在机械通气的重症监护病房患者中使用呼气末阻断法预测容量反应性

Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients.

作者信息

Monnet Xavier, Osman David, Ridel Christophe, Lamia Bouchra, Richard Christian, Teboul Jean-Louis

机构信息

AP-HP, Hôpital de Bicêtre, Service de Réanimation Médicale, Le Kremlin-Bicêtre, France.

出版信息

Crit Care Med. 2009 Mar;37(3):951-6. doi: 10.1097/CCM.0b013e3181968fe1.

DOI:10.1097/CCM.0b013e3181968fe1

PMID:19237902

Abstract

OBJECTIVE

During mechanical ventilation, inspiration cyclically decreases the left cardiac preload. Thus, an end-expiratory occlusion may prevent the cyclic impediment in left cardiac preload and may act like a fluid challenge. We tested whether this could serve as a functional test for fluid responsiveness in patients with circulatory failure.

DESIGN

Prospective study.

SETTING

Medical intensive care unit.

PATIENTS

Thirty-four mechanically ventilated patients with shock in whom volume expansion was planned.

INTERVENTION

A 15-second end-expiratory occlusion followed by a 500 mL saline infusion.

MEASUREMENTS

Arterial pressure and pulse contour-derived cardiac index (PiCCOplus) at baseline, during passive leg raising (PLR), during the 5-last seconds of the end-expiratory occlusion, and after volume expansion.

MAIN RESULTS

Volume expansion increased cardiac index by >15% (2.4 +/- 1.0 to 3.3 +/- 1.2 L/min/m, p < 0.05) in 23 patients ("responders"). Before volume expansion, the end-expiratory occlusion significantly increased arterial pulse pressure by 15% +/- 15% and cardiac index by 12% +/- 11% in responders whereas arterial pulse pressure and cardiac index did not change significantly in nonresponders. Fluid responsiveness was predicted by an increase in pulse pressure >or=5% during the end-expiratory occlusion with a sensitivity and a specificity of 87% and 100%, respectively, and by an increase in cardiac index >or=5% during the end-expiratory occlusion with a sensitivity and a specificity of 91% and 100%, respectively. The response of pulse pressure and cardiac index to the end-expiratory occlusion predicted fluid responsiveness with an accuracy that was similar to the response of cardiac index to PLR and that was significantly better than the response of pulse pressure to PLR (receiver operating characteristic curves area 0.957 [95% confidence interval [CI:] 0.825-0.994], 0.972 [95% CI: 0.849-0.995], 0.937 [95% CI: 0.797-0.990], and 0.675 [95% CI: 0.497-0.829], respectively).

CONCLUSIONS

The hemodynamic response to an end-expiratory occlusion can predict volume responsiveness in mechanically ventilated patients.

摘要

目的

在机械通气期间，吸气会周期性地降低左心前负荷。因此，呼气末阻断可能会防止左心前负荷的周期性阻碍，其作用类似于液体负荷试验。我们测试了这是否可作为循环衰竭患者液体反应性的功能测试。

设计

前瞻性研究。

地点

医学重症监护病房。

患者

34例计划进行容量扩充的机械通气休克患者。

干预措施

进行15秒的呼气末阻断，随后输注500毫升生理盐水。

测量指标

在基线、被动抬腿（PLR）期间、呼气末阻断的最后5秒以及容量扩充后测量动脉压和脉搏轮廓导出的心脏指数（PiCCOplus）。

主要结果

23例患者（“反应者”）容量扩充后心脏指数增加>15%（从2.4±1.0升至3.3±1.2升/分钟/平方米，p<0.05）。在容量扩充前，呼气末阻断使反应者的动脉脉压显著增加15%±15%，心脏指数增加12%±11%，而非反应者的动脉脉压和心脏指数无显著变化。呼气末阻断期间脉压增加≥5%可预测液体反应性，敏感性和特异性分别为87%和100%；呼气末阻断期间心脏指数增加≥5%也可预测液体反应性，敏感性和特异性分别为91%和100%。脉压和心脏指数对呼气末阻断的反应预测液体反应性的准确性与心脏指数对PLR的反应相似，且显著优于脉压对PLR的反应（受试者工作特征曲线面积分别为0.957[95%置信区间[CI]：0.825 - 0.994]、0.972[95%CI：0.849 - 0.995]、0.937[95%CI：0.797 - 0.990]和0.675[95%CI：0.497 - 0.829]）。