被动抬腿试验预测感染性休克患者容量反应性的临床研究

摘要

Objective To investigate whether passive leg raising ( PLR) combined arterial pressure waveform analysis of cardiac output ( APCO) could be used to predict the hemodynamic response to volume expansion in patients with septic shock. Methods The study was performed with prospective, cohort study method, and patients with septic shock who were admitted to the intensive care unit (ICU) of the Second Affiliated Hospital of Harbin Medical University from April 2011 to March 2012 were enrolled. The hemodynamics including stroke volume(SV) and cardiac output (CO) were obtained with VigileoTM monitor during PLR and volume expansion. Patients were responders to volume expansion if SV increased ≥ 15%. The role of PLR for predicting volume responsiveness was evaluated by receiver operating characteristic ( ROC) curves. Results Among forty - seven patients included in this study, twenty - six were responders and twenty - one were non - responders. SV and pulse pressure induced by PLR (PLR - ΔSV) were increased significantly in response group [ (76. 5 ± 23. 4) mL vs (65. 1 ±20. 5)mL, P < 0. 05 ] , while in nonresponse group there were no significant change. PLR -ΔSV was highly correlated to ASV after volume expansion ( r = 0. 653, P = 0. 024). The area under the ROC curve (AUC) for PLR predicting volume responsiveness was 0. 945 ±0. 047. PLR - ΔSV≥13% predicted fluid responsiveness with sensitivity of 83.0% and specificity of 92.5%. Conclusion PLR combined with APCO can be used generally to predict volume responsiveness accurately in patients with septic shock, and the procedure can be used to fluid therapy in clinical practice.%目的 评价被动抬腿试验(PLR)联合外周动脉压心排量监测(arterial pressure waveform analysis of cardiac output,APCO)技术预测感染性休克患者容量反应性的价值.方法 本研究采用前瞻性、观察性队列研究的设计方法,选择2011-04～2012-03我院重症医学科(ICU)的感染性休克患者纳入研究.所有患者均先后进行PLR和扩容,并用APCO持续监测PLR前后和扩容前后各项血流动力学指标的变化.根据对扩容的反应(扩容后SV增加≥15%为有反应)将患者分为有反应组和无反应组,用受试者工作特征曲线(ROC曲线)评价PLR预测容量反应性的价值.结果 共有47例感染性休克患者纳入本研究,扩容后有反应者占55.3%(26/47).反应组PLR后SV较之前明显增加[(76.5±23.4)mL比(65.1±20.5)mL,P<0.05],而无反应组PLR前后SV无明显变化(P>0.05);PLR期间△SV与扩容后△SV呈显著正相关(r=0.653,P=0.024);PLR预测容量反应性的ROC曲线下面积(AUC)为0.945±0.047,以PLR-△SV≥13%预测容量反应性的敏感性和特异性分别为83.0%和92.5%.结论 用APCO测量由PLR所引起的SV变化能精确预测感染性休克患者液体治疗时的容量反应性,可用来指导临床液体治疗.