AUC=0.580,sensitivity of 47.06%and specificity of 71.43%;P<0.05).Multiple linear regression analysis showed that both Vt_(DI) andΔSV were independently associated withΔPP_(DI)(P<0.01),the AUC ofΔP

关 键 词：脓毒症 液体治疗 潮气量 成本收益分析 自主呼吸 

分 类 号：R459.7[医药卫生—急诊医学]