腹腔内高压导致被动抬腿试验出现假阴性。

Intra-Abdominal Hypertension Is Responsible for False Negatives to the Passive Leg Raising Test.

机构信息

Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, Assistance publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France.

Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France.

出版信息

Crit Care Med. 2019 Aug;47(8):e639-e647. doi: 10.1097/CCM.0000000000003808.

DOI:10.1097/CCM.0000000000003808

PMID:31306258

Abstract

OBJECTIVES

To compare the passive leg raising test ability to predict fluid responsiveness in patients with and without intra-abdominal hypertension.

DESIGN

Observational study.

SETTING

Medical ICU.

PATIENTS

Mechanically ventilated patients monitored with a PiCCO2 device (Pulsion Medical Systems, Feldkirchen, Germany) in whom fluid expansion was planned, with (intra-abdominal hypertension+) and without (intra-abdominal hypertension-) intra-abdominal hypertension, defined by an intra-abdominal pressure greater than or equal to 12 mm Hg (bladder pressure).

INTERVENTIONS

We measured the changes in cardiac index during passive leg raising and after volume expansion. The passive leg raising test was defined as positive if it increased cardiac index greater than or equal to 10%. Fluid responsiveness was defined by a fluid-induced increase in cardiac index greater than or equal to 15%.

MEASUREMENTS AND MAIN RESULTS

We included 60 patients, 30 without intra-abdominal hypertension (15 fluid responders and 15 fluid nonresponders) and 30 with intra-abdominal hypertension (21 fluid responders and nine fluid nonresponders). The intra-abdominal pressure at baseline was 4 ± 3 mm Hg in intra-abdominal hypertension- and 20 ± 6 mm Hg in intra-abdominal hypertension+ patients (p < 0.01). In intra-abdominal hypertension- patients with fluid responsiveness, cardiac index increased by 25% ± 19% during passive leg raising and by 35% ± 14% after volume expansion. The passive leg raising test was positive in 14 patients. The passive leg raising test was negative in all intra-abdominal hypertension- patients without fluid responsiveness. In intra-abdominal hypertension+ patients with fluid responsiveness, cardiac index increased by 10% ± 14% during passive leg raising (p = 0.01 vs intra-abdominal hypertension- patients) and by 32% ± 18% during volume expansion (p = 0.72 vs intra-abdominal hypertension- patients). Among these patients, the passive leg raising test was negative in 15 patients (false negatives) and positive in six patients (true positives). Among the nine intra-abdominal hypertension+ patients without fluid responsiveness, the passive leg raising test was negative in all but one patient. The area under the receiver operating characteristic curve of the passive leg raising test for detecting fluid responsiveness was 0.98 ± 0.02 (p < 0.001 vs 0.5) in intra-abdominal hypertension- patients and 0.60 ± 0.11 in intra-abdominal hypertension+ patients (p = 0.37 vs 0.5).

CONCLUSIONS

Intra-abdominal hypertension is responsible for some false negatives to the passive leg raising test.

摘要

目的

比较被动抬腿试验预测合并与不合并腹腔内高压患者液体反应性的能力。

设计

观察性研究。

地点

重症监护病房。

患者

使用脉搏指示剂连续心排血量监测仪（德国费尔德基兴的脉冲医疗系统）监测的机械通气患者，计划进行液体扩张，分为合并（腹腔内高压+）和不合并（腹腔内高压-）腹腔内高压，通过膀胱压定义腹腔内压力大于或等于 12mmHg。

干预措施

我们测量了被动抬腿和容量扩张期间心指数的变化。如果心指数增加大于或等于 10%，则将被动抬腿试验定义为阳性。液体反应性定义为液体诱导的心指数增加大于或等于 15%。

测量和主要结果

我们纳入了 60 名患者，其中 30 名患者无腹腔内高压（15 名液体反应性患者和 15 名液体无反应性患者），30 名患者合并腹腔内高压（21 名液体反应性患者和 9 名液体无反应性患者）。腹腔内高压-患者的基础腹腔内压力为 4±3mmHg，腹腔内高压+患者为 20±6mmHg（p<0.01）。在腹腔内高压-液体反应性患者中，被动抬腿时心指数增加 25%±19%，容量扩张时增加 35%±14%。14 名患者的被动抬腿试验为阳性。所有腹腔内高压-液体无反应性患者的被动抬腿试验均为阴性。在腹腔内高压+液体反应性患者中，被动抬腿时心指数增加 10%±14%（与腹腔内高压-患者相比，p=0.01），容量扩张时增加 32%±18%（与腹腔内高压-患者相比，p=0.72）。在这些患者中，15 名患者（假阴性）的被动抬腿试验为阴性，6 名患者（真阳性）为阳性。在 9 名无液体反应性的腹腔内高压+患者中，除 1 名患者外，其余患者的被动抬腿试验均为阴性。被动抬腿试验检测腹腔内高压-患者液体反应性的受试者工作特征曲线下面积为 0.98±0.02（p<0.001 与 0.5 相比），腹腔内高压+患者为 0.60±0.11（p=0.37 与 0.5 相比）。