急性呼吸窘迫综合征患者的液体反应性：HEMOPRED 研究的事后分析。

Fluid responsiveness in acute respiratory distress syndrome patients: a post hoc analysis of the HEMOPRED study.

机构信息

Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France.

Inserm U1173, Laboratory of Infection & Inflammation, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France.

出版信息

Intensive Care Med. 2024 Nov;50(11):1850-1860. doi: 10.1007/s00134-024-07639-6. Epub 2024 Sep 10.

DOI:10.1007/s00134-024-07639-6

PMID:39254736

Abstract

PURPOSE

Optimal fluid management in patients with acute respiratory distress syndrome (ARDS) is challenging due to risks associated with both circulatory failure and fluid overload. The performance of dynamic indices to predict fluid responsiveness (FR) in ARDS patients is uncertain.

METHODS

This post hoc analysis of the HEMOPRED study compared the performance of dynamic indices in mechanically ventilated patients with shock, with and without ARDS, to predict FR, defined as an increase in aortic velocity time integral (VTI) > 10% after passive leg raising (PLR).

RESULTS

Among 540 patients, 117 (22%) had ARDS and were ventilated with a median tidal volume of 7.6 mL/kg [6.9-8.4] and a median positive end-expiratory pressure of 7 cmHO [5-9]. FR was observed in 45 ARDS patients (39% vs 44% in non-ARDS patients, p = 0.384). Reliability of dynamic indices to predict FR remained consistent in ARDS patients, though with different thresholds. Collapsibility index of the superior vena cava (ΔSVC) showed the best predictive performance in both ARDS (area under the curve [AUC] = 0.763 [0.659-0.868]) and non-ARDS (AUC = 0.750 [0.698-0.802]) patients. A right to left ventricle end-diastolic area ratio > 0.8 or paradoxical septal motion were strongly linked to the absence of FR (> 80% specificity). FR was not associated with intensive care unit (ICU) mortality (47% vs. 46%, p = 1). However, hypovolemia, defined as an aortic VTI increase > 32% during PLR (median increase in patients with a partial SVC collapse) was independently associated with ICU mortality (odds ratio [OR] = 1.355 [1.077-1.705], p = 0.011), as well as pulse pressure variation (OR = 1.014 [1.001-1.026], p = 0.034).

CONCLUSION

Performance of dynamic indices to predict FR appears preserved in ARDS patients, albeit with distinct thresholds. Hypovolemia, indicated by a > 32% increase in aortic VTI during PLR, rather than FR, was associated with ICU mortality in this population.

摘要

目的

急性呼吸窘迫综合征（ARDS）患者的最佳液体管理具有挑战性，因为这与循环衰竭和液体超负荷的风险都相关。目前，预测 ARDS 患者液体反应性（FR）的动态指标的性能尚不确定。

方法

本 HEMOPRED 研究的事后分析比较了合并和不合并 ARDS 的休克机械通气患者的动态指标在预测 FR 方面的性能，FR 定义为被动抬腿（PLR）后主动脉速度时间积分（VTI）增加>10%。

结果

在 540 例患者中，117 例（22%）患有 ARDS，潮气量中位数为 7.6ml/kg[6.9-8.4]，呼气末正压中位数为 7cmH2O[5-9]。在 45 例 ARDS 患者中观察到 FR（ARDS 患者中为 39%，非 ARDS 患者中为 44%，p=0.384）。尽管 ARDS 患者的 FR 预测存在不同的阈值，但预测 FR 的动态指标的可靠性仍然一致。上腔静脉塌陷指数（ΔSVC）在 ARDS 患者（曲线下面积[AUC]：0.763[0.659-0.868]）和非 ARDS 患者（AUC：0.750[0.698-0.802]）中均具有最佳的预测性能。右室与左室舒张末期面积比>0.8 或矛盾性室间隔运动与 FR 缺失（>80%特异性）密切相关。FR 与 ICU 死亡率（47%vs.46%，p=1）无关。然而，PLR 期间主动脉 VTI 增加>32%（患者中 SVC 部分塌陷）定义为低血容量，与 ICU 死亡率独立相关（比值比[OR]：1.355[1.077-1.705]，p=0.011），脉搏压变异（OR：1.014[1.001-1.026]，p=0.034）也与 ICU 死亡率相关。