Zhang Hongmin, Lian Hui, Zhang Qing, Zhao Hua, Wang Xiaoting
Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
Ann Intensive Care. 2024 Jul 20;14(1):114. doi: 10.1186/s13613-024-01352-9.
To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation.
This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D).
A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%).
CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.
探讨机械通气的危重症患者中心静脉压（CVP）与急性右心室（RV）功能障碍之间的关系。
本回顾性研究纳入了接受经胸超声心动图检查和CVP监测的机械通气危重症患者。收集超声心动图指标，包括三尖瓣环平面收缩期位移（TAPSE）、面积变化分数（FAC）和三尖瓣外侧环收缩期速度波（S'），以评估右心室功能。然后根据右心室功能以及通过下腔静脉直径（IVCD）和肝静脉（HV）多普勒评估的全身静脉充血情况，将患者分为三组：右心室功能正常（TAPSE≥17mm，FAC≥35%且S'≥9.5cm/秒）、孤立性右心室功能障碍（TAPSE＜17mm或FAC＜35%或S'＜9.5cm/秒且IVCD≤20mm或HV S≥D）以及伴有充血的右心室功能障碍（TAPSE＜17mm或FAC＜35%或S'＜9.5cm/秒且IVCD＞20mm且HV S＜D）。
本研究共纳入518例患者，其中301例归类于右心室功能正常组，164例归类于孤立性右心室功能障碍组，53例归类于伴有充血的右心室功能障碍组。受试者工作特征分析显示，CVP对识别伴有充血的右心室功能障碍患者具有良好的鉴别能力（曲线下面积[AUC]0.839；95%置信区间：0.795 - 0.883；p＜0.001）。CVP的最佳截断值为10mmHg，敏感性为79.2%，特异性为69.4%，阴性预测值为96.7%，阳性预测值为22.8%。9mmHg至12mmHg之间存在一个较大的灰色区域，包含95例患者（18.3%）。对于识别所有右心室功能障碍患者，CVP的鉴别能力较低（AUC 0.616；95%置信区间：0.567 - 0.665；p＜0.001）。此外，灰色区域甚至更大，范围从5mmHg至12mmHg，包括349例患者（67.4%）。
CVP可能是机械通气危重症患者中伴有全身静脉充血的急性右心室功能障碍患者的一个有用指标，但其准确性有限。CVP小于10mmHg几乎可以排除伴有充血的右心室功能障碍。相比之下，CVP不应被用于识别一般性的右心室功能障碍。
