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Article(id=1203061228756250639, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203061212524290053, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2023.01.0064, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1641657600000, receivedDateStr=2022-01-09, revisedDate=null, revisedDateStr=null, acceptedDate=1659801600000, acceptedDateStr=2022-08-07, onlineDate=1764761748731, onlineDateStr=2025-12-03, pubDate=1674835200000, pubDateStr=2023-01-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1764761748731, onlineIssueDateStr=2025-12-03, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1764761748731, creator=13701087609, updateTime=1764761748731, updator=13701087609, issue=Issue{id=1203061212524290053, tenantId=1146029695717560320, journalId=1189873630562394117, year='2023', volume='48', issue='1', pageStart='1', pageEnd='120', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1764761744816, creator=13701087609, updateTime=1764763211166, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1203067362732913657, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203061212524290053, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1203067362732913658, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1203061212524290053, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=64, endPage=70, ext={EN=ArticleExt(id=1203061232929583138, articleId=1203061228756250639, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Alternative value of volume evaluation of internal jugular vein and subclavian vein collapse index in different respiratory states, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To explore the alternative value of internal jugular vein collapsibility index (IJVCI) and subclavian vein collapsibility index (SCVCI) used to substitute for inferior vena cava collapsibility index (IVCCI) in volume evaluation under spontaneous breathing and mechanical ventilation. Methods A total of 100 patients were selected who underwent elective surgery in the Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University from December 2020 to August 2021, the cyclic indicators of patients with different respiratory states were compared. According to the cut-off value of IVCCI, the patients were divided into hypovolemic group and non-hypovolemic group, and the cyclic indicators of the two groups were compared under different respiratory states. Pearson correlation analysis and Bland-Altman analysis were used to determine the relevance and consistency between IJVCI, SCVCI and IVCCI. ROC curve was used to analyze the efficiency of IJVCI and SCVCI in volume evaluation. Results Under mechanical ventilation condition, compared to spontaneous breathing condition, the SpO2 of patients was obviously increased, and heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), IVCCI, IJVCI and SCVCI were significantly decreased (P<0.01). IJVCI and SCVCI in non-hypovolemic group were significantly lower than those in hypovolemic group under the condition of spontaneous respiration (P<0.001). Under the condition of mechanical ventilation, SBP in non-hypovolemic group was significantly increased than that in hypovolemic group (P<0.05), while IJVCI and SCVCI were significantly lower than those in hypovolemic group (P<0.001). Under the condition of spontaneous breathing and mechanical ventilation, there was a significant positive correlation and consistency between IJVCI and IVCCI (r=0.586, P<0.01; r=0.514, P<0.001), and that a significant positive correlation and consistency between SCVCI and IVCCI (r=0.385, P<0.01; r=0.521, P<0.01). The area under the ROC curve (AUC) of IJVCI and SCVCI for the diagnosis of hypovolemia was 0.828, 0.684, and the best cut-off value was 22.2%, 25.4% under the condition of spontaneous breathing. The AUC of hypovolemia diagnosed by IJVCI and SCVCI were 0.701, 0.773, and the best cut-off value was 19.8%, 13.2% under the condition of mechanical ventilation. Conclusion Both IJVCI and SCVCI can replace IVCCI for volume evaluation in different respiratory states, but the alternative value of IJVCI is higher in spontaneous breathing state while of SCVCI is higher in mechanical ventilation state for volume evaluation.

, correspAuthors=Jun Cao, authorNote=null, correspAuthorsNote=
E-mail:
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目的 探讨自主呼吸及机械通气状态下颈内静脉塌陷指数(IJVCI)、锁骨下静脉塌陷指数(SCVCI)替代下腔静脉塌陷指数(IVCCI)评估低血容量的临床价值。方法 纳入2020年12月-2021年8月于重庆医科大学附属第一医院麻醉科行择期手术的100例患者。依据IVCCI的截断值，将患者分为低血容量组与非低血容量组，比较机械通气与自主呼吸状态下患者的各项循环指标。采用Pearson相关分析及Bland-Altman图分析IJVCI、SCVCI与IVCCI的相关性和一致性。采用ROC曲线分析IJVCI、SCVCI评估低血容量的效能。结果 机械通气状态下患者的SpO2较自主呼吸状态下明显增高，心率、收缩压(SBP)、舒张压(DBP)、IVCCI、IJVCI、SCVCI明显降低(P<0.01)。自主呼吸状态下，非低血容量组IJVCI、SCVCI较低血容量组明显降低(P<0.001)；机械通气状态下，非低血容量组SBP较低血容量组明显升高(P<0.05)，IJVCI、SCVCI较低血容量组明显降低(P<0.001)。自主呼吸和机械通气状态下，IJVCI与IVCCI均呈明显正相关关系(r=0.586，P<0.01；r=0.514，P<0.001)，且一致性较好；SCVCI与IVCCI均呈正相关关系(r=0.385，P<0.01；r=0.521，P<0.01)，且一致性较好。自主呼吸状态下，IJVCI、SCVCI评估低血容量的ROC曲线下面积(AUC)分别为0.828、0.684，最佳截断值分别为22.2%、25.4%；机械通气状态下，IJVCI、SCVCI评估低血容量的AUC分别为0.701、0.773，最佳截断值分别为19.8%、13.2%。结论 IJVCI与SCVCI在不同呼吸状态下均可替代IVCCI进行低血容量评估，但自主呼吸状态下IJVCI评估低血容量的价值更高，机械通气状态下SCVCI评估低血容量的价值更高。

, correspAuthors=曹俊, authorNote=null, correspAuthorsNote=
曹俊，E-mail：
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陈代宇，硕士研究生，主要从事围手术期精神紊乱防治、超声可视化应用方面的研究

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陈代宇，硕士研究生，主要从事围手术期精神紊乱防治、超声可视化应用方面的研究

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陈代宇，硕士研究生，主要从事围手术期精神紊乱防治、超声可视化应用方面的研究

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IVCCI. 下腔静脉塌陷指数；IJVCI. 颈内静脉塌陷指数；SCVCI. 锁骨下静脉塌陷指数；A、B. 自主呼吸状态下IJVCI、SCVCI与IVCCI的相关性；C、D. 机械通气状态下IJVCI、SCVCI与IVCCI的相关性

, figureFileSmall=KLPgLCwpToiwK1RssTWyOA==, figureFileBig=Bh8CW8RNYPsFsIajPhk9LQ==, tableContent=null), ArticleFig(id=1203061243264348647, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=EN, label=Fig. 2, caption=Consistency of IJVCI and SCVCI with IVVCI under spontaneous breathing and mechanical ventilation, figureFileSmall=E740VcaHUh5OPtaZkyn3hg==, figureFileBig=cq8zeZFrzb3KODYsXfpZcQ==, tableContent=null), ArticleFig(id=1203061243385983472, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=CN, label=图2, caption=自主呼吸及机械通气状态下IJVCI、SCVCI与IVCCI的一致性分析

IVCCI. 下腔静脉塌陷指数；IJVCI. 颈内静脉塌陷指数；SCVCI. 锁骨下静脉塌陷指数；X轴表示两种静脉塌陷指数的平均值；Y轴表示两种静脉塌陷指数的差值；深蓝色实线表示两种塌陷指数差值的平均值；深红色虚线示上下一致性界限；A、B. 自主呼吸状态下IJVCI、SCVCI与IVCCI的一致性分析；C、D. 机械通气状态下IJVCI、SCVCI与IVCCI的一致性分析

, figureFileSmall=E740VcaHUh5OPtaZkyn3hg==, figureFileBig=cq8zeZFrzb3KODYsXfpZcQ==, tableContent=null), ArticleFig(id=1203061243469869563, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=EN, label=Fig. 3, caption=ROC curve of hypovolemic patients tested with IJVCI and SCVCI under different ventilation conditions, figureFileSmall=fv/zRb6Priyc0xEOXqjs9A==, figureFileBig=iEcgutopaboidrof44v4gA==, tableContent=null), ArticleFig(id=1203061243625058825, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=CN, label=图3, caption=不同呼吸状态下IJVCI与SCVCI评估低血容量的ROC曲线

IJVCI. 颈内静脉塌陷指数；SCVCI. 锁骨下静脉塌陷指数；A. 自主呼吸状态下IJVCI、SCVCI评估低血容量的ROC曲线；B. 机械通气状态下IJVCI、SCVCI评估低血容量的ROC曲线

, figureFileSmall=fv/zRb6Priyc0xEOXqjs9A==, figureFileBig=iEcgutopaboidrof44v4gA==, tableContent=null), ArticleFig(id=1203061243759276564, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=EN, label=Tab. 1, caption=

Comparison of circulatory indexes between spontaneous breathing and mechanical ventilation in 100 patients ($\bar{x}±s$, n=100)

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指标自主呼吸状态机械通气状态P
心率(次/min)80.86±12.0870.48±13.04<0.001
SpO2(%)98.55±1.5799.75±0.50<0.001
SBP(mmHg)135.64±18.69109.20±21.92<0.001
DBP(mmHg)78.50±9.9862.80±11.68<0.001
IVCCI(%)40.0±14.025.0±13.0<0.001
IJVCI(%)26.0±13.022.0±11.00.005
SCVCI(%)27.0±13.018.0±10.0<0.001
), ArticleFig(id=1203061243885105693, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=CN, label=表1, caption=

100例患者自主呼吸与机械通气状态下循环指标比较($\bar{x}±s$，n=100)

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指标自主呼吸状态机械通气状态P
心率(次/min)80.86±12.0870.48±13.04<0.001
SpO2(%)98.55±1.5799.75±0.50<0.001
SBP(mmHg)135.64±18.69109.20±21.92<0.001
DBP(mmHg)78.50±9.9862.80±11.68<0.001
IVCCI(%)40.0±14.025.0±13.0<0.001
IJVCI(%)26.0±13.022.0±11.00.005
SCVCI(%)27.0±13.018.0±10.0<0.001
), ArticleFig(id=1203061243998351909, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=EN, label=Tab. 2, caption=

Comparison of circulatory indexes between hypovolemic and non-hypovolemic patients under spontaneous breathing and mechanical ventilation ($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
指标自主呼吸状态机械通气状态
低血容量组(n=48)非低血容量组(n=52)P低血容量组(n=69)非低血容量组(n=31)P
心率(次/min)83.29±12.6578.62±11.220.05070.33±12.9170.81±13.550.860
SpO2(%)98.35±1.7398.73±1.390.23099.74±0.5099.77±0.500.740
SBP(mmHg)133.48±18.49137.63±18.840.270105.90±20.48116.55±23.550.020
DBP(mmHg)77.90±9.8179.06±10.190.56061.57±11.7865.55±11.140.110
IJVCI(%)34.0±14.019.0±8.0<0.00125.0±11.017.0±7.0<0.001
SCVCI(%)32.0±14.023.0±10.0<0.00120.0±11.012.0±5.0<0.001
), ArticleFig(id=1203061244145152558, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1203061228756250639, language=CN, label=表2, caption=

自主呼吸及机械通气状态下低血容量与非低血容量患者循环指标比较($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
指标自主呼吸状态机械通气状态
低血容量组(n=48)非低血容量组(n=52)P低血容量组(n=69)非低血容量组(n=31)P
心率(次/min)83.29±12.6578.62±11.220.05070.33±12.9170.81±13.550.860
SpO2(%)98.35±1.7398.73±1.390.23099.74±0.5099.77±0.500.740
SBP(mmHg)133.48±18.49137.63±18.840.270105.90±20.48116.55±23.550.020
DBP(mmHg)77.90±9.8179.06±10.190.56061.57±11.7865.55±11.140.110
IJVCI(%)34.0±14.019.0±8.0<0.00125.0±11.017.0±7.0<0.001
SCVCI(%)32.0±14.023.0±10.0<0.00120.0±11.012.0±5.0<0.001
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不同呼吸状态下颈内静脉及锁骨下静脉塌陷指数对低血容量的评估价值
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陈代宇 , 高吴茜 , 王思琦 , 李佼妮 , 曹俊 *
解放军医学杂志 | 临床研究 2023,48(1): 64-70
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解放军医学杂志 | 临床研究 2023, 48(1): 64-70
不同呼吸状态下颈内静脉及锁骨下静脉塌陷指数对低血容量的评估价值
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陈代宇, 高吴茜, 王思琦, 李佼妮, 曹俊*
作者信息
  • 重庆医科大学附属第一医院麻醉科，重庆 400016

    • 陈代宇，硕士研究生，主要从事围手术期精神紊乱防治、超声可视化应用方面的研究

通讯作者:

曹俊，E-mail：
Alternative value of volume evaluation of internal jugular vein and subclavian vein collapse index in different respiratory states
Dai-Yu Chen, Wu-Xi Gao, Si-Qi Wang, Jiao-Ni Li, Jun Cao*
Affiliations
  • Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
出版时间: 2023-01-28 doi: 10.11855/j.issn.0577-7402.2023.01.0064
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摘要
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目的 探讨自主呼吸及机械通气状态下颈内静脉塌陷指数(IJVCI)、锁骨下静脉塌陷指数(SCVCI)替代下腔静脉塌陷指数(IVCCI)评估低血容量的临床价值。方法 纳入2020年12月-2021年8月于重庆医科大学附属第一医院麻醉科行择期手术的100例患者。依据IVCCI的截断值，将患者分为低血容量组与非低血容量组，比较机械通气与自主呼吸状态下患者的各项循环指标。采用Pearson相关分析及Bland-Altman图分析IJVCI、SCVCI与IVCCI的相关性和一致性。采用ROC曲线分析IJVCI、SCVCI评估低血容量的效能。结果 机械通气状态下患者的SpO2较自主呼吸状态下明显增高，心率、收缩压(SBP)、舒张压(DBP)、IVCCI、IJVCI、SCVCI明显降低(P<0.01)。自主呼吸状态下，非低血容量组IJVCI、SCVCI较低血容量组明显降低(P<0.001)；机械通气状态下，非低血容量组SBP较低血容量组明显升高(P<0.05)，IJVCI、SCVCI较低血容量组明显降低(P<0.001)。自主呼吸和机械通气状态下，IJVCI与IVCCI均呈明显正相关关系(r=0.586，P<0.01；r=0.514，P<0.001)，且一致性较好；SCVCI与IVCCI均呈正相关关系(r=0.385，P<0.01；r=0.521，P<0.01)，且一致性较好。自主呼吸状态下，IJVCI、SCVCI评估低血容量的ROC曲线下面积(AUC)分别为0.828、0.684，最佳截断值分别为22.2%、25.4%；机械通气状态下，IJVCI、SCVCI评估低血容量的AUC分别为0.701、0.773，最佳截断值分别为19.8%、13.2%。结论 IJVCI与SCVCI在不同呼吸状态下均可替代IVCCI进行低血容量评估，但自主呼吸状态下IJVCI评估低血容量的价值更高，机械通气状态下SCVCI评估低血容量的价值更高。

外周静脉  /  塌陷指数  /  超声  /  容量评估

Objective To explore the alternative value of internal jugular vein collapsibility index (IJVCI) and subclavian vein collapsibility index (SCVCI) used to substitute for inferior vena cava collapsibility index (IVCCI) in volume evaluation under spontaneous breathing and mechanical ventilation. Methods A total of 100 patients were selected who underwent elective surgery in the Department of Anesthesiology, the First Affiliated Hospital of Chongqing Medical University from December 2020 to August 2021, the cyclic indicators of patients with different respiratory states were compared. According to the cut-off value of IVCCI, the patients were divided into hypovolemic group and non-hypovolemic group, and the cyclic indicators of the two groups were compared under different respiratory states. Pearson correlation analysis and Bland-Altman analysis were used to determine the relevance and consistency between IJVCI, SCVCI and IVCCI. ROC curve was used to analyze the efficiency of IJVCI and SCVCI in volume evaluation. Results Under mechanical ventilation condition, compared to spontaneous breathing condition, the SpO2 of patients was obviously increased, and heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), IVCCI, IJVCI and SCVCI were significantly decreased (P<0.01). IJVCI and SCVCI in non-hypovolemic group were significantly lower than those in hypovolemic group under the condition of spontaneous respiration (P<0.001). Under the condition of mechanical ventilation, SBP in non-hypovolemic group was significantly increased than that in hypovolemic group (P<0.05), while IJVCI and SCVCI were significantly lower than those in hypovolemic group (P<0.001). Under the condition of spontaneous breathing and mechanical ventilation, there was a significant positive correlation and consistency between IJVCI and IVCCI (r=0.586, P<0.01; r=0.514, P<0.001), and that a significant positive correlation and consistency between SCVCI and IVCCI (r=0.385, P<0.01; r=0.521, P<0.01). The area under the ROC curve (AUC) of IJVCI and SCVCI for the diagnosis of hypovolemia was 0.828, 0.684, and the best cut-off value was 22.2%, 25.4% under the condition of spontaneous breathing. The AUC of hypovolemia diagnosed by IJVCI and SCVCI were 0.701, 0.773, and the best cut-off value was 19.8%, 13.2% under the condition of mechanical ventilation. Conclusion Both IJVCI and SCVCI can replace IVCCI for volume evaluation in different respiratory states, but the alternative value of IJVCI is higher in spontaneous breathing state while of SCVCI is higher in mechanical ventilation state for volume evaluation.

peripheral vein  /  collapse index  /  ultrasound  /  volume evaluation
陈代宇, 高吴茜, 王思琦, 李佼妮, 曹俊. 不同呼吸状态下颈内静脉及锁骨下静脉塌陷指数对低血容量的评估价值. 解放军医学杂志, 2023 , 48 (1) : 64 -70 . DOI: 10.11855/j.issn.0577-7402.2023.01.0064
Dai-Yu Chen, Wu-Xi Gao, Si-Qi Wang, Jiao-Ni Li, Jun Cao. Alternative value of volume evaluation of internal jugular vein and subclavian vein collapse index in different respiratory states[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (1) : 64 -70 . DOI: 10.11855/j.issn.0577-7402.2023.01.0064
正文
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严重的低血容量状态是导致患者预后不良的独立危险因素，可能引起心肌梗死、脑梗死、心力衰竭、急性肾损伤等并发症[1]，因此低血容量评估对临床工作具有重要意义。超声测量下腔静脉塌陷指数(inferior vena cava collapsibility index，IVCCI)已被临床广泛用于循环容量评估，具有无创性、实时性、便捷性的优点[2-3]。但由于腹胀、肥胖、复杂腹部创伤等因素的影响，10%~15%的患者无法进行下腔静脉参数测量[4-5]。颈内静脉位置表浅，是人体颈部最大的静脉血管，其解剖位置靠近上腔静脉；锁骨下静脉的内径变化与右心系统密切相关，且受到覆盖组织及锁骨的保护，使其免受外部压力的挤压[6]。研究发现，颈内静脉塌陷指数(internal jugular vein collapsibility index，IJVCI)、锁骨下静脉塌陷指数(subclavian vein collapsibility index，SCVCI)更易测量，并同样可用于评估循环容量状态[4,7-8]。此外有研究发现，IJVCI和SCVCI的检查时间明显短于IVCCI，能够帮助临床决策者快速判断患者的循环容量状态[9]。目前，同时测量并比较不同呼吸状态下IJVCI、SCVCI对于循环容量评估价值的研究尚少。本研究探讨自主呼吸及机械通气状态下IJVCI、SCVCI替代IVCCI评估低血容量的价值。
1 资料与方法
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1.1 研究对象
本研究为前瞻性研究。纳入2020年12月-2021年8月于重庆医科大学附属第一医院麻醉科行择期手术的100例患者。纳入标准：性别不限；年龄>18岁；美国麻醉医师协会(American Society of Anesthesiologists，ASA)分级Ⅰ或Ⅱ级；无心血管系统器质性病变及心律失常；无异常腹内压增高。排除标准：难以获得清晰超声图像。根据文献[2]及文献[10]，自主呼吸状态下，以IVCCI=40%为截断值，将患者分为低血容量组(n=48)与非低血容量组(n=52)；机械通气状态下，以IVCCI=18%为截断值，将患者分为低血容量组(n=69)与非低血容量组(n=31)。本研究经重庆医科大学附属第一医院伦理委员会批准(2020-384)，且通过中国临床试验中心注册(注册号：ChiCTR2000039702)。
1.2 麻醉方法
患者入室后进行心电监护、桡动脉穿刺置管，监测心率、血压、血氧饱和度(pulse blood oxygen saturation，SpO2)。采用1.5 mg/kg丙泊酚+0.5 μg/kg舒芬太尼+0.6 mg/kg罗库溴铵诱导插管。术中持续吸入1.5%七氟烷，氧流量1.0 L/min，氧浓度50%，潮气量8 ml/kg，呼吸频率15次/min，吸呼比1:2，设置呼气终末正压(positive end expiratory pressure，PEEP)为0 mmHg，静脉持续泵注丙泊酚、瑞芬太尼以维持麻醉。
1.3 临床资料收集
记录患者性别、年龄、身高、体重，以及麻醉诱导5 min前(自主呼吸)和麻醉诱导5 min后(机械通气)的心率、收缩压(systolic blood pressure，SBP)、舒张压(diastolic blood pressure，DBP)、SPO2、下腔静脉最大内径(maximum internal diameter of inferior vena cava，dIVCmax)、下腔静脉最小内径(minimum internal diameter of inferior vena cava，dIVCmin)、锁骨下静脉最大内径(maximum internal diameter of subclavian，dSVCmax)、锁骨下静脉最小内径(minimum internal diameter of subclavian，dSVCmin)、颈内静脉最大内径(maximum internal diameter of internal jugular vein，dIJVmax)、颈内静脉最小内径(minimum internal diameter of internal jugular vein，dIJVmin)等临床资料。
1.4 超声测量
每个部位进行3次超声扫查后取平均值，由一名经过超声培训的麻醉科住院医师进行图像采集，并与另一名具备5年超声经验的麻醉医师共同进行图像结果甄别及参数测定。
1.4.1 IVCCI
患者取平卧位，使用GE Logiq V2超声，选择4C凸阵探头(频率3~5 MHz)。将探头放置在剑突下，腹部正中纵切面探查，采样线垂直于血管置于离右心房-下腔静脉2 cm处，M模式测量dIVCmax、dIVCmin。IVCCI=(dIVCmax-dIVCmin)/dIVCmax。
1.4.2 SCVCI
患者取平卧位，选择GE Logiq V2超声，将12L线阵探头(频率4.2~13.0 MHz)平行于锁骨中点下端放置，滑动探头，扫查到锁骨下静脉后旋转探头，保持探头与锁骨下静脉长轴垂直，获取最佳短轴视图，M模式测量dSCVmax、dSCVmin。SCVCI=(dSCVmax-dSCVmin)/dSCVmax。
1.4.3 IJVCI
患者取平卧、头正中位，选择GE Logiq V2超声，将12L线阵探头(频率4.2~13.0 MHz)轻置于颈部平环状软骨水平，扫查到颈内静脉并保持探头与颈内静脉长轴垂直，获取最佳短轴视图，M模式测量dIJVmax、dIJVmin。IJVCI=(dIJVmax-dIJVmin)/dIJVmax。
1.5 观察指标
比较不同呼吸状态下患者的循环指标；采用双变量Pearson相关分析不同呼吸状态下SCVCI、IJVCI与IVCCI的关系；采用MedCalC V15.2.2绘制Bland-Altman图，分析SCVCI、IJVCI与IVCCI的一致性；采用受试者工作特征(receiver operating characteristics，ROC)曲线分析IJVCI、SCVCI在不同呼吸状态下评估低血容量的效能。
1.6 统计学处理
采用IBM SPSS Statistics 25软件进行统计分析。计量资料以$\bar{x}±s$表示，两组间比较采用配对t检验。P<0.05为差异有统计学意义。
2 结果
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2.1 基线资料
符合纳入标准的有108例患者，其中8例超声显像质量不佳予以排除，最终纳入100例。其中男43例(43.0%)，女57例(57.0%)，年龄(53.7±13.4)岁，体重指数(body mass index，BMI)(23.10±3.55) kg/m2；来自骨科31例(31.0%)，胸外科31例(31.0%)，甲状腺乳腺外科13例(13.0%)，肝胆外科11例(11.0%)，神经外科10例(10.0%)，血管外科2例(2.0%)，泌尿外科1例(1.0%)，胃肠外科1例(1.0%)。
2.2 不同呼吸状态下循环指标比较
与自主呼吸状态下比较，机械通气状态下患者的SpO2明显增高，心率、SBP、DBP、IVCCI、IJVCI、SCVCI明显降低，差异均有统计学意义(P<0.01，表1)。
自主呼吸状态下，以IVCCI=40%为截断值，将患者分为低血容量组(n=48)与非低血容量组(n=52)，两组心率、SpO2、SBP、DBP比较，差异均无统计学意义(P≥0.05)；非低血容量组IJVCI、SCVCI较低血容量组明显降低，差异有统计学意义(P<0.001，表2)。
机械通气状态下，以IVCCI=18%为截断值，将患者分为低血容量组(n=69)与非低血容量组(n=31)，两组心率、SpO2、DBP比较，差异均无统计学意义(P>0.05)；非低血容量组SBP较低血容量组明显升高(P<0.05)，IJVCI、SCVCI较低血容量组明显降低(P<0.001，表2)。
2.3 不同呼吸状态下IVCCI与IJVCI、SCVCI的相关性及一致性分析
双变量Pearson相关分析结果显示，自主呼吸状态下，IJVCI与IVCCI呈明显正相关关系(r=0.586，P<0.01，图1A)，SCVCI与IVCCI亦呈正相关关系(r=0.385，P<0.01，图1B)；机械通气状态下，IJVCI与IVCCI呈明显正相关关系(r=0.514，P<0.001，图1C)，SCVCI与IVCCI亦呈明显正相关关系(r=0.521，P<0.01，图1D)。
Bland-Altman分析结果显示，自主呼吸状态下，IVCCI与IJVCI、SCVCI差值(服从正态分布)的平均值分别为0.14、0.13。IJVCI与IVCCI的一致性上下界限分别为0.38、–0.10，约8%的点落在一致性界限外(8/100)；SCVCI与IVCCI的一致性上下界限分别为0.41、–0.16，约5%的点落在一致性界限外(5/100)。考虑到一致性界限的上下置信区间，约4%的点落在IJVCI与IVCCI一致性界限外(4/100)，约3%的点落在SCVCI与IVCCI一致性界限外(3/100)(图2A、B)。
机械通气状态下，IVCCI与IJVCI、SCVCI差值(服从正态分布)的平均值分别为0.03、0.07。IJVCI与IVCCI的一致性上下界限分别为0.27、–0.21，约8%的点落在一致性界限外(8/100)；SCVCI与IVCCI的一致性上下界限分别为0.31、–0.16，约5%的点落在一致性界限外(5/100)。考虑到一致性界限的上下置信区间，约2%的点落在IJVCI与IVCCI一致性界限外(2/100)，约4%的点落在SCVCI与IVCCI一致性界限外(4/100) (图2C、D)。
2.4 IJVCI、SCVCI对低血容量的评估价值
自主呼吸状态下，IJVCI评估低血容量的ROC曲线下面积(AUC)为0.828(95%CI 0.742~0.913，P<0.001)，最佳截断值为22.2%，Youden指数为0.585，敏感度和特异度分别为0.854、0.731；SCVCI评估低血容量的AUC为0.684(95%CI 0.578~0.790，P<0.001)，最佳截断值为25.4%，Youden指数为0.354，敏感度和特异度分别为0.604、0.750(图3)。
机械通气状态下，IJVCI评估低血容量的AUC为0.701(95%CI 0.600~0.802，P<0.001)，最佳截断值为19.8%，Youden指数为0.383，敏感度和特异度分别为0.609、0.774；SCVCI评估低血容量的AUC为0.773(95%CI 0.680~0.865，P<0.001)，最佳截断值为13.2%，Youden指数为0.546，敏感度和特异度分别为0.739、0.806(图3)。
3 讨论
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临床工作中及时有效地评估循环容量可保证患者围手术期安全。相较其他传统的循环容量监测方法，超声具有无创、便携、实时的优点[10-11]。大量研究发现，IVCCI能够准确地评估患者循环容量的状态[2,12-13]，但腹痛、腹胀、肌紧张、异常肥胖或被敷料遮盖腹部的患者下腔静脉图像较难获得[14-15]。
本研究发现，自主呼吸时低血容量组患者的SBP与非低血容量组比较并无明显差异，但在机械通气状态下，非低血容量组患者的SBP明显高于低血容量组。这是由于对患者进行了麻醉诱导，血管扩张后循环容量重新分布，造成血压降低。在麻醉诱导前低血容量患者的动脉系统可通过自主调节维持血压，但当麻醉诱导循环容量重新分布后，低血容量患者血压下降的程度较非低血容量患者高，因此机械通气时两组患者的SBP存在明显差异。同时，这也提示采用动脉系统参数评估患者循环容量状态时，会因为动脉代偿能力而增加循环容量评估假阴性的可能[16-17]。
既往研究中，Kumar等[18]证实自主呼吸状态下SCVCI与IVCCI具有相关性，Haliloğlu等[4]证实自主呼吸状态下IJVCI与IVCCI具有相关性。本研究证实，自主呼吸及机械通气状态下IJVCI、SCVCI与IVCCI均具有相关性及较好的一致性。
Killu等[19]研究发现，IJVCI评估低血容量的最佳截断值为39%。本研究结果显示，自主呼吸及机械通气状态下，IJVCI评估低血容量的最佳截断值分别为22.2%和19.8%，与Killu等[19]得出的IJVCI截断值不同。分析原因可能为Killu等[19]的研究未区分患者的呼吸状态，而是将自主呼吸及机械通气状态下的数据混淆进行计算。腔静脉塌陷指数评估循环容量的机制为：吸气动作造成胸腔内负压，进而引起心室舒张充盈，抽吸静脉血液回流，引发血管的塌陷趋势，而呼气动作时该过程是相反的[20]。当机械通气时，吸气相造成胸腔内压增高，影响静脉回流从而扩张静脉，呼气相胸腔内压降低，静脉回流加快静脉塌陷。因此，机械通气与自主呼吸时腔静脉的血管塌陷趋势不同，这也是本研究在两种不同呼吸状态下分别探讨低血容量评估能力及替代价值的原因。一项前瞻性研究发现，IJVCI在机械通气时评估低血容量的最佳截断值为11.4%，与本研究结果一致[21]。虽然机械通气状态下，IJVCI与SCVCI评估低血容量的AUC分别为0.701、0.773，但是IJVCI评估低血容量的敏感度低于SCVCI(0.609 vs. 0.739)，评估低血容量时假阳性的可能性较大，因此不推荐在机械通气时使用IJVCI替代IVCCI进行低血容量评估。
本研究发现，在自主呼吸及机械通气状态下SCVCI的最佳截断值分别为25.4%和13.2%，与Giraud等[7]的研究中机械通气时SCVCI的最佳截断值(14%)一致。但在自主呼吸状态下，SCVCI评估低血容量的AUC(0.684，95%CI 0.578~0.790)明显低于IJVCI(0.828，95%CI 0.742~0.913)，同时与IVCCI的相关性程度(r=0.385)低于IJVCI(r=0.586)，因此不推荐在自主呼吸时使用SCVCI替代IVCCI进行低血容量评估。
上腔静脉收集来自头颈胸部的静脉血[22]，能够较好地反映右心房前负荷，因此上腔静脉塌陷指数(superior vena cava collapsibility index，SVCCI)被认为是替代IVCCI的一个良好指标[23]。但SVCCI的测量需要通过经食管超声心动图(TEE)获得，因此从操作便捷程度及患者安全考虑，SVCCI替代IVCCI评估循环容量的价值较低[24-25]，且颈内静脉与上腔静脉、右心房在解剖结构上呈一条直线，IJVCI实际上直接反映了中心水平循环容量的情况[26]，因此IJVCI更适合用于循环容量替代评估。
本研究存在不足之处：在自主呼吸和机械通气状态下患者均采用8 ml/kg潮气量及15次/min呼吸频率，未探讨在其他潮气量状态下IJVCI、SCVCI替代IVCCI进行低血容量评估的价值；纳入对象均为ASA Ⅰ或Ⅱ级择期手术患者，而对急性循环容量丢失等患者IJVCI、SCVCI的低血容量评估价值需要进一步探究。
综上所述，IJVCI与SCVCI在不同呼吸状态下均可替代IVCCI进行低血容量评估，自主呼吸状态下IJVCI评估低血容量的替代价值更高，机械通气状态下SCVCI评估低血容量的替代价值更高。
基金
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  • 国家临床重点专科建设项目((2011)170)
  • 重庆市医学重点学科项目((2007)2)
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2023年第48卷第1期
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doi: 10.11855/j.issn.0577-7402.2023.01.0064
  • 接收时间：2022-01-09
  • 首发时间：2025-12-03
  • 出版时间：2023-01-28
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  • 收稿日期：2022-01-09
  • 录用日期：2022-08-07
基金
National Key Clinical Specialty Construction Project((2011)170)
国家临床重点专科建设项目((2011)170)
Chongqing Medical Key Discipline Project((2007)2)
重庆市医学重点学科项目((2007)2)
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    重庆医科大学附属第一医院麻醉科，重庆 400016

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