2019 年第 12 期 第 14 卷

股动脉与桡动脉脉压快速评估脓毒症休克患者液体反应性的价值

Rapid assessment of fluid responsiveness by pulse pressure at the femoral and radial sites in patients with septic shock

作者：陈鸣钱雅君李静刘洋陈显成顾勤

英文作者：

单位：210008南京鼓楼医院南京大学医学院附属鼓楼医院重症医学科

英文单位：

关键词：脓毒症休克；容量负荷试验；液体反应性；股动脉脉压；桡动脉脉压

英文关键词：

• 摘要：

• 【摘要】目的    探究容量复苏后股动脉脉压（PPF）和桡动脉脉压（PPR）改变对快速判断脓毒症休克患者液体反应性的临床价值。方法    选择2013年2月至2018年11月南京鼓楼医院重症医学科收治的脓毒症休克患者55例，以容量负荷试验（500 ml 0.9%氯化钠注射液在30 min内快速输注）后经脉搏指示连续心输出量技术监测的每搏输出量指数（SVI）上升≥15%为液体有反应组，SVI上升＜15%为液体无反应组。比较2组患者接受容量负荷试验前后的血流动力学指标水平，对容量负荷试验前后PPF和PPR的变化值（ΔPPF和ΔPPR）与相应的SVI的变化值（ΔSVI）进行线性回归分析，通过受试者工作特征（ROC）曲线分析容量负荷试验前后PPF和PPR变化百分比对脓毒症休克患者液体反应性的评估价值。结果    容量负荷试验后液体有反应组22例，液体无反应组33例，液体有反应组复苏后PPF、PPR较复苏前明显升高［(59±16)mmHg（1 mmHg=0.133 kPa）比(49±16)mmHg，（47±18）mmHg比（38±18）mmHg］，外周血管阻力指数明显下降［987(917,1 703)dyn·s/(cm5·m2)比1 526(1 241,1 998)dyn·s/(cm5·m2)］（均P<0.05），但液体无反应组复苏后上述参数变化则不明显（均P>0.05）。线性回归分析结果显示ΔPPF和ΔPPR分别与ΔSVI呈正相关（r=0.801、0.551，均P＜0.001），容量复苏前后PPF和PPR变化百分比评估液体反应性的ROC曲线下面积分别为0.787和0.665，评估液体有反应的最佳截断值为复苏后PPF升高12.8%、PPR升高7.7%，其敏感度分别为81.8%、77.3%，特异度为66.7%、54.5%。结论    PPF和PPR均可作为快速判断脓毒症休克患者液体反应性的指标，以PPF变化判断液体反应性较PPR更为准确。

• 【Abstract】Objective    To determine whether pulse pressure changes recorded at the femoral and radial sites during fluid challenge can evaluate fluid responsiveness in patients with septic shock. Methods    Fifty-five patients who met the criteria of septic shock were enrolled from February 2013 to November 2018 in Intensive Care Unit of Nanjing Drum Tower Hospital. All patients received fluid challenge by intravenous infusion of 500 ml 0.9% sodium chloride in 30 min. The responders were defined as patients who showed an increase in stroke volume index(SVI)≥15% after fluid challenge. Femoral pulse pressure(PPF), radial pulse pressure(PPR) and SVI were measured before and after fluid challenge. Relations among the difference values of PPF, PPR and SVI（ΔPPF， ΔPPR and ΔSVI） were analyzed by linear regression. Assessment values of PPF and PPR change percentages for fluid responsiveness were analyzed by receiver operating characteristic（ROC） curve. Results    After fluid challenge, PPF and PPR significantly increased and systemic vascular resistance index significantly decreased compared with those before treatment in the responders（22 cases）［(59±16)mmHg vs (49±16)mmHg, (47±18)mmHg vs (38±18)mmHg, 987(917,1 703)(dyn·s)/(cm5·m2) vs 1 526(1 241,1 998)dyn·s/(cm5·m2)］（all P<0.05); there was no significant change in the nonresponders（33 cases）(all P>0.05). Linear regression analysis showed that ΔPPF and ΔPPR were positively correlated with ΔSVI(r=0.801, 0.551, both P<0.001). Areas under ROC curve of PPF and PPR change percentages for fluid responsiveness were 0.787 and 0.665; the best cut-off values were 12.8% increase in PPF and 7.7% increase in PPR; the sensitivities were 81.8% and 77.3%; the specificities were 66.7% and 54.5%. Conclusion    In patients with septic shock, PPF and PPR can be used as indicators in rapid assessment of fluid responsiveness after fluid resuscitation; PPF is more accurate than PPR in the assessment.