经胸壁床旁超声预测机械通气患者急性循环衰竭容量反应性的临床研究

摘要

目的 探究颈内静脉呼吸塌陷指数(IJVR)、下腔静脉塌陷指数(IVCR)等指标在预测患者容量反应性中的价值.方法 本研究为前瞻性临床研究,选取56例机械通气情况下诊断为急性循环衰竭(ACF)的患者.患者在输入500 mL胶体前后使用床旁超声测量颈内静脉呼吸周期中最大前后径IJVmax、最小前后径IJVmin,计算颈内静脉塌陷指数为(IJVmax-IJVmin)/IJVmax×100％,同时测量并计算出中心静脉压(CVP)及IVCR.通过分析相关指标的敏感度、特异度和受试者特征曲线(ROC)来评估IJVR、CVP及IVCR指标在预测容量反应性中的价值.结果 56例患者中有容量反应性者32例占57％,无反应者24例占43％.扩容前后IJVR与△SV呈正相关性(r=0.809,P＜0.05);以IJVR≥13％为阈值,其曲线下面积(AUC)为0.735 (95％ CI0.603～0.866),敏感度为85.7％,特异度为70.3％;以IVCR≥18.7％为界值,AUC是0.853(95％ CI0.696 ～0.956),敏感度为86.7％,特异度为83％.IJVR联合IVCR预测容量反应性的AUC 0.895 (95％ CI0.801 ～0.990),敏感度为90.9％,特异度为89.3％.而当CVP≤10 cm H2O时其AUC为0.653 (95％ CI0.441～0.828),敏感度为56.7％,特异度为50.8％.结论 应用超声测量是一个无创且简单的预测ACF患者容量反应性的方法,当其联合IVCR时则能提高敏感度和特异度,更准确地进行容量反应性的预测.%Objective To This study would evaluate the value of measurement of internal jugular vein (IJVR) collapsibility and inferior vena cava (IVCR) in fluid responsiveness.Methods This study was a prospective clinical analysis and 56 mechanically ventilated patients were assessed.Ultrasound of IJVR dimensions was performed before and after fluid challenge (500 mL colloid fluid bolus).IJVR collapsibility was calculated as (IJVmax-IJVmin)/IJVmax and expressed as a percentage.Central venous pressure (CVP) and IVCR collapsibility were also collected.We would evaluate the value of IJVR collapsibility,CVP and IVCR collapsibility by the sensitivity,specificity and likelihood ratios of receiver operating characteristic (ROC) curves in predicting volume responsiveness.Results We enrolled 56 patients,32 were responsiveness (57％) and 24 (43％) were no responsiveness.IJVR and △SV were correlated (r =0.809,P ＜ 0.05).Fluid responsiveness was defined when collapsibility value for IJVR was ≥ 13％.The area under the ROC curve was 0.735 (95％ CI 0.603～ 0.866),with a sensitivity of 85.7％ and specificity of 70.3％.Fluid responsiveness was defined when collapsibility value for IVCR was ≥ 18.7％.The area under the ROC curve was 0.853 (95％ CI 0.696 ～ 0.956),with a sensitivity of 86.7％ and specificity of 83％.Interestingly,combining IJVR collapsibility more than 13％ and IVCR collapsibility more than 18％ predicted fluid responsiveness with a sensitivity of 90.9％ and specificity of 89.3％.But fluid responsiveness was defined when CVP was ≤ 10 cm H2O.The area under the ROC curve was 0.653 (95％ CI 0.441 ～ 0.828),with a sensitivity of 56.7％ and specificity of 50.8％.Conclusion IJVR collapsibility may be an accurate,easily acquired non-invasive parameter of fluid responsiveness in acute circulatory failure.The combined use of IJVR and IVCR can improve the sensitivity and specificity.