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中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2020, Vol. 13 ›› Issue (05) : 345 -350. doi: 10.3877/cma.j.issn.1674-6880.2020.05.005

所属专题： 文献；

论著

呼气末屏气试验联合肱动脉峰流速预测机械通气-休克患者容量反应性的价值
沈珏1, 刘文生1, 唐江锋1, 单丽红1, 柳开忠1,†()   
  1. 1. 310022　杭州，中国科学院大学附属肿瘤医院（浙江省肿瘤医院）重症医学科、中国科学院基础医学与肿瘤研究所
  • 收稿日期:2020-06-28 出版日期:2020-10-31
  • 通信作者: 柳开忠
  • 基金资助:
    浙江省医药卫生科技计划项目(2017KY245、2018KY295)

Value of end-expiratory occlusion tests combined with brachial artery peak velocity in predicting volume responsiveness of mechanically ventilated patients with shock

Jue Shen1, Wensheng Liu1, Jiangfeng Tang1, Lihong Shan1, Kaizhong Liu1,†()   

  1. 1. Department of Critical Care Medicine, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou 310022, China
  • Received:2020-06-28 Published:2020-10-31
  • Corresponding author: Kaizhong Liu
  • About author:
    Corresponding author: Liu Kaizhong, Email:
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沈珏, 刘文生, 唐江锋, 单丽红, 柳开忠. 呼气末屏气试验联合肱动脉峰流速预测机械通气-休克患者容量反应性的价值[J]. 中华危重症医学杂志(电子版), 2020, 13(05): 345-350.

Jue Shen, Wensheng Liu, Jiangfeng Tang, Lihong Shan, Kaizhong Liu. Value of end-expiratory occlusion tests combined with brachial artery peak velocity in predicting volume responsiveness of mechanically ventilated patients with shock[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2020, 13(05): 345-350.

目的

评价呼气末屏气（EEO）试验联合肱动脉峰流速（Vpeak-BA）能否作为判断机械通气-休克患者容量反应性的指标。

方法

选择2018年4月至2019年11月中国科学院大学附属肿瘤医院（浙江省肿瘤医院）重症医学科收治的行机械通气的40例休克患者，对所有入组患者序贯进行EEO试验和补液试验。记录所有患者的一般资料以及EEO试验前后和补液试验前后的左室流出道速度-时间积分（VTI）、Vpeak-BA，计算EEO试验前后的Vpeak-BA变化（△VBA-EEO）和VTI变化（△VTI-EEO）。将补液试验后VTI增加值≥ 15%的患者纳入有反应组（23例），否则纳入无反应组（17例）。采用受试者工作特征（ROC）曲线评价△VBA-EEO预测容量反应性的价值。

结果

EEO试验前，有反应组和无反应组患者Vpeak-BA [（48 ± 4）cm/s vs. （55 ± 5）cm/s]及VTI [（19.1 ± 4.7）cm vs.（23.0 ± 4.8）cm]比较，差异均有统计学意义（t = 5.715、3.010，P均< 0.05）；有反应组患者EEO试验后Vpeak-BA [（56 ± 6）cm/s vs.（48 ± 4）cm/s]和VTI [（22.8 ± 5.2）cm vs.（19.1 ± 4.7）cm]均较EEO试验前显著升高（t = 5.324、2.495，P均< 0.05）。补液试验前，有反应组和无反应组患者Vpeak-BA [（48 ± 4）cm/s vs.（54 ± 5）cm/s]及VTI [（19.0 ± 4.7）cm vs.（23.0 ± 4.4）cm]比较，差异均有统计学意义（t = 5.222、3.155，P均< 0.05）；有反应组患者补液试验后Vpeak-BA [（58 ± 6）cm/s vs.（48 ± 4）cm/s]、VTI [（23.5 ± 5.0）cm vs.（19.0 ± 4.7）cm]均较补液试验前显著升高（t = 6.800、3.133，P均< 0.05）。△VBA-EEO预测容量反应性的ROC曲线下面积（AUC）为0.830，95%置信区间（CI）（0.718，0.941），P < 0.001；△VTI-EEO的AUC为0.887，95%CI（0.772，1.003），P < 0.001。以△VBA-EEO ≥ 12.5%为界值点，预测容量反应性的敏感度和特异度分别为82.6%和70.6%；以△VTI-EEO ≥ 9.9%为界值点，预测容量反应性的敏感度和特异度分别为87.0%和88.2%。

结论

△VBA-EEO可以较准确地预测机械通气-休克患者的容量反应性，指导液体复苏治疗。

关键词: 休克, 呼气末屏气试验, 容量反应性, 肱动脉峰流速
Objective

To evaluate whether the brachial artery peak velocity (Vpeak-BA) induced by end-expiratory occlusion (EEO) tests can predict volume responsiveness of mechanically ventilated patients with shock.

Methods

From April 2018 to November 2019, 40 patients with shock undergoing mechanical ventilation were selected from the Department of Critical Care Medicine, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital). The sequential EEO and rehydration tests were performed on all enrolled patients. Their general data were recorded, as well as their left ventricle outflow tract velocity-time integral (VTI) and Vpeak-BA before and after the EEO and rehydration tests. The Vpeak-BA change (△VBA-EEO) and VTI change (△VTI-EEO) before and after the EEO test were calculated. Patients with a VTI increase of ≥ 15% after the rehydration test were included in the response group (23 patients), otherwise they were included in the non-response group (17 patients). The receiver operating characteristic (ROC) curve was used to evaluate the value of △VBA-EEO in predicting volume responsiveness.

Results

Before the EEO test, the Vpeak-BA [(48 ± 4) cm/s vs. (55 ± 5) cm/s] and VTI [(19.1 ± 4.7) cm vs. (23.0 ± 4.8) cm] between the response group and non-response group were statistically significantly different (t = 5.715, 3.010; both P < 0.05). The Vpeak-BA [(56 ± 6) cm/s vs. (48 ± 4) cm/s] and VTI [(22.8 ± 5.2) cm vs. (19.1 ± 4.7) cm] in the response group were significantly higher after the EEO test than before the EEO test (t = 5.324, 2.495; both P < 0.05). Before the rehydration test, the Vpeak-BA [(48 ± 4) cm/s vs. (54 ± 5) cm/s] and VTI [(19.0 ± 4.7) cm vs. (23.0 ± 4.4) cm] between the response group and non-response group were statistically significantly different (t = 5.222, 3.155; both P < 0.05). The Vpeak-BA [(58 ± 6) cm/s vs. (48 ± 4) cm/s] and VTI [(23.5 ± 5.0) cm vs. (19.0 ± 4.7) cm] in the response group were significantly higher after the rehydration test than before the rehydration test (t = 6.800, 3.133; both P < 0.05). The area under the ROC curve (AUC) of △VBA-EEO for predicting volume responsiveness was 0.830 [95% confidence interval (CI) (0.718, 0.941), P < 0.001], while the AUC of △VTI-EEO was 0.887 [95%CI (0.772, 1.003), P < 0.001]. Based on △VBA-EEO ≥ 12.5%, its sensitivity and specificity of predicting volume responsiveness were 82.6% and 70.6% respectively. Furthermore, its sensitivity and specificity of predicting volume responsiveness were 87.0% and 88.2% respectively, using △VTI-EEO ≥ 9.9% as the boundary point.

Conclusion

△VBA-EEO can relatively accurately predict the volume responsiveness of mechanically ventilated patients with shock and guide their fluid resuscitation therapy.

Key words: Shock, End-expiratory occlusion test, Volume responsiveness, Brachial artery peak velocity
表1 两组休克患者一般资料比较（ ± s）
组别 例数 年龄（岁） 性别（例，男/女） 体质量指数（kg/m2） 脓毒症（例） 潮气量（mL/kg） 总PEEP（mmHg） 应用血管活性药物（例） 去甲肾上腺素用量（μg·kg-1·min-1） APACHEⅡ评分（分）
有反应组 23 59 ± 9 15/8 22.2 ± 4.0 21 7.2 ± 0.9 5.9 ± 1.8 16 0.9 ± 0.3 16.3 ± 5.0
无反应组 17 57 ± 12 12/5 22.1 ± 3.5 16 7.5 ± 0.9 6.1 ± 1.4 11 1.0 ± 0.3 16.4 ± 6.4
χ2/t值   0.468 0.129 0.084 0.112 1.122 0.358 0.105 1.086 0.027
P值   0.642 0.720 0.934 0.738 0.269 0.722 0.746 0.288 0.979
表2 两组休克患者EEO试验前后Vpeak-BA及VTI比较（ ± s）
组别 例数 Vpeak-BA（cm/s） VTI（cm）
有反应组      
  EEO试验前 23 48 ± 4 19.1 ± 4.7
  EEO试验后 23 56 ± 6a 22.8 ± 5.2a
无反应组      
  EEO试验前 17 55 ± 5b 23.0 ± 4.8b
  EEO试验后 17 58 ± 4 24.4 ± 4.9
表3 两组休克患者补液试验前后Vpeak-BA及VTI比较（ ± s）
组别 例数 Vpeak-BA（cm/s） VTI（cm）
有反应组      
  补液试验前 23 48 ± 4 19.0 ± 4.7
  补液试验后 23 58 ± 6a 23.5 ± 5.0a
无反应组      
  补液试验前 17 54 ± 5b 23.0 ± 4.4b
  补液试验后 17 58 ± 5 24.3 ± 4.8
图1 △VBA-EEO和△VTI-EEO预测机械通气休克患者容量反应性的ROC曲线
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