摘要目的 探讨临床评估预测血流动力学状态的准确性和脉搏指示连续心输出量测定(PiCCO)血流动力学监测对临床治疗的指导性.方法 将2008年至2011年本院ICU/EICU收治的96例血流动力学不稳定、拟行PiCCO监测的患者进行临床评估,由主管医师预测血流动力学状态,并选择治疗方案,并在得到监测结果后,决定是否更改治疗方案.根据不同分类情况,来比较预测准确率和治疗方案更改率.结果 临床评估预测患者血流动力学参数的准确率分别为心指数(CI)55.2％、全心舒张末容量指数(GEDI) 60.4％、系统性血管阻力指数(SVRI) 63.5％和血管外肺水指数(EVLWI)78.1％.EVLWI预测准确率明显高于前三者(x2=11.344,7.071,4.941,均P＜0.05).根据PiCCO监测结果,49％医师更改了治疗方案.APACHEⅡ评分在15 ～ 25分之间的B组患者,其临床预测CI准确率较A组(APACHEⅡ评分＜15分)(42.3％ vs 67.9％,x2=4.755,P=0.029)和C组(APACHEⅡ评分≥25分)低(42.3％ vs 75.0％,x2=5.231,P=0.022).急性心肌梗死患者临床评估预测CI、GEDI和SVRI的准确率明显高于非急性心肌梗死者,而治疗更改率低于非急性心肌梗死者(21.1％ vs 55.8％,x2=7.382,P=0.007).因低氧血症置管患者临床评估预测准确率较低血压者低,但差异无统计学意义(P＞0.05)；其更改治疗方案比例较低(32.3％ vs 56.9％,x2=5.110,P =0.024).而入选时间早的患者CI预测准确率明显低于入选晚的患者(40％ vs 63.9％,x2=5.152,P=0.023),且更改治疗方案更频繁(65.7％ vs 39.3％,x2=6.189,P=0.013).结论 临床评估预测血流动力学状态的准确率较低,PiCCO监测能指导临床医师制定最佳治疗方案.

abstractsObjective To investigate the accuracy of careful clinical evaluation in hemodynamic status and guidance of PiCCO monitor in clinical treatment.Methods A total of 96 hemodynamic unstable cases were evaluated prior to the insertion of the PiCCO catheter.The attending physician in charge of the patient was required to complete a questionnaire to predict the range of key hemodynamic variables for CI,GEDI,SVRI and EVLWI.Additionally,the attending was also asked to indicate a plan for therapy based on the predicted hemodynamic profile and decide if the predicted therapy plan was altered after the the first measurement of hemodynamic variables.Results The accurate prediction of hemodynamic variables was CI (55.2％),GEDI(60.4％),SVRI(63.5％) 和 EVLWI (78.1％),among which EVLWI had a higher accuracy(P ＜ 0.05).49％ doctors altered their planned therapy according to the result of the PiCCO information.Doctors had more difficulty in accurately predicting hemodynamic values in critical patients which APACHE Ⅱ scored 15 ～25 (42.3％ vs 67.9％ and 42.3 ％ vs 75.0％,x2 =4.755,5.231,P ＜ 0.05).The prediction of patients with acute myocardial infarction was more accurate than those of without acute myocardial infarction,and less to alter the planned therapy(21.1％ vs 55.8％,x2 =7.382,P =0.007).The patients of impaired oxygenation had less accurate predictions and less therapy alterations(32.3％ vs 56.9％,x2 =5.110,P =0.024).Attending was able to predict the hemodynamic status more accurately(63.9％ vs 40％,x2 =5.152,P =0.023) and alter the predicted therapy less(39.3％ vs 65.7％,x2 =6.189,P =0.013) in patients who were enrolled later.Conclusions Clinical evaluation in hemodynamic status of critically ill patients had a lower accuracy,the information obtained by PiCCO often instruct clinical doctors to choose the optimal treatment.