摘要目的 探讨被动抬腿试验(PLR)联合超声心动图监测容量变化指标对感染性休克患者容量反应性的预测价值.方法 选择2016年7月至2018年8月天津市第一中心医院重症加强治疗病房(ICU)收治的30例有自主呼吸的感染性休克患者,先后进行PLR和容量负荷试验(VE).分别在PLR前(基线水平)、PLR后及VE试验后采用超声心动图测量患者左室舒张期末容积(LVEDV)、左室收缩期末容积(LVESV)、每搏量(SV)、左室射血分数(LVEF)等血流动力学指标,并持续监测中心静脉压(CVP).VE试验后SV增加值(ΔSV)≥15%者作为有反应组,ΔSV＜15%者作为无反应组,比较两组患者基线水平及PLR、VE试验后LVEDV、LVESV、SV、LVEF、CVP的变化.采用Pearson相关法分析PLR与VE试验后ΔSV和LVEF增加值(ΔLVEF)的相关性;绘制受试者工作特征曲线(ROC),评价PLR后ΔSV、ΔLVEF对容量反应性的预测价值.结果 30例患者均成功实施了PLR和VE试验,其中VE试验有反应性23例(占76.7%),无反应性7例(占23.3%).与基线水平相比,有反应组LVEDV、SV、LVEF于PLR后即明显增加〔LVEDV(mL):83.5±9.6比77.1±6.2,SV (mL):48.5±5.6比43.2±4.9,LVEF:0.58±0.04比0.56±0.06,均P＜0.05〕,CVP于VE试验后明显增加〔cmH2O (1 cmH2O＝0.098 kPa):7.4±3.3比4.6±0.7,P＜0.01〕,而LVESV始终无明显变化;无反应组SV、LVEF于PLR后即明显增加〔SV(mL):42.7±3.7比40.6±3.1,LVEF :0.52±0.05比0.50±0.05,均P＜0.05〕,LVEDV、CVP于VE试验后明显增加〔LVEDV(mL):84.4±4.1比80.6±5.9,CVP(cmH2O):10.6±3.5比7.6±0.5,均P＜0.05〕,而LVESV始终无明显变化.Pearson相关分析显示,PLR后ΔSV、ΔLVEF与VE试验后ΔSV、ΔLVEF均呈显著正相关(r1＝0.86,r2＝0.65,均P＜0.01).ROC曲线分析显示,PLR诱导的ΔSV、ΔLVEF预测容量反应性的ROC曲线下面积(AUC)分别为 0.85、0.66.当PLR后ΔSV的最佳截断值为10.6%时,其敏感度为78.2%,特异度为82.3% ;当PLR后ΔLVEF的最佳截断值为3.6%时,其敏感度为78.2%,特异度为73.2%.结论 PLR联合超声心动图监测的ΔSV、ΔLVEF可用于评估感染性休克患者的容量反应性,从而指导液体治疗.

abstractsObjective To assess the value of passive leg raising (PLR) combined with echocardiography in predicting volume responsiveness in patients with septic shock. Methods Thirty septic shock patients with spontaneous respiration admitted to intensive care unit (ICU) of Tianjin First Center Hospital from July 2016 to August 2018 were enrolled. PLR and volume expansion (VE) were performed successively. The hemodynamic parameters including left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), stroke volume (SV) and left ventricular ejection fraction (LVEF) before PLR (baseline level), after PLR, immediately after VE were examined by echocardiography, and the central venous pressure (CVP) was monitored. The patients with increase in SV after VE (ΔSV) ≥ 15% were served as reaction group, while ΔSV < 15% were served as non-reaction group. The changes in LVEDV, LVESV, SV, LVEF and CVP at baseline level, after PLR and after VE were compared between the two groups. Pearson correlation method was used to analyze the correlation between ΔSV, increase in LVEF (ΔLVEF) after PLR and ΔSV, and ΔLVEF after VE. Receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of ΔSV and ΔLVEF after PLR for volume responsiveness. Results PLR and VE were successfully performed in 30 patients, of which 23 patients (76.7%) were enrolled in the reaction group, and 7 patients (23.3%) in the non-reaction group. Compared with baseline levels, LVEDV, SV, and LVEF in the reaction group were significantly increased after PLR [LVEDV (mL): 83.5±9.6 vs. 77.1±6.2, SV (mL): 48.5±5.6 vs. 43.2±4.9, LVEF: 0.58±0.04 vs. 0.56±0.06, all P < 0.05], and CVP was significantly increased after VE [cmH2O (1 cmH2O = 0.098 kPa): 7.4±3.3 vs. 4.6±0.7, P < 0.01], however, there was no significant change in LVESV. In the non-reaction group, SV and LVEF were significantly increased after PLR as compared with those at baseline levels [SV (mL): 42.7±3.7 vs. 40.6±3.1, LVEF: 0.52±0.05 vs. 0.50±0.05, both P < 0.05], while LVEDV and CVP were significantly increased after VE as compared with those at baseline levels [LVEDV (mL): 84.4±4.1 vs. 80.6±5.9, CVP (cmH2O): 10.6±3.5 vs. 7.6±0.5, both P < 0.05], however, there was no significant change in LVESV. Pearson correlation analysis showed that ΔSV and ΔLVEF after PLR were positively correlated with ΔSV and ΔLVEF after VE (r1 = 0.86, r2 = 0.65, both P < 0.01). ROC curve analysis showed that the area under ROC curve (AUC) of PLR-induced ΔSV and ΔLVEF for predicting volume responsiveness was 0.85 and 0.66 respectively. When the cut-off value of ΔSV after PLR was 10.6%, the sensitivity was 78.2%, the specificity was 82.3%; when the cut-off value of ΔLVEF after PLR was 3.6%, the sensitivity was 78.2%, and the specificity was 73.2%. Conclusion ΔSV and ΔLVEF measured by PLR combined with echocardiography can be used to evaluate the volume responsiveness in patients with septic shock and can guide fluid therapy.