重脓毒症患者容量判断中的作用

被动直腿抬高试验在严重脓毒症患者容量判断中的作用

董绉绉方强

【摘要】目的探讨被动直腿抬高试验（passive leg raising, PLR）在判断严重脓毒症的机械通气患者中血流动力学反应的作用，指导脓毒性患者的容量复苏。方法前瞻性研究，入选2010年5月至2011年5月浙江大学医学院附属第一医院ICU和宁波市医疗中心李惠利医院ICU符合严重脓毒症诊断标准的机械通气患者28例进行液体复苏。排除非窦性心律者、心律不齐者和产妇。用脉搏波指示剂连续心排血量（pulse indicator continuous cardiac output, PiCCO）技术分别记录在半卧位、PLR后、液体输注后（30分钟内快速输注6%羟乙基淀粉500 ml）的血流动力学参数。根据每搏量指数变化（ΔSVI）是否大于等于15%，分为液体反应阳性组和液体反应阴性组。比较两组间基线水平时心率（HR）、收缩压（ABPs）、舒张压（ABPd）、平均动脉压（ABPm）、平均中心静脉压（CVPm）和心指数（CI）的差异；比较两组患者PLR后及快速输液后ABPs、ABPm、CVPm、SVI与基线水平之间的差异；ROC 曲线评价ΔSVI、ΔCVPm对预测患者液体反应的价值。用SPSS17.0统计软件包进行统计分析。结果28例患者中液体反应阳性组18例，液体反应阴性组10例。液体反应阳性组PLR 后ABPs、ABPm、CVPm比基线水平显著升高[（115.9±13.1）和（100.1±18.1），（77.8±13.0）和（68.1±12.4），（10.1±4.1）和（7.2±3.4）]，分别为P=0.005，P=0.03，P=0.03。PLR后，ΔSVI和ΔCVPm预测液体反应阳性的ROC曲线下面积分别为0.897±0.059（95%CI=0.762~1.000）和0.819±0.081（95%CI=0.661~0.977）。分别取ΔSVI=10.5%和ΔCVPm=12.7%为界值，预测患者液体反应阳性的敏感性为72.2%和72.2%，特异性为90.0%和80.0%。结论PLR后的ΔSVI和ΔCVPm可以作为严重脓毒症机械通气患者的一项准确而可逆的液体反应预测指标。

【关键词】被动直腿抬高试验；液体复苏；血流动力学监测；每搏量指数；中心静脉压；严重脓毒症；液体反应；ROC曲线

Passive leg raising is predictive of fluid responsiveness in patients with severe sepsis

作者单位：315040 宁波，宁波市医疗中心李惠利医院ICU（董绉绉）；浙江大学医学院附属第一医院ICU （方强）

通讯作者：方强，310006，电话：1805735654，Email:fangqicu@.

DONG Zhou-zhou, FANG Qiang*. *Intensive care unit, First Affiliated Hospital, Zhejiang University College Of Medicine,Zhejiang,310006,China.

Corresponding author: FANG qiang, 310006，Tel: 1805735654, Email:fangqicu@.

[Abstract] Objective To assess the value of passive leg raising as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsisk to guide volume resuscitation.Method This was a prospective study. Twenty eight mechanically ventilated patients with severe sepsis, admitted in ICU of First Affiliated Hospital, Zhejiang University College Of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to May 2011, were collected for volume resuscitation. Non-sinus rhythm or arrhythmia ones, parturients were excluded.Hemodynamic indices of the patients were obtained in a semi-recumbent position, then after passive leg raising, and after volume expansion (500 mL 6% hydroxyethyl starch infusion within 30 mins) by the technique of pulse indicator continuous cardiac output (PiCCO) system. The volume resuscitation were resulted into two groups according to the change in stroke volume index (ΔSVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between two groups. The changes of ABPs, ABPm, CVPm, SVI after PLR and after fluid resuscitation were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS l7.0 software was used for statistic. Results Among twenty eight patients included in this study, eighteen were responders and ten were non-responders. After PLR among the responders, some hemodynamic variables including (ABPs, ABPm and CVPm) were significantly elevated, [ (100.1±18.1) and (115.9±13.1), P=0.005; (68.1±12.4) and (77.8±13.0), P=0.03; (7.2±3.4) and (10.1±4.1), P=0.03]. After PLR, the area under curve (AUC) of the ROC curve of ΔSVI and ΔCVPm to predict the responsiveness after fluid resuscitation were 0.897±0.059 (95%CI 0.762~1.000) and 0.819±0.081 (95%CI0.661~0.977) when the cut-off levels of ΔSVI and ΔCVPm were 10.5% and 12.7%, the sensitivities were 72.2% and 72.2%, the specificities were 90% and 80%. Conclusions Changes in ΔSVI and ΔCVPm induced by passive leg raising