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液体复苏是感染性休克病人治疗的基础,及时有效的液体复苏可明显改善组织灌注,恢复有效循环血流量。但相关研究[1]报道,感染性休克病人早期快速地给予液体复苏治疗后,仍可能表现为组织灌注不足,若继续盲目补液治疗,可能导致肺水肿、腹内高压等一系列并发症,甚至增加病人死亡风险。容量反应性指感染性休克病人对快速扩容的反应性,可有效反映病人心脏前负荷的储备状态。感染性休克病人自身的容量反应性情况是液体治疗的基本[2]。因此,寻找能准确评估容量反应性的指标及方法,对指导感染性休克病人液体复苏具有重要价值。中心静脉压(central venous pressure,CVP)指标的变化可有效评估血管容量,CVP监测主要是以特定病人的特定问题为导向,其对了解有效循环血容量和心功能状态有重要的作用及意义,所以其目前仍然是危重病人中指导液体复苏最常用的血流动力学变量,但临床常因心室顺应性、胸腔压力等因素的影响而导致评估效果不佳[3]。被动抬腿试验(passive leg raising,PLR)是一种模拟式的快速液体冲击补液方法,有操作简便、不良反应小及受自主呼吸影响小等优势,近年来逐渐用于评估病人容量反应,临床预测价值较好,但单纯抬高双下肢后病人回心血量增加有所受限,单独使用可能影响预测准确性[4]。因此,本研究旨在探讨CVP联合PLR预测感染性休克病人容量反应性情况,以期能更好地指导液体复苏治疗。
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本研究110例病人共进行192次PLR和容量负荷试验,其中88例次容量反应阳性(45.83%),归为阳性组;104例次容量反应阴性(54.17%),归为阴性组。
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2组病人CVP、MAP、SV、SVV、CO、CI、HR基础值相比差异均无统计学意义(P>0.05)。PLR试验后2组病人CVP、SV、CI均高于基础值,且阳性组高于阴性组,2组病人SVV均低于基础值,且阳性组低于阴性组,差异均有统计学意义(P < 0.05)(见表 1)。
分组 n CVP/mmH2O MAP/mmHg SV/mL SVV/% CO/(L/min) CI/(L·min-1·m-2) HR/(次/分) 基础值 阳性组 88 7.56±1.94 69.34±17.80 62.68±15.99 14.04±3.57 4.98±1.30 3.34±0.86 103.98±26.35 阴性组 104 7.49±1.90 69.02±17.74 61.57±15.44 14.50±3.66 4.90±1.24 3.29±0.83 105.24±25.97 t — 0.25 0.12 0.49 0.88 0.44 0.41 0.33 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 PLR试验后 阳性组 88 10.01±2.61* 72.25±19.15 72.91±18.63* 11.82±3.05* 5.07±1.41 4.05±1.02* 104.52±26.80 阴性组 104 9.05±2.33# 71.83±19.06 67.34±16.52# 12.93±3.26# 5.15±1.32 3.68±0.95# 106.88±27.01 t — 2.69 0.15 2.20 2.42 0.41 2.60 0.61 P — < 0.05 >0.05 < 0.05 < 0.05 >0.05 < 0.05 >0.05 组内配对t检验:与阳性组基础值比较*P < 0.05;与阴性组基础值比较#P < 0.05 表 1 2组PLR试验前后病人血流动力学参数比较(x±s)
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感染性休克病人△CVP与△SV呈正相关关系(r=0.567,P < 0.05), 与△SVV呈负相关关系(r=-0.548,P < 0.05), 与△CI呈正相关关系(r=0.612,P < 0.05)。
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△CVP、△SV、△SVV、△CI联合预测感染性休克病人容量反应性的曲线下面积高于四者单独预测,其预测敏感度为85.60%,特异度为98.90%(见表 2、图 1)。
指标 曲线下面积 最佳截断值/% 敏感度/% 特异度/% P 95%CI △CVP 0.818 26.97 62.50 89.80 < 0.01 0.759~0.878 △SV 0.880 12.75 73.10 90.90 < 0.01 0.833~0.927 △SVV 0.703 15.08 47.10 87.50 < 0.01 0.629~0.777 △CI 0.778 16.84 56.40 88.10 < 0.01 0.713~0.843 四者联合 0.963 — 85.60 98.90 < 0.01 0.938~0.988 表 2 △CVP、△SV、△SVV、△CI对感染性休克病人容量反应性的预测价值
中心静脉压联合被动抬腿试验在感染性休克病人容量反应评估中的作用
Role of central venous pressure combined with passive leg raising in the assessment of volume responsiveness in patients with septic shock
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摘要:
目的探讨中心静脉压(CVP)联合被动抬腿试验(PLR)在感染性休克病人容量反应评估中的作用。 方法选取感染性休克病人110例作为研究对象,均使用脉搏指数连续心输出量(PiCCO)持续监测病人CVP、平均动脉压(MAP)、每搏输出量(SV)、每搏量变异度(SVV)、心输出量(CO)、心指数(CI)及心率(HR),并接受PLR和容量负荷试验,将PLR试验后CVP、SV、SVV、CI变化率,记录为△CVP、△SV、△SVV、△CI;将容量负荷试验后SV增幅(△SV容量负荷试验)≥10%作为阳性组,△SV容量负荷试验 < 10%作为阴性组。使用Pearson检验分析感染性休克病人△CVP与△SV、△SVV、△CI的相关性,并采用ROC曲线分析△CVP、△SV、△SVV、△CI对感染性休克病人容量反应性的预测价值。 结果110例病人共进行192次PLR和容量负荷试验,其中阳性组88例次(45.83%),阴性组104例次(54.17%)。PLR后2组病人CVP、SV、CI均高于基础值,且阳性组病人高于阴性组病人,2组病人SVV均低于基础值,且阳性组病人低于阴性组病人,差异均有统计学意义(P < 0.05)。感染性休克病人△CVP与△SV和△CI呈正相关关系(P < 0.05),与△SVV呈负相关关系(P < 0.05)。△CVP、△SV、△SVV、△CI联合预测感染性休克病人容量反应性的曲线下面积为0.963,高于四者单独预测,其预测敏感度85.60%,特异度98.90%。 结论△CVP、△SV、△SVV、△CI联合使用,对感染性休克病人容量反应性的预测效果最好。 Abstract:ObjectiveTo investigate the role of central venous pressure(CVP) combined with passive leg raising(PLR) in the assessment of volume responsiveness in patients with septic shock. MethodsOne hundred and ten patients with septic shock who were enrolled were selected as the research objects.The CVP, mean arterial pressure(MAP), stroke volume(SV), stroke volume variation(SVV), cardiac output(CO), cardiac index(CI) and heart rate(HR) were continuously monitored by pulse index continuous cardiac output(PiCCO), and PLR and volume load test were carried out.The change rates of CVP, SV, SVV and CI after PLR test were recorded as △CVP, △SV, △SVV, and △CI.The SV increment(△SV volume load test) ≥ 10% was regarded as positive group after volume load test, △SV volume load test < 10% was taken as negative group.Pearson test was used to analyze the correlation between △CVP and △SV, △SVV, △CI in patients with septic shock, and the ROC curve was used to analyze the predictive values of △CVP, △SV, △SVV, △CI on the volume responsiveness of patients with septic shock. ResultsA total of 192 PLR and volume load test were carried out in 110 patients, including 88 cases in the positive group(45.83%) and 104 cases in the negative group(54.17%).After PLR test, CVP, SV and CI in the two groups were higher than the basic value, and those in the positive group were higher than the negative group; the SVV of the two groups was lower than the basic value, and that in the positive group was lower than the negative group, the difference was statistically significant(P < 0.05).△CVP of patients with septic shock was positively correlated with △SV and △CI(P < 0.05), negatively correlated with △SVV(P < 0.05).The area under the curve of the combination of △CVP, △SV, △SVV and △CI in predicting the volume response of patients with septic shock was 0.963, which was higher than that predicted by the four alone, the predictive sensitivity was 85.60%, and the specificity was 98.90%. ConclusionsThe combination of △CVP, △SV, △SVV, △CI has the best prediction effect on the volume responsiveness of patients with septic shock. -
Key words:
- septic shock /
- central venous pressure /
- passive leg raising /
- volume responsiveness
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表 1 2组PLR试验前后病人血流动力学参数比较(x±s)
分组 n CVP/mmH2O MAP/mmHg SV/mL SVV/% CO/(L/min) CI/(L·min-1·m-2) HR/(次/分) 基础值 阳性组 88 7.56±1.94 69.34±17.80 62.68±15.99 14.04±3.57 4.98±1.30 3.34±0.86 103.98±26.35 阴性组 104 7.49±1.90 69.02±17.74 61.57±15.44 14.50±3.66 4.90±1.24 3.29±0.83 105.24±25.97 t — 0.25 0.12 0.49 0.88 0.44 0.41 0.33 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 PLR试验后 阳性组 88 10.01±2.61* 72.25±19.15 72.91±18.63* 11.82±3.05* 5.07±1.41 4.05±1.02* 104.52±26.80 阴性组 104 9.05±2.33# 71.83±19.06 67.34±16.52# 12.93±3.26# 5.15±1.32 3.68±0.95# 106.88±27.01 t — 2.69 0.15 2.20 2.42 0.41 2.60 0.61 P — < 0.05 >0.05 < 0.05 < 0.05 >0.05 < 0.05 >0.05 组内配对t检验:与阳性组基础值比较*P < 0.05;与阴性组基础值比较#P < 0.05 表 2 △CVP、△SV、△SVV、△CI对感染性休克病人容量反应性的预测价值
指标 曲线下面积 最佳截断值/% 敏感度/% 特异度/% P 95%CI △CVP 0.818 26.97 62.50 89.80 < 0.01 0.759~0.878 △SV 0.880 12.75 73.10 90.90 < 0.01 0.833~0.927 △SVV 0.703 15.08 47.10 87.50 < 0.01 0.629~0.777 △CI 0.778 16.84 56.40 88.10 < 0.01 0.713~0.843 四者联合 0.963 — 85.60 98.90 < 0.01 0.938~0.988 -
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