中国实用儿科杂志

中国实用儿科杂志

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无创血流动力学监测对儿童脓毒性休克液体复苏容量反应性的预测价值

  

  1. 湖南省儿童医院急救中心，湖南  长沙  410007
  • 出版日期:2021-03-06 发布日期:2021-04-08

Predictive value of noninvasive hemodynamic monitoring for fluid therapy responsiveness in children with septic shock

  1. Department of Pediatric Emergency Center， Hunan Provincial Children’s Hospital，Changsha  410007，China
  • Online:2021-03-06 Published:2021-04-08

摘要： 目的　探讨无创血流动力学监测对脓毒性休克液体复苏容量反应性的预测价值。方法　选取2018年2月至2020年3月于湖南省儿童医院儿童重症监护病房（PICU）确诊的脓毒性休克患儿92例纳入研究， 患儿均给予无创心输出量测量仪床旁监测心脏指数（CI）、 每搏输出量指数（SVI）、 系统血管阻力指数（SVRI）等指标。根据液体复苏治疗前后每搏输出量指数变化率（△SVI）分为有反应组（△SVI≥10%）和无反应组（△SVI＜10%）。观察患儿治疗前后各项血流动力学指标的变化， 并行受试者工作特征（ROC）曲线分析预测儿童脓毒性休克液体复苏容量反应性。 结果　（1）两组患儿年龄、 性别、 感染源及感染部位儿童危重病例评分（PCIS）、 序贯器官衰竭（SOFA）评分、 输液量及机械通气各参数等比较差异均无统计学意义（P＞0.05）， 液体复苏后无反应组较有反应组肺水肿发生率及病死率增高， 住院时间及机械通气时间延长（P＜0.05）。（2）治疗前有反应组患儿CI、 SVI与无反应组比较差异有统计学意义（P＜0.05）［CI（2.55±0.63） L/（min·m2） vs. （3.12±0.75） L/（min·m2）； SVI （35.8±10.3） mL/（min·m2） vs. （40.5±6.3） mL/（min·m2）］， 治疗后CI、 SVI较治疗前明显增高， 心率（HR）、 系统血管阻力指数（SVRI）及每搏变异率（SVV）较治疗前下降， 差异有统计学意义（P＜0.05）， 但胸腔液体水平（TFC）增高不明显（P＞0.05）； 无反应组CI、 SVV、 SVI及SVRI等治疗前后变化不明显（P＞0.05）， 但TFC经液体复苏治疗后明显高于治疗前（P＜0.05）。（3）ROC曲线分析显示SVV， SVI和CI对液体治疗容量反应性有预测价值。SVV， SVI和CI预测液体治疗反应性的AUC分别为0.836（95%CI 0.725～0.947 ）、 0.778（95%CI 0.651～0.905）、 0.793（95%CI 0.663～0.922）（P＜0.005）。且当SVV≥13%时， 其预测液体治疗反应性的敏感度为85.8%，特异度为80.3%， 当SVI≤38 mL/（min·m2）， 其敏感度为81.0%， 特异度为75.8%， 当CI≤2.865 L/（min·m2）时， 其敏感度为78.5%， 特异度为79.2%。结论　无创心输出量测量仪可动态监测无创血流动力学指标， 且SVV、 SVI、 CI可预测儿童脓毒性休克液体治疗的容量反应性， 对指导脓毒性休克早期液体复苏和优化液体管理及预负荷有重要意义，值得临床推广。

关键词: 无创血流动力学监测, 脓毒性休克, 容量反应性, 儿童

Abstract: Objective　To explore the predictive value of noninvasive hemodynamic monitoring for fluid therapy volumetrical responsiveness in children with septic shock. Methods　A total of  92 children with septic shock admitted to PICU Department of Hunan Children’s Hospital between February 2018 to March 2020 were enrolled. Hemodynamic parameters of all children were supervised by ICON noninvasive cardiac output monitoring（NICOM）. The hemodynamic parameters included cardiac index（CI）， stroke volume index（SVI） and systemic vascular resistance index（SVRI）， etc. According to the △SVI， the patients were assigned into two groups，responsive group with a △SVI ≥10% and non-responsive group with a △SVI＜10%. The changes in hemodynamic indexes before and after fluid therapy in the two groups were compared， and the predictive value of SVV， CI and SVI in fluid responsiveness was analyzed by receiver operating characteristic（ROC） curve. Results　1. There was no difference in age， gender， infection source， infection site PCIS or SOFA scores between the two groups（P＞0.05）. Both groups received mechanical ventilation， and the mechanical ventilation parameters were not statistically different（P＞0.05）； the incidence and mortality of pulmonary edema were significantly higher and the length of hospital stay and time on the machine were significantly longer in the non-responsive group than those in the responsive group after fluid therapy. 2. There were statistically significant differences in CI and SVI between the responsive group and the non-responsive group before treatment［CI （2.55±0.63） L/（min·m2） vs. （3.12±0.75） L/（min·m2）； SVI （35.8±10.37） mL/（min·m2） vs.（40.5±6.3） mL/（min·m2）. The CI， SVI and EF after fluid therapy were significantly higher after treatment than before fluid therapy， while HR， SVRI and SVV were significantly lower， which had  statistically significant differences（P＜0.05）， but the increase in TFC was not significant（P＞0.05）. There was no obvious change in CI， SVV， SVI or SVRI before and after therapy（P＞0.05） in the non-responsive group， but TFC was significantly higher after fluid therapy（P＜0.05）. 3. ROC curve analysis showed that SVV， SVI and CI had predictive value for volume responsiveness of liquid therapy. The area under the curve of SVV， SVI and CI was 0.836（95%CI 0.725～0.947）， 0.778（95%CI 0.651～0.905） and 0.793（95%CI 0.663～0.922）（P＜0.005）， respectively. The sensitivity was 85.8% and the specificity was 80.3% when SVV≥13%， and they were 81.0% and 75.8% when SVI≤38 mL/（min·m2）， and 78.5% and 79.2% when CI≤2.865 L/（min·m2）. Conclusion　NICOM can dynamically monitor the noninvasive hemodynamic indexes， and the SVV， SVI and CI can predict the fluid therapy volume responsiveness in children with septic shock. It is important in guiding early fluid resuscitation of septic shock and in optimizing fluid management and preload.

Key words: noninvasive hemodynamics monitoring, septic shock, volume responsiveness, child