被动抬腿试验引起体积描记变异性指数的变化，以评估急性循环衰竭的危重症机械通气患者的液体反应性。

Passive leg raising test induced changes in plethysmographic variability index to assess fluid responsiveness in critically ill mechanically ventilated patients with acute circulatory failure.

作者信息

Mallat Jihad, Lemyze Malcolm, Fischer Marc-Olivier

机构信息

Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.

Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France.

出版信息

J Crit Care. 2024 Feb;79:154449. doi: 10.1016/j.jcrc.2023.154449. Epub 2023 Oct 17.

DOI:10.1016/j.jcrc.2023.154449

PMID:37857068

Abstract

BACKGROUND

Passive leg raising (PLR) reliably predicts fluid responsiveness but requires a real-time cardiac index (CI) measurement or the presence of an invasive arterial line to achieve this effect. The plethysmographic variability index (PVI), an automatic measurement of the respiratory variation of the perfusion index, is non-invasive and continuously displayed on the pulse oximeter device. We tested whether PLR-induced changes in PVI (ΔPVI) could accurately predict fluid responsiveness in mechanically ventilated patients with acute circulatory failure.

METHODS

This was a secondary analysis of an observational prospective study. We included 29 mechanically ventilated patients with acute circulatory failure in this study. We measured PVI (Radical-7 device; Masimo Corp., Irvine, CA) and CI (Echocardiography) before and during a PLR test and before and after volume expansion of 500 mL of crystalloid solution. A volume expansion-induced increase in CI of >15% defined fluid responsiveness. To investigate whether ΔPVI can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and gray zones for ΔPVI.

RESULTS

Of the 29 patients, 27 (93.1%) received norepinephrine. The median tidal volume was 7.0 [IQR: 6.6-7.6] mL/kg ideal body weight. Nineteen patients (65.5%) were classified as fluid responders (increase in CI > 15% after volume expansion). Relative ΔPVI accurately predicted fluid responsiveness with an AUROC of 0.89 (95%CI: 0.72-0.98, p < 0.001). A decrease in PVI ≤ -24.1% induced by PLR detected fluid responsiveness with a sensitivity of 95% (95%CI: 74-100%) and a specificity of 80% (95%CI: 44-97%). Gray zone was acceptable, including 13.8% of patients. The correlations between the relative ΔPVI and changes in CI induced by PLR and by volume expansion were significant (r = -0.58, p < 0.001, and r = -0.65, p < 0.001; respectively).

CONCLUSIONS

In sedated and mechanically ventilated ICU patients with acute circulatory failure, PLR-induced changes in PVI accurately predict fluid responsiveness with an acceptable gray zone.

TRIAL REGISTRATION

ClinicalTrials.govNCT03225378.

摘要

背景

被动抬腿试验（PLR）能可靠地预测液体反应性，但需要实时测量心脏指数（CI）或存在有创动脉导管才能达到此效果。体积描记变异指数（PVI）是对灌注指数呼吸变化的自动测量，是非侵入性的，且能在脉搏血氧仪设备上持续显示。我们测试了PLR诱导的PVI变化（ΔPVI）是否能准确预测急性循环衰竭的机械通气患者的液体反应性。

方法

这是一项观察性前瞻性研究的二次分析。本研究纳入了29例急性循环衰竭的机械通气患者。我们在PLR试验前、试验期间以及500 mL晶体溶液扩容前、扩容后测量PVI（Radical-7设备；Masimo公司，加利福尼亚州欧文市）和CI（超声心动图）。扩容诱导CI增加>15%定义为液体反应性。为了研究ΔPVI是否能预测液体反应性，我们确定了ΔPVI的受试者工作特征曲线下面积（AUROC）和灰色区域。

结果

29例患者中，27例（93.1%）接受去甲肾上腺素治疗。潮气量中位数为7.0[四分位间距：6.6 - 7.6]mL/kg理想体重。19例患者（65.5%）被归类为液体反应者（扩容后CI增加>15%）。相对ΔPVI能准确预测液体反应性，AUROC为0.89（95%置信区间：0.72 - 0.98，p<0.001）。PLR诱导PVI降低≤ - 24.1%可检测到液体反应性，敏感性为95%（95%置信区间：74 - 100%），特异性为80%（95%置信区间：44 - 97%）。灰色区域是可接受的，包括13.8%的患者。PLR和扩容诱导的CI变化与相对ΔPVI之间的相关性显著（分别为r = - 0.58，p<0.001和r = - 0.65，p<0.001）。