目的探讨床旁超声监测被动抬腿试验（PLR）前后颈动脉速度时间积分（VTI）和校正血流时间（FTc）预测危重患者容量反应性的价值。
方法采用前瞻性观察性研究方法，选择2020年1月至2021年3月杭州市富阳区第一人民医院收治的50例危重患者作为研究对象。收集患者的性别、年龄、体质量指数（BMI）、急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）、机械通气时间等临床资料。所有患者在PLR实施前后，利用超声监测颈动脉VTI和FTc，采用脉搏指示连续心排血量监测（PiCCO）心率、平均动脉压（MAP）、中心静脉压（CVP）、每搏量指数（SVI）及胸腔内血容量指数（ITBVI）的变化。根据PLR前后SVI的变化情况进行分组，以PLR后SVI变化率≥15%为容量有反应组，<15%为容量无反应组。比较两组患者PLR前后颈动脉VTI差值（ΔVTI）和FTc差值（ΔFTc）、CVP差值（ΔCVP）、ITBVI差值（ΔITBVI）的差异；采用受试者工作特征曲线（ROC曲线）分析上述指标对危重患者容量反应性的预测价值；采用Pearson相关分析法评估上述指标与PLR前后SVI差值（ΔSVI）的相关性。
结果共纳入50例患者，其中容量有反应组27例，容量无反应组23例，两组基线资料比较差异无统计学意义。容量有反应组PLR前后ΔVTI、ΔFTc、ΔCVP、ΔITBVI均明显高于容量无反应组〔ΔVTI（cm）：2.07±1.16比0.67±0.86，ΔFTc（ms）：4.00±6.10比0.01±2.26，ΔCVP（cmH 2O，1 cmH 2O＝ 0.098 kPa）：1.67±1.14比1.00±1.17，ΔITBVI（mL/m 2）：98±69比48±70，均 P<0.05〕。ROC曲线分析显示，ΔVTI、ΔFTc、ΔCVP、ΔITBVI对机体容量反应性均有预测价值，ROC曲线下面积（AUC）和95%可信区间（95% CI）分别为0.870 （0.769~0.972）、0.694（0.547~0.841）、0.684（0.535~0.832）、0.709（0.564~0.855）；当最佳截点值分别为0.92 cm、1.45 ms、1.50 cmH 2O、44.50 mL/m 2时，其敏感度分别为96.3%、63.0%、44.4%、81.5%，特异度分别为65.2%、78.3%、82.6%、56.5%，以ΔVTI的预测价值更高。相关性分析显示，ΔVTI、ΔFTc、ΔCVP、ΔITBVI与ΔSVI均呈显著正相关（ r值分别为0.971、0.334、0.440、0.650， P分别为0.000、0.018、0.001、0.000）。
结论床旁超声监测PLR前后颈动脉ΔVTI、ΔFTc与传统指标均能预测危重患者的容量反应性，且ΔVTI具有较好的预测价值。
ObjectiveTo investigate the value of monitor carotid velocity time integral (VTI) and corrected flow time (FTc) by bedside ultrasound before and after passive leg raising (PLR) in predicting fluid responsiveness in critically ill patients.
MethodsA prospective observational study was conducted. Fifty patients with critical illness admitted to the First People's Hospital of Fuyang Hangzhou from January 2020 to March 2021 were enrolled. The clinical data including the gender, age, body mass index (BMI), acute physiology and chronic health evaluationⅡ(APACHEⅡ) score, and the duration of mechanical ventilation were recorded. The changes of carotid VTI and FTc were measured by bedside ultrasound, and the values of heart rate, mean arterial pressure (MAP), central venous pressure (CVP), stroke volume index (SVI), and intrathoracic blood volume index (ITBVI) were measured by pulse indicated continuous cardiac output (PiCCO) monitor before and after PLR in all patients. According to the changes of SVI before and after PLR, the patients were divided into fluid responsiveness positive group with the change rate of SVI≥15% and fluid responsiveness negative group with the change rate of SVI < 15%. The differences in the values of VTI, FTc, CVP, and ITBVI obtained before and after PLR (ΔVTI, ΔFTc, ΔCVP and ΔITBVI) were calculated and then compared between the two groups. The predictive values of these indicators on fluid responsiveness in critically ill patients were analyzed by receiver operator characteristic curve (ROC curve), and their relationship with the difference in SVI (ΔSVI) obtained before and after PLR was evaluated by Pearson correlation analysis.
ResultsFifty patients were all enrolled in this study, in which 27 patients were fluid response and 23 patients were fluid nonresponse. Basic clinical data were not different between the two groups. The values of ΔVTI, ΔFTc, ΔCVP, and ΔITBVI in fluid response were all significantly higher than those in fluid nonresponse [ΔVTI (cm): 2.07±1.16 vs. 0.67±0.86, ΔFTc (ms): 4.00±6.10 vs. 0.01±2.26, ΔCVP (cmH 2O, 1 cmH 2O = 0.098 kPa): 1.67±1.14 vs. 1.00±1.17, ΔITBVI (mL/m 2): 98±69 vs. 48±70, all P < 0.05]. ROC curve analysis showed that ΔVTI, ΔFTc, ΔCVP and ΔITBVI were all positive for predicting fluid responsiveness, their area under ROC curve (AUC) and 95% confidence interval (95% CI) were 0.870 (0.769-0.972), 0.694 (0.547-0.841), 0.684 (0.535-0.832) and 0.709 (0.564-0.855), respectively. When using ΔVTI 0.92 cm, ΔFTc 1.45 ms, ΔCVP 1.50 cmH 2O and ΔITBVI 44.50 mL/m 2 as the threshold values, the sensitivities were 96.3%, 63.0%, 44.4% and 81.5%, and the specificities were 65.2%, 78.3%, 82.6% and 56.5%, respectively, in which the predictive value of ΔVTI was the largest. Pearson correlation analysis indicated that ΔVTI, ΔFTc, ΔCVP, and ΔITBVI were positively associated with ΔSVI ( r values were 0.971, 0.334, 0.440, 0.650, P values were 0.000, 0.018, 0.001, 0.000, respectively).
ConclusionCarotid ΔVTI and ΔFTc monitored by bedside ultrasound before and after PLR could be as effective as conventional indicators in predicting fluid responsiveness in critically ill patients, and the predictive value of ΔVTI was better than others.
邵雪波,陈琪,唐卫东,等. 颈动脉超声联合被动抬腿试验对危重患者容量反应性的预测价值[J]. 中华危重病急救医学,2021,33(09)：1105-1109.
DOI:10.3760/cma.j.cn121430-20210706-01013版权归中华医学会所有。
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