摘要目的 探讨PEEP抬高试验、呼气末屏气试验等基于心肺交互机制的监测技术对感染性休克患者容量反应性的预测价值.方法 前瞻性纳入2016年1月至2017年6月江苏省南通市第一人民医院重症医学科(ICU)收治的感染性休克机械通气患者45例,监测患者心率(HR)、收缩压(SBP)、平均动脉压(MAP)、中心静脉压(CVP)、心脏指数(CI)、每搏变异度(SVV)和脉压变异度(PPV)等血流动力学指标.序贯进行PEEP抬高试验、呼气末屏气试验及容量负荷试验,以容量负荷试验后CI增加≥15％将全组病例分为容量反应阳性组和容量反应阴性组,绘制受试者工作曲线(ROC曲线)评价上述指标预测容量反应性的价值,采用Youden指数法取最佳截断值,计算灵敏度和特异度.结果 45例患者中,容量反应阳性组24例,阴性组21例.两组患者基本临床资料比较差异无统计学意义.两组患者PEEP抬高试验后CVP均升高(P＜0.05),SBP、CI均降低(P＜0.05),其中容量反应阳性组患者△SBP和△CI幅度显著大于阴性组(P＜0.05).两组患者呼气末屏气试验后CVP均降低(P＜0.05),SBP、MAP及CI均升高(P＜0.05),其中容量反应阳性组患者△MAP和△CI显著高于阴性组(P＜0.05).容量反应阳性组患者SVV、PPV显著高于阴性组(Jp＜0.05).PEEP抬高试验△SBP、△CI预测容量反应性ROC曲线下面积(AUC)分别为0.737(95％CI:0.581～0.893)和0.803(95％CI:0.660～0.946).呼气末屏气试验△MAP、△CI预测容量反应性的AUC分别为0.763(95％CI:0.617～0.908)和0.808(95％CI:0.673～0.942),均高于或与SVV、PPV相当.PEEP抬高试验取△CI=12％、△SBP =9.5％为截断值,敏感度及特异度分别为70.8％和95.2％、75％和71.4％;呼气末屏气试验取△CI=8.5％、△MAP =5.5％为截断值,敏感度及特异度分别为79.2％和76.2％、75％和76.2％.结论 PEEP抬高试验△SBP、△CI,呼气末屏气试验△MAP、△CI可用于预测感染性休克患者容量反应性.

abstractsObjective To assess the predictive value of cardiopulmonary interaction monitoring technology on volume responsiveness in septic shock patients.Methods A cohort of 45 septic shock patients treated with mechanical ventilation at First People's Hospital of Nantong City from January 2016 to June 2017 were prospectively selected.The hemodynamic variables including heart rate (HR),systolic pressure (SBP),mean arterial pressure (MAP),central venous pressure (CVP),cardiac index (CI),stroke volume variability (SVV),and pulse pressure variability (PPV) were monitored.PEEP elevation test,end-expiratory occlusion test and volume expansion were sequential conducted.Volume responsiveness was defined as an increase in CI (△CI) of 15％ or greater after volume expansion,namely the response group (△CI ≥ 15％) and non-response group (△CI＜15％).Receiver operating characteristic (ROC) curve was constructed to indicate the predictive value of cardiopulmonary interaction monitoring technology in septic shock patients.The best cut-off value was assessed by Youden Index,and sensitivity and specificity were calculated respectively.Results There were 24 patients in the response group and 21 patients in the non-response group.There were no significant differences in basic clinical data between the two groups.△fter PEEP elevation test,CVP increased significantly,while SBP and CI decreased significantly in both groups (P＜0.05).The degrees of △SBP and △CI in the response group were much higher than those in the non-response group (P＜0.05).After end-expiratory occlusion test,CVP decreased significantly,while SBP,MAP and CI increased significantly in both groups (P＜0.05).The degrees of △MAP and △CI in the response group were much higher than those in the non-response group (P＜0.05).SVV and PPV in the response group were higher than those in the non-response group (P＜0.05).The area under the ROC curve (AUC) of the △SBP and △CI after PEEP elevation test and △MAP and △CI after end-expiratory occlusion test were 0.737 (95％CI:0.581-0.89;P＜0.05),0.803 (95％CI:0.660-0.946;P＜0.05),0.763 (95％CI:0.617-0.908;P＜0.05),and 0.808 (95％CI:0.673-0.942;P＜0.05),respectively.These AUC values were higher than or similar to traditional indicators,such as SVV and PPV.The best cut-off value of △CI and △SBP after PEEP elevation test was 12％ and 9.5％,yielding a sensitivity and specificity of 70.8％and 95.2％,75％ and 71.4％,respectively.The best cut-off value of △CI and △MAP after end-expiratory occlusion test was 8.5％ and 5.5％,yielding a sensitivity and specificity of 79.2％ and 76.2％,75％ and 76.2％ respectively.Conclusion △SBP and △CI after PEEP elevation test and △MAP and △CI after endexpiratory occlusion test can accurately predict volume responsiveness in septic shock patients.