床旁超声联合被动抬腿试验评估感染性休克患者容量反应性的价值研究

发布时间：2018-06-13 21:42

本文选题：感染性休克 + 床旁超声　；参考：《浙江大学》2017年硕士论文

【摘要】：研究背景:感染性休克是重症监护病房(ICU)中的危重疾病之一。早期、合理的液体复苏方案对于感染性休克患者而言是不可或缺的重要治疗手段之一,但过度的液体治疗反而会导致患者病情的恶化。在评估时,容量状态指的是心脏的前负荷状态。而容量反应性则是指快速扩容后,每搏输出量(stroke volume SV)或心输出量(cardiac output,CO)能随之明显升高的现象。近年来研究则发现,通过进行被动抬腿(passive leg raising,PLR)试验结合测定每搏输出量或是其它的替代指标进行动态监测,可以预测机体的容量反应性。经胸心脏超声的发展使得临床工作中也可对重症患者进行床旁超声评估,以获取患者的每搏量和心输出量的变化,使得通过被动抬腿试验判断患者的容量反应性更为准确和方便。目的:探讨通过床旁超声评估被动抬腿试验前后血流动力学指标对感染性休克患者液体复苏时的容量反应性预测的价值。方法:选择51例感染性休克患者,根据液体复苏结果(补液扩容后SV较基线提升是否超过15%)将患者分为容量反应性组(n=27)和无容量反应性组(n=24)。监测两组患者被动抬腿试验开始前后和扩容结束后的超声评估的血流动力学等指标变化情况。结果:被动抬腿试验后容量反应性组患者的每搏输出量(62.12±11.31 vs.71.14±8.09(ml),P=0.004)、心输出量(6.24±1.07 vs.6.82± 1.52(L/min),P=0.026)和中心静脉压(10.81±4.13vs.14.12±3.51(mmHg),P=0.001)均明显增加,在患者完成被动抬腿试验后,上述指标有所下降(P0.05)。容量反应性组患者接受补液扩容后,上述血流动力学指标再一次明显增加(P0.05)。但以上变化在下腔静脉直径变异率中并未出现。当患者接受被动抬腿试验后,其SV变异率为7.95%时,对患者补液试验后容量反应性阳性有最高的预测灵敏度和特异度,此时,ROC曲线下面积为 0.878(P=0.006)。结论:被动抬腿试验联合床旁超声评估血流动力学可有效评估感染性休克患者早期液体复苏时的容量反应性。
[Abstract]:Background: septic shock is one of the critical diseases in intensive care unit (ICU). In the early stage, rational fluid resuscitation is an indispensable and important treatment for septic shock patients, but excessive fluid therapy will lead to the deterioration of the patient's condition. At the time of evaluation, the volume state refers to the preload state of the heart. Volumetric reactivity is a phenomenon in which stroke volume or cardiac output volume increase after rapid dilatation. In recent years, it has been found that the volume reactivity of the body can be predicted by the passive leg lifting leg raisinging-PLR test combined with the measurement of stroke output or other alternative indicators. With the development of transthoracic echocardiography, bedside ultrasound can also be used in the clinical work to obtain the changes of stroke volume and cardiac output. It makes it more accurate and convenient to judge the patient's volumetric reactivity by passive leg lifting test. Objective: to evaluate the predictive value of hemodynamic parameters before and after passive leg lifting test in patients with septic shock during fluid resuscitation by bedside ultrasound. Methods: 51 patients with septic shock were divided into two groups according to the results of fluid resuscitation (whether SV was more than 15 after resuscitation compared with baseline elevation) and non-volumetric reactivity group (n = 27) and no volume reactivity group (n = 24). The changes of hemodynamics were monitored before and after passive leg lifting test and after dilatation. Results: after the passive leg lifting test, the volume output per stroke was 62.12 卤11.31 vs.71.14 卤8.09 vs.71.14, the cardiac output was 6.24 卤1.07 vs.6.82 卤1.52L / min P 0.026) and the central venous pressure was 10.81 卤3.51mm 4.13vs.14.12 卤3.51mmHg P0.001). After the patients completed the passive leg lifting test, the above indexes were decreased (P 0.05). After the volume reactivity group received fluid infusion expansion, the above hemodynamic indexes were significantly increased again (P 0. 05). However, these changes did not occur in the variation rate of inferior vena cava diameter. When the patients received passive leg lifting test, the SV variation rate was 7.95 and had the highest predictive sensitivity and specificity for volumetric reactivity positive after the fluid rehydration test, and the area under the ROC curve was 0.878 P0. 006. Conclusion: passive leg lifting test combined with bedside ultrasound can effectively evaluate the volume reactivity of septic shock patients during early fluid resuscitation.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7

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