潮气量负荷试验在机械通气脓毒症患者容量反应性评估中的应用

doi:10.3969/j.issn.1002-1949.2019.04.015

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摘要目的探讨潮气量负荷试验(TVC)在机械通气脓毒症患者容量反应性评估中的作用。方法纳入2017年1月至2017年12月兰州大学第一医院重症医学科(ICU)收治的72例行机械通气的脓毒症患者，记录基础特征，首先以潮气量(Vt) 6 mL/kg（理想体质量）进行机械通气，监测脉压差变异度(PPV6)和每搏输出量变异度(SVV 6)，然后进行TVC，即将Vt由6 mL/kg增加至8 mL/kg维持2 min，监测PPV8和SVV8。TVC结束后继续以Vt 6 mL/kg通气并稳定10 min，再进行改良被动抬腿试验（PLRT），记录PLRT前后心脏指数(CI)变化，以PLRT后ΔCI%≥10%定义为容量反应阳性，将患者分为无反应组和有反应组，同时计算TVC前后PPV变化值(ΔPPV)和SVV变化值(ΔSVV)。结果纳入患者中无反应组32例，有反应组40例，两组患者的性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分、序贯器官功能障碍（SOFA）评分、呼吸功能、血流动力学指标以及TVC前的中心静脉压（CVP）、CI、脉压差变异度（PPV）、每搏输出量变异度（SVV）差异均无统计学意义（P>0.05）。TVC后有反应组患者PPV8和SVV8较PPV6和SVV6显著增加(P＜0.05)，而无反应组患者无明显变化（P>0.05）；两组患者PPV8(13.3±4.5 vs. 7.3±3.2，P＜0.01）和SVV8（14.6±5.6 vs. 7.8±3.5，P＜0.01)差异有统计学意义。PPV8和SVV8对容量反应性评估的准确性较PPV6和SVV6均增高(P＜0.01)，而TVC前后ΔPPV和ΔSVV对患者的容量反应性有最好的预测价值，曲线下面积(AUROC）分别为0.97和0.95。结论机械通气脓毒症患者进行TVC后PPV变化值(ΔPPV)和SVV变化值(ΔSVV)可以准确预测其容量反应性。

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	窦志敏
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	刘健

关键词 ：潮气量负荷试验（TVC）, 脓毒症, 容量反应性, 机械通气, 改良被动抬腿试验（PLRT）, 心脏指数（CI）, 脉压差变异度（PPV）, 每搏输出量变异度（SVV）

通讯作者: 李斌（1972-），男，硕士，主任医师，E-mail:lynd001@163.com。

作者简介: 窦志敏（1987-），男，博士研究生，主治医师，E-mail:douzhm@126.com。

引用本文:

窦志敏，林庆玲，曹永强，李斌，刘健. 潮气量负荷试验在机械通气脓毒症患者容量反应性评估中的应用[J]. 中国急救医学, 2019, 39(4): 366-370.
Dou Zhi-min, Lin Qing-ling, Cao Yong-qiang, Li Bin, Liu Jian. Effect of tidal volume challenge on fluid responsiveness in septic patients with mechanical ventilation. Chinese Journal of Critical Care Medicine, 2019, 39(4): 366-370.

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http://www.cnemergency.org.cn/CN/10.3969/j.issn.1002-1949.2019.04.015 或 http://www.cnemergency.org.cn/CN/Y2019/V39/I4/366

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