Réanimation chirurgicale polyvalente, service d'anesthésie-réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes, France.
Service de réanimation polyvalente, CHRU de Tours, Tours, France.
Br J Anaesth. 2017 Mar 1;118(3):355-362. doi: 10.1093/bja/aew478.
During fluid challenge, volume expansion (VE)-induced increase in cardiac output (Δ VE CO) is seldom measured.
In patients with shock undergoing strictly controlled mechanical ventilation and receiving VE, we assessed minimally invasive surrogates for Δ VE CO (by transthoracic echocardiography): fluid-induced increases in end-tidal carbon dioxide (Δ VE E'CO2 ); pulse (Δ VE PP), systolic (Δ VE SBP), and mean systemic blood pressure (Δ VE MBP); and femoral artery Doppler flow (Δ VE FemFlow). In the absence of arrhythmia, fluid-induced decrease in heart rate (Δ VE HR) and in pulse pressure respiratory variation (Δ VE PPV) were also evaluated. Areas under the receiver operating characteristic curves (AUC ROC s) reflect the ability to identify a response to VE (Δ VE CO ≥15%).
In 86 patients, Δ VE E'CO2 had an AUC ROC =0.82 [interquartile range 0.73-0.90], significantly higher than the AUC ROC for Δ VE PP, Δ VE SBP, Δ VE MBP, and Δ VE FemFlow (AUC ROC =0.61-0.65, all P <0.05). A value of Δ VE E'CO2 >1 mm Hg (>0.13 kPa) had good positive (5.0 [2.6-9.8]) and fair negative (0.29 [0.2-0.5]) likelihood ratios. The 16 patients with arrhythmia had similar relationships between Δ VE E'CO2 and Δ VE CO to patients with regular rhythm ( r 2 =0.23 in both subgroups). In 60 patients with no arrhythmia, Δ VE E'CO2 (AUC ROC =0.84 [0.72-0.92]) outperformed Δ VE HR (AUC ROC =0.52 [0.39-0.66], P <0.05) and tended to outperform Δ VE PPV (AUC ROC =0.73 [0.60-0.84], P =0.21). In the 45 patients with no arrhythmia and receiving ventilation with tidal volume <8 ml kg -1 , Δ VE E'CO2 performed better than Δ VE PPV, with AUC ROC =0.86 [0.72-0.95] vs 0.66 [0.49-0.80], P =0.02.
Δ VE E'CO2 outperformed Δ VE PP, Δ VE SBP, Δ VE MBP, Δ VE FemFlow, and Δ VE HR and, during protective ventilation, arrhythmia, or both, it also outperformed Δ VE PPV. A value of Δ VE E'CO2 >1 mm Hg (>0.13 kPa) indicated a likely response to VE.
在进行液体冲击时，很少测量容量扩张（VE）引起的心输出量（ΔVECO）的增加。
在接受严格控制机械通气和 VE 的休克患者中，我们评估了用于 ΔVECO 的微创替代物（通过经胸超声心动图）：潮气末二氧化碳（ΔVEE'CO2）的增加；脉搏（ΔVEPP）、收缩压（ΔVESBP）和平均全身血压（ΔVEMBP）；以及股动脉多普勒流量（ΔVEFemFlow）。在没有心律失常的情况下，还评估了液体诱导的心率（ΔVEHR）和脉搏压呼吸变化（ΔVEPPV）的降低。接受者操作特征曲线下的面积（AUCROC s）反映了识别 VE（ΔVECO≥15%）反应的能力。
在 86 名患者中，ΔVEE'CO2 的 AUCROC=0.82（四分位间距 0.73-0.90），显著高于 ΔVEPP、ΔVESBP、ΔVEMBP 和 ΔVEFemFlow 的 AUCROC（0.61-0.65，均 P<0.05）。ΔVEE'CO2 值>1mmHg（>0.13kPa）具有良好的阳性（5.0[2.6-9.8]）和适度的阴性（0.29[0.2-0.5]）似然比。16 名心律失常患者与窦性节律患者的 ΔVEE'CO2 和 ΔVECO 之间存在相似的关系（两组的 r2=0.23）。在 60 名无心律失常的患者中，ΔVEE'CO2（AUCROC=0.84[0.72-0.92]）优于 ΔVEHR（AUCROC=0.52[0.39-0.66]，P<0.05），且倾向于优于 ΔVEPPV（AUCROC=0.73[0.60-0.84]，P=0.21）。在 45 名无心律失常且接受潮气量<8mlkg-1通气的患者中，ΔVEE'CO2 的表现优于 ΔVEPPV，AUCROC=0.86[0.72-0.95]与 0.66[0.49-0.80]，P=0.02。
ΔVEE'CO2 优于 ΔVEPP、ΔVESBP、ΔVEMBP、ΔVEFemFlow 和 ΔVEHR，在保护性通气、心律失常或两者同时存在时，它也优于 ΔVEPPV。ΔVEE'CO2 值>1mmHg（>0.13kPa）表明可能对 VE 有反应。
