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
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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。 
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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。
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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
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