摘要目的 比较下腔静脉超声指标、脉搏指示剂连续心排出量监测(PiCCO)指标和CVP预测脓毒症休克合并心肌抑制患者容量反应性的准确性.方法 脓毒症休克合并心肌抑制患者50例,年龄＞18岁,补液试验方法:经20 min静脉输注0.9％氯化钠注射液或乳酸林格液注射液500 ml,补液后PiCCO监测的CO升高＞10％定义为补液试验阳性,根据补液试验分为容量反应阳性组和容量反应阴性组.于补液前采用PiCCO监测每搏输出量(SV)、每搏量变异度(SVV)、脉搏压变异度(PPV),测定CVP及床旁超声测定下腔静脉内径(d-IVC)及其呼吸变异度(v-IVC).绘制受试者工作特征(ROC)曲线评价各项指标预测容量反应性的准确性.结果 与容量反应阴性组比较,容量反应阳性组补液前d-IVC降低,v-IVC、SVV和PPV升高(P＜0.01).CVP、d-IVC、v-IVC、SVV、PPV分别取3.5 mmHg、14.5 mm、16.5％、17.0％、11.5％为截断值,预测容量反应性的敏感度分别为100％、92％、80％、44％、68％;特异度分别为28％、80％、72％、100％、72％;ROC曲线下面积及95％可信区间分别为0.609(0.450～0.768)、0.862(0.750～0.974)、0.777(0.642～0.911)、0.734(0.596～0.873)、0.733(0.594～0.872).结论 PiCCO指标和下腔静脉超声指标预测脓毒症休克合并心肌抑制患者容量反应性的准确性较高;因检查无创性,下腔静脉超声指标更具有优势.

abstractsObjective To compare the accuracy of inferior vena cava (IVC) ultrasound,central venous pressure (CVP) and pulse indicator continuous cardiac output (PiCCO) in predicting fluid responsiveness in septic shock patients with myocardial depression.Methods Fifty patients with septic shock complicated with myocardial depression,aged ＞ 18 yr,were enrolled in the study.The method for fluid replacement test was as follows:0.9％ sodium chloride injectionor lactated Ringer's solution 500 ml was intravenously infused over 20 min,and positive fluid responsiveness was defined as an increase in PiCCO-monitored CO＞ 10％ after fluid replacement.Patients were divided into positive fluid responsiveness group and negative fluid responsiveness group according to the fluid replacement test.PiCCO was used to monitor stroke volume (SV),stroke volume variation (SVV) and pulse pressure variability (PPV) before fluid replacement,CVP was measured,and the diameter of IVC (d-IVC) and variability of IVC (v-IVC) were measured by bedside ultrasound.The receiver operating characteristic curve was drawn to evaluate the accuracy of each index in predicting fluid responsiveness.Results Compared with negative fluid responsiveness group,d-IVC was significantly decreased and v-IVC,SVV and PPV were increased before fluid replacement in positive fluid responsiveness group (P＜0.01).Three point five mmHg,14.5 mm,16.5％,17.0％ and 11.5％ were selected as the cutoff value for CVP,d-IVC,v-IVC,SVV and PPV,respectively.The sensitivity of CVP,d-IVC,v-IVC,SVV and PPV in predicting fluid responsiveness was 100％,92％,80％,44％ and 68％,respectively,and the specificity was 28％,80％,72％,100％ and 72％,respectively,and the area under the receiver operating characteristic curve (95％ confidence interval) was 0.609 (0.450-0.768),0.862 (0.750-0.974),0.777 (0.642-0.911),0.734 (0.596-0.873) and 0.733 (0.594-0.872),respectively.Conclusion PiCCO and IVC ultrasound provide higher accuracy in predicting fluid responsiveness in septic shock patients with myocardial depression,and IVC ultrasound is more superior because of non-invasive examination.