腹内压对脉压变异预测液体反应性特异性的影响。

Influence of intra-abdominal pressure on the specificity of pulse pressure variations to predict fluid responsiveness.

作者信息

Royer Patrick, Bendjelid Karim, Valentino Ruddy, Résière Dabor, Chabartier Cyrille, Mehdaoui Hossein

机构信息

From the Medical and Surgical Intensive Care Unit (P.R., R.V., D.R., C.C., H.M.), Fort de France University Hospital, Martinique, French West Indies, France; Intensive Care Service (K.B.), Geneva University Hospitals, Geneva, Switzerland; and Medical Intensive Care Unit (P.R.), Cochin Hospital, Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Universitaire Cochin Broca Hôtel-Dieu, Paris, France.

出版信息

J Trauma Acute Care Surg. 2015 May;78(5):994-9. doi: 10.1097/TA.0000000000000605.

DOI:10.1097/TA.0000000000000605

PMID:25909421

Abstract

BACKGROUND

The positive predictive value of pulse pressure variations (ΔPP) to discriminate patients who should respond to volume expansion (VE) may be altered in mechanically ventilated patients. Our goal was to determine whether intra-abdominal pressure (IAP) measurements could discriminate patients with true-positive ΔPP values versus patients with false-positive ΔPP values.

METHODS

We designed a prospective pathophysiologic study in a mixed intensive care unit of a university hospital. Sixteen mechanically ventilated patients with hypotension (SAP, <90 mm Hg) and with ΔPP of 13% or more were included. Cardiac output was assessed using Doppler echocardiography before and after VE; IAP was measured using the bladder pressure method. Patients were classified into two groups according to their response to a standardized VE (500 mL of NaCl 0.9%): responders (≥15% increase in cardiac output) and nonresponders.

RESULTS

Nine patients (57%) were responders, and seven patients (43%) were nonresponders. Before VE, IAP was statistically higher in nonresponders (15 [11-22] mm Hg vs. 9 [6.5-11] mm Hg; p = 0.008). The area under the curve of the receiver operating characteristic curve was 0.9 ± 0.08. In patients with ΔPP of 13% or more, an IAP cutoff value of 10.5 mm Hg discriminated between responders and nonresponders with a sensitivity of 100% (59-100%) and a specificity of 78% (40-97%).

CONCLUSION

An increase in IAP of more than 10.5 mm Hg can decrease the positive predictive value of ΔPP. Hence, in patients prone to present abnormal IAP values, IAP should be measured before performing VE directed by the ΔPP marker.

LEVEL OF EVIDENCE

Diagnostic study, level II.

摘要

背景

在机械通气患者中，脉压变异（ΔPP）用于鉴别对容量扩充（VE）有反应患者的阳性预测值可能会发生改变。我们的目标是确定腹内压（IAP）测量能否区分ΔPP值为真阳性的患者与ΔPP值为假阳性的患者。

方法

我们在一所大学医院的混合重症监护病房设计了一项前瞻性病理生理学研究。纳入16例机械通气的低血压患者（收缩压<90 mmHg），其ΔPP为13%或更高。在进行容量扩充前后，使用多普勒超声心动图评估心输出量；使用膀胱压力法测量腹内压。根据患者对标准化容量扩充（500 mL 0.9%氯化钠溶液）的反应将患者分为两组：有反应者（心输出量增加≥15%）和无反应者。

结果

9例患者（57%）为有反应者，7例患者（43%）为无反应者。在进行容量扩充前，无反应者的腹内压在统计学上更高（15[11 - 22] mmHg对9[6.5 - 11] mmHg；p = 0.008）。受试者工作特征曲线下面积为0.9±0.08。在ΔPP为13%或更高的患者中，腹内压临界值为10.5 mmHg可区分有反应者和无反应者，敏感性为100%（59 - 100%），特异性为78%（40 - 97%）。