The predictive value of variation index of inferior vena cava measured by ultrasonography and central venous pressure in volume responsiveness in patients with septic shock
-
摘要:
目的 比较下腔静脉超声指标、中心静脉压(central venous pressure，CVP)预测脓毒性休克患者容量反应性的准确性。 方法 选取2019年1月—2020年2月蚌埠医学院第一附属医院呼吸与危重症医学科监护室(respiratory intensive care unit, RICU)收治的脓毒性休克患者27例，于液体复苏前以床旁超声测定下腔静脉直径(diameter of inferior vena cava，d-IVC)及计算其呼吸变异度(variation with respiration，v-IVC)、测定中心静脉压(CVP)、测定动脉血乳酸水平(lactate), 采用PiCCO监测复苏前后心脏指数(cardiac index，CI)。液体复苏方法：20 min内输入乳酸钠林格液注射液7 mL/kg(理想体重)，复苏后监测ΔCI≥15%定义为容量反应阳性，阳性为有反应组(R组)，阴性为无反应组(NR组)。根据复苏前所测指标绘制ROC曲线评价其预测容量反应性的准确性。 结果 与容量反应阴性组比较, 容量反应阳性组复苏前v-IVC明显增大，IVCmin、IVCmax明显减小，其差异有统计学意义(P < 0.05), 复苏前动脉血乳酸水平、CVP差异无统计学意义(P > 0.05)。应用ROC曲线分析v-IVC取17.65%为截断值，预测脓毒性休克患者容量反应阳性的敏感度为100.0%，特异度87.5%，ROC曲线下面积(AUC)为0.924(95% CI: 0.781~1.000)。 结论 下腔静脉超声计算指标v-IVC可以作为脓毒性休克患者补液前预测容量反应性的指标，当v-IVC>17.65%时预测价值较高。 Abstract:Objective To compare the predictive value of inferior vena cava ultrasound indicators and central venous pressure (CVP) as predictors of fluid of responsiveness in patients who experienced septic shock. Methods Twenty-seven patients who experienced septic shock were enrolled in the study. The diameter of inferior vena cava (d-IVC) and its variation with respiration (v-IVC), CVP measured by bedside ultrasound, arterial blood lactate level and cardiac index (CI) were collected at hospitalisation and after resuscitation. The fluid resuscitation was performed as follows: All patients were administered with 7 mL/kg lactated Ringer's solution (ideal body weight) within 20 min. Fluid responsiveness was defined as ΔCI≥15% after resuscitation (responding group or R group, n=19; the rest was classified as nonresponding group or NR group, n=8). The accuracy of predicting volume responsiveness was evaluated by plotting the receiver operating characteristic (ROC) curve on the basis of the measured indicators before resuscitation. Results Compared with the NR group, the R group had a low d-IVCmin, d-IVCmax and a significantly high v-IVC before resuscitation (P < 0.05). However, no significant difference was observed in lactate level of arterial blood, CVP before resuscitation (P > 0.05). The optimal cut-off value of v-IVC was 17.65%. The sensitivity and specificity of the predictive value of volume responsiveness in patient who experienced septic shock were 100.0% and 87.5%, respectively. The area under the ROC curve of v-IVC for predicting volume responsiveness was 0.924 (95% CI: 0.781-1.000). Conclusion The predictive value of v-IVC in the volume responsiveness of patients who experienced septic shock is high, and the predictive value is higher when v-IVC >17.65%. -
表 1 2组脓毒性休克患者一般资料(x ±s)
组别 例数 性别(男/女，例) 年龄(岁) APACHE Ⅱ (分) 心率(次/min) 平均动脉压[M(P25, P75)，mm Hg] 体质量[M(P25, P75)，kg] 血清白蛋白(g/L) 去甲肾上腺素剂量[μg/(kg·min)] R组 19 15/4 73.74±8.83 22.63±6.78 102.58±25.52 90.00(82.67，97.00) 68(65，72) 33.60±6.35 0.581±0.431 NR组 8 6/2 68.63±11.76 23.88±7.85 103.38±30.75 95.33(84.08，111.33) 70(62，75) 30.94±3.84 0.504±0.515 统计量 0.051a 1.245b -0.416b -0.070b -1.142c -0.773c 1.096b 0.400b P值 0.822 0.225 0.681 0.945 0.253 0.439 0.283 0.691 注：a为χ2值，b为t值，c为Z值。1 mm Hg=0.133 kPa。 
下载: 导出CSV
表 2 2组脓毒性休克患者基础超声及相关指标[M(P25, P75)]
组别 例数 CI[x±s，L/(min·m2)] Lactate (x±s，mmol/mL) CVP (cm H2O) IVCmax (mm) IVCmin (mm) v-IVC (%) R组 19 3.29±0.54 3.14±1.95 11.00(11.00, 13.00) 15.0(15.0, 21.0) 9.0(4.0, 11.0) 40.0(30.7, 66.7) NR组 8 4.04±0.67 2.44±1.96 13.00(10.25, 16.50) 22.5(16.5, 27.2) 19.5(12.0, 24.0) 6.0(4.5, 12.8) 统计量 -3.076a 0.858a -1.216b -2.032b -3.280b 3.429b P值 0.005 0.399 0.224 0.042 0.001 0.001 注：a为t值，b为Z值。1 cm H2O=0.098 kPa。
下载: 导出CSV
表 3 补液前各指标预测容量反应性的ROC曲线
指标 AUC 临界值 灵敏度(%) 特异度(%) P值 95%CI CVP 0.352 13.5 cm H2O 5.3 50.0 0.232 0.073~0.631 v-IVC 0.924 17.65% 100.0 87.5 0.001 0.781~1.000 IVCmin 0.095 1.05 cm 36.8 0.0 0.001 0.000~0.210 IVCmax 0.250 2.15 cm 21.1 37.5 0.044 0.027~0.473 Lactate 0.678 1.70 mmol/L 89.5 50.0 0.152 0.439~0.916
下载: 导出CSV
-
[1] PERNER A, CECCONI M, CRONHJORT M, et al. Expert statement for the management of hypovolemia in sepsis[J]. Intensive Care Med, 2018, 44(6): 791-798. doi: 10.1007/s00134-018-5177-x [2] PRESCOTT H C, ANGUS D C. Postsepsis morbidity[J]. JAMA, 2018, 319(1): 91. doi: 10.1001/jama.2017.19809 [3] REINHART K, DANIELS R, KISSOON N, et al. Recognizing sepsis as a global health priority-a WHO resolution[J]. N Engl J Med, 2017, 377(5): 414-417. doi: 10.1056/NEJMp1707170 [4] VINCENT J L, JONES G, DAVID S, et al. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis[J]. Crit Care, 2019, 23(1): 196. doi: 10.1186/s13054-019-2478-6 [5] LI Y, YANG S, WANG G, et al. Effects of immunotherapy on mortality in neonates with suspected or proven sepsis: a systematic review and network meta-analysis[J]. BMC Pediatr, 2019, 19(1): 270 doi: 10.1186/s12887-019-1609-1 [6] KIPONZA R, BALANDYA B, MAJIGO M V, et al. Laboratory confirmed puerperal sepsis in a national referral hospital in Tanzania: etiological agents and their susceptibility to commonly prescribed antibiotics[J]. BMC Infect Dis, 2019, 19(1): 690 doi: 10.1186/s12879-019-4324-5 [7] DELLINGER R P, LEVY M M, RHODES A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock[J]. Intensive Care Med, 2017, 43(3): 304-377. doi: 10.1007/s00134-017-4683-6 [8] KUHN S O, MEISSNER K, REHBERG S. Fluid Resuscitation in Sepsis: "Get the Balance Right"[J]. Crit Care Med, 2017, 45(3): 555-556. doi: 10.1097/CCM.0000000000002244 [9] 曹钰, 柴艳芬, 邓颖, 等. 中国脓毒症/脓毒性休克急诊治疗指南(2018)[J]. 临床急诊杂志, 2018, 38(9): 741-756. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC201809001.htm [10] 董岩, 杨立新, 梁伟, 等. 下腔静脉内径呼吸变异度对休克患者容量反应性的评估价值[J]. 中国医学前沿杂志(电子版), 2017, 9(2): 124-127. https://www.cnki.com.cn/Article/CJFDTOTAL-YXQY201702032.htm [11] SINGER M, DEUTSCHMAN C S, SEYMOURCW, et al. The third international consensus definitions for sepsis and septic shock(sepsis-3)[J]. JAMA, 2016, 315(8): 801-810. doi: 10.1001/jama.2016.0287 [12] GHALATI P F, SAMAL S S, BHAT J S, et al. Critical transitions in intensive care units: a sepsis case study[J]. Sci Rep, 2019, 9(1): 12888. doi: 10.1038/s41598-019-49006-2 [13] ZHANG Y, SHAO D R, HE Z P, et al. Efficacy of continuous renal replacement on acute renal injury developed in severe sepsis[J]. Biol Regul Homeost Agents, 2019, 33(2): 525-530. http://www.researchgate.net/publication/332845484_Efficacy_of_continuous_renal_replacement_on_acute_renal_injury_developed_in_severe_sepsis [14] 卢露, 潘国权, 汤鲁明, 等. PICCO指导下液体复苏对脓毒症休克患者免疫功能及炎症介质的影响[J]. 中华全科医学, 2017, 15(4): 562-564. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201704006.htm [15] BENTZER P, GRIESDALE D E, BOYD J, et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? [J]. JAMA, 2016, 316(12): 1298-1309. doi: 10.1001/jama.2016.12310 [16] ANDREW R, LAURA E, WALEED A, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016[J]. Intensive Care Med, 2017, 43(3): 304-377. doi: 10.1007/s00134-017-4683-6 [17] LU N F, XI X M, JIANG L, et al. Exploring the best predictors of fluid responsiveness in patients with septic shock[J]. Am J Emerg Med, 2017, 35(9): 1258-1261. doi: 10.1016/j.ajem.2017.03.052 [18] BROWN S M, SEKIGUCHI H, PINSKJ M R. A new era in critical care ultrasound: professionalization[J]. Ann Am Thorac Soc, 2017, 14(12): 1747-1749. doi: 10.1513/AnnalsATS.201708-624PS [19] 孙文朋, 孙中莎. 超声测量下腔静脉横切面内径及面积快速评估老年患者术前血容量的价值分析[J]. 北京医学, 2020, 42(7): 639-642. https://www.cnki.com.cn/Article/CJFDTOTAL-BJYX202007014.htm [20] LEVITOV A, FRANKEL H L, BLAIVAS M, et al. Guidelines for the appropriate use of bed side general and cardiac ultrasonography in the evaluation of critically ill patients partⅡ: cardiac ultrasonography[J]. Crit Care Med, 2016, 44(6): 1206-1227. doi: 10.1097/CCM.0000000000001847 -
点击查看大图
图(1) / 表(3)
计量
- 文章访问数: 296
- HTML全文浏览量: 150
- PDF下载量: 8
- 被引次数: 0
