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Article(id=1208791312359355199, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208791311621157694, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.11.08, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1611763200000, receivedDateStr=2021-01-28, revisedDate=1621440000000, revisedDateStr=2021-05-20, acceptedDate=null, acceptedDateStr=null, onlineDate=1766127907122, onlineDateStr=2025-12-19, pubDate=1638028800000, pubDateStr=2021-11-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766127907122, onlineIssueDateStr=2025-12-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766127907122, creator=13701087609, updateTime=1766127907122, updator=13701087609, issue=Issue{id=1208791311621157694, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='11', pageStart='1061', pageEnd='1164', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766127906946, creator=13701087609, updateTime=1766128932678, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1208795613920104935, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208791311621157694, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1208795613920104936, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208791311621157694, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1112, endPage=1117, ext={EN=ArticleExt(id=1208791312657150786, articleId=1208791312359355199, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Predictive value of continuous non-invasive arterial pressure monitor combined with passive leg raising test for volume responsiveness assessment in patients with septic shock, columnId=1190310110212751762, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Basic Research, runingTitle=null, highlight=null, articleAbstract=

Objective To investigate the predictive value of continuous non-invasive arterial pressure monitor (CNAP)combined with passive leg raising (PLR) test for volume responsiveness assessment in patients with septic shock. Methods Prospective and observational study was performed in the patients with septic shock admitted to the Fourth Department of Intensive Care Unit (ICU) of Fujian Provincial Hospital from July 2019 to July 2020. Subclavian venous catheter was indwelled in each patient, then the hemodynamic parameters including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP),cardiac output (CO) and pulse pressure variability (PPV) were measured non-invasively by CNAP before and after PLR and volume expansion (VE) test. The changes of CO during PLR test (ΔCOPLR) and VE test (ΔCOVE) were calculated respectively. Patients were classified as responder group or non-responder group according to the ΔCOVE increased ≥15% or not after VE test. Moreover,Pearson's test was used for the correlation analysis. The roles of ΔCOPLR and PPV before VE test in predicting volume responsiveness were evaluated by receiver operating characteristic (ROC) curve. Results A total of 40 VE tests in these 36 patients were evaluated and resulting in 18 responder group and 22 non-responder group. There was no significant difference between two groups in the hemodynamics parameters before PLR and VE test (P>0.05). Both in responder group and non-responder group, there was no significant change in HR and MAP after PLR and VE test (P>0.05). After PLR, CVP did not change significantly in the two groups(P>0.05). CVP after VE test increased significantly in the two groups (P<0.05), but there was no significant difference between the two groups (P>0.05). CO was obviously increased after PLR and VE test in the two groups (P<0.05). In responder group, CO after PLR and VE test were significantly higher than those in non-responder group [(6.01±1.28) L/min vs. (5.16±1.22) L/min,(6.31±1.33) L/min vs. (5.15±1.39) L/min, P<0.05]. Besides, the ΔCOPLR and ΔCOVE in responder group were significantly higher than those in non-responder group (21.21%±8.54% vs. 10.76%±4.94%, 26.32%±8.64% vs. 9.44%±3.45%, P<0.05).Correlation analysis showed that the ΔCOPLR was positively related to ΔCOVE (r=0.820, P<0.05), while the PPV before VE test was unrelated to ΔCOVE (r=0.194, P>0.05). Furthermore, the area under the ROC curve (AUC) of ΔCOPLR and PPV predicting volume responsiveness were 0.855 (95%CI 0.707-0.946, P<0.05) and 0.525 (95%CI 0.362-0.685, P>0.05) respectively. The sensitivity and specificity of ΔCOPLR ≥13.95% to predict volume responsiveness in patients with septic shock were 83.3% and 81.8%, respectively. Conclusion ΔCOPLR measured by CNAP can predict the volume responsiveness in patients with septic shock and it is reliable to guide further fluid resuscitation.

, correspAuthors=Feng Chen, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 探讨每搏连续无创血压监测系统(CNAP)结合被动抬腿试验(PLR)对脓毒性休克患者容量反应性的预测价值。方法 前瞻性观察福建省立医院重症医学四科2019年7月—2020年7月收治的脓毒性休克患者36例，置入锁骨下静脉导管后，先进行PLR，再行容量负荷试验(VE)。研究过程采用CNAP监测，每个试验前后均监测心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心排量(CO)及脉压变异度(PPV)，记录PLR前后CO的变化率(ΔCOPLR)及VE前后CO的变化率(ΔCOVE)。将ΔCOVE≥15%定义为有容量反应性并纳入有反应组，ΔCOVE<15%者纳入无反应组。采用Pearson检验分析ΔCOPLR、VE前PPV与ΔCOVE的相关性；采用受试者工作特征(ROC)曲线评估ΔCOPLR、VE前PPV对容量反应性的预测价值。结果 36例脓毒性休克患者共进行40例次VE，其中有反应组18例次，无反应组22例次。两组患者PLR及VE前的血流动力学指标差异均无统计学意义(P>0.05)。两组患者PLR及VE后HR、MAP均无明显变化(P>0.05)；两组PLR后CVP无明显变化(P>0.05)，VE后CVP均明显增加(P<0.05)，但组间差异无统计学意义(P>0.05)。两组患者PLR及VE后CO均明显增加(P<0.05)，有反应组PLR及VE后CO明显高于无反应组[(6.01±1.28) L/min vs. (5.16±1.22) L/min、(6.31±1.33) L/min vs. (5.15±1.39) L/min，P<0.05]。有反应组ΔCOPLR、ΔCOVE明显高于无反应组(21.21%±8.54% vs.10.76%±4.94%、26.32%±8.64% vs. 9.44%±3.45%，P<0.05]。ΔCOPLR与ΔCOVE呈正相关(r=0.820，P<0.05)，而VE前PPV与ΔCOVE无相关性(r=0.194，P>0.05)。ΔCOPLR预测脓毒性休克患者容量反应性的曲线下面积(AUC)为0.855(95%CI 0.707~0.946，P<0.05)，最佳截断值为13.95%，敏感度为83.3%，特异度为81.8%；VE前PPV预测容量反应性的AUC仅为0.525(95%CI 0.362~0.685，P>0.05)。结论 CNAP监测ΔCOPLR可用于预测脓毒性休克患者的容量反应性，指导临床液体治疗。

, correspAuthors=陈锋, authorNote=null, correspAuthorsNote=
陈锋，E-mail:
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薛贻敏，医学硕士，副主任医师，主要从事危重症患者血流动力学监测与治疗方面的研究

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薛贻敏，医学硕士，副主任医师，主要从事危重症患者血流动力学监测与治疗方面的研究

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薛贻敏，医学硕士，副主任医师，主要从事危重症患者血流动力学监测与治疗方面的研究

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Br J Anaesth, 2017, 118(1): 58-67., articleTitle=Non-invasive assessment of fluid responsiveness using CNAP™ technology is interchangeable with invasive arterial measurements during major open abdominal surgery, refAbstract=null), Reference(id=1208791321393885339, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2016, volume=30, issue=4, pageStart=487, pageEnd=493, url=null, language=null, rfNumber=[18], rfOrder=19, authorNames=Wagner JY, Grond J, Fortin J, journalName=J Clin Monit Comput, refType=null, unstructuredReference=Wagner JY, Grond J, Fortin J, et al. Continuous noninvasive cardiac output determination using the CNAP system: evaluation of a cardiac output algorithm for the analysis of volume clamp method-derived pulse contour[J]. J Clin Monit Comput, 2016, 30(4): 487-493., articleTitle=Continuous noninvasive cardiac output determination using the CNAP system: evaluation of a cardiac output algorithm for the analysis of volume clamp method-derived pulse contour, refAbstract=null), Reference(id=1208791321515520161, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2019, volume=199, issue=1, pageStart=22, pageEnd=31, url=null, language=null, rfNumber=[19], rfOrder=20, authorNames=Teboul JL, Monnet X, Chemla D, journalName=Am J Respir Crit Care Med, refType=null, unstructuredReference=Teboul JL, Monnet X, Chemla D, et al. Arterial pulse pressure variation with mechanical ventilation[J]. Am J Respir Crit Care Med, 2019, 199(1): 22-31., articleTitle=Arterial pulse pressure variation with mechanical ventilation, refAbstract=null), Reference(id=1208791321607794852, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2000, volume=162, issue=1, pageStart=134, pageEnd=138, url=null, language=null, rfNumber=[20], rfOrder=21, authorNames=Michard F, Boussat S, Chemla D, journalName=Am J Respir Crit Care Med, refType=null, unstructuredReference=Michard F, Boussat S, Chemla D, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure[J]. Am J Respir Crit Care Med, 2000, 162(1): 134-138., articleTitle=Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure, refAbstract=null), Reference(id=1208791321708458155, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2016, volume=35, issue=2, pageStart=93, pageEnd=102, url=null, language=null, rfNumber=[21], rfOrder=22, authorNames=Preau S, Dewavrin F, Demaeght V, journalName=Anaesth Crit Care Pain Med, refType=null, unstructuredReference=Preau S, Dewavrin F, Demaeght V, et al. The use of static and dynamic haemodynamic parameters before volume expansion:a prospective observational study in six French intensive care units[J]. Anaesth Crit Care Pain Med, 2016, 35(2): 93-102., articleTitle=The use of static and dynamic haemodynamic parameters before volume expansion:a prospective observational study in six French intensive care units, refAbstract=null), Reference(id=1208791321792344239, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2019, volume=31, issue=10, pageStart=1231, pageEnd=1235, url=null, language=null, rfNumber=[22], rfOrder=23, authorNames=Xue YM, Wu W, Chen MG, journalName=Chin Crit Care Med, refType=null, unstructuredReference=Xue YM, Wu W, Chen MG, et al. A clinical study of the evaluation of hemodynamic status in mechanically ventilated critically ill patients by continuous non-invasive arterial pressure monitor[J]. Chin Crit Care Med, 2019, 31(10): 1231-1235., articleTitle=A clinical study of the evaluation of hemodynamic status in mechanically ventilated critically ill patients by continuous non-invasive arterial pressure monitor, refAbstract=null), Reference(id=1208791321913979063, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, doi=null, pmid=null, pmcid=null, year=2019, volume=31, issue=10, pageStart=1231, pageEnd=1235, url=null, language=null, rfNumber=[22], rfOrder=24, authorNames=薛贻敏, 吴畏, 陈明光, journalName=中华危重病急救医学, refType=null, unstructuredReference=[薛贻敏, 吴畏, 陈明光, 等. 每搏连续无创血压监测系统评估机械通气重症患者血流动力学状态的临床研究[J]. 中华危重病急救医学, 2019, 31(10): 1231-1235.], articleTitle=每搏连续无创血压监测系统评估机械通气重症患者血流动力学状态的临床研究, refAbstract=null)], funds=[Fund(id=1208791318097162263, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, awardId=2017-510, language=EN, fundingSource=Critical Care Medical Center Construction Projects of Fujian Province(2017-510), fundOrder=null, country=null), Fund(id=1208791318176854041, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, awardId=2017-510, language=CN, fundingSource=福建省重症医学中心建设项目(2017-510), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1208791313575703377, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, xref=1, ext=[AuthorCompanyExt(id=1208791313579897682, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313575703377, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Provincial Clinical Medical College of Fujian Medical University, Fuzhou 350001, China), AuthorCompanyExt(id=1208791313588286291, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313575703377, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1福建医科大学省立临床医学院，福州 350001)]), AuthorCompany(id=1208791313705726808, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, xref=2, ext=[AuthorCompanyExt(id=1208791313714115417, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313705726808, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2The Fourth Department of Intensive Care Unit, Fujian Provincial Hospital, Fuzhou 350001, China), AuthorCompanyExt(id=1208791313722504026, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313705726808, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2福建省立医院重症医学四科，福州 350001)]), AuthorCompany(id=1208791313785418590, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, xref=3, ext=[AuthorCompanyExt(id=1208791313793807199, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313785418590, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3Department of Emergency/Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou 350001, China), AuthorCompanyExt(id=1208791313802195808, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, companyId=1208791313785418590, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3福建省立医院急诊科/福建省急诊医学重点实验室，福州 350001)])], figs=[ArticleFig(id=1208791317195387891, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=EN, label=Fig. 1, caption=ROC curve of ΔCOPLR and PPV before VE on predicting volumetric reactivity in patients with septic shock, figureFileSmall=cA0Y/lZW0qoraC6WLGIZ7g==, figureFileBig=JF3xyWuLpJTRygXbEIQOOA==, tableContent=null), ArticleFig(id=1208791317283468279, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=CN, label=图1, caption=ΔCOPLR、VE前PPV预测脓毒性休克患者容量反应性的ROC曲线, figureFileSmall=cA0Y/lZW0qoraC6WLGIZ7g==, figureFileBig=JF3xyWuLpJTRygXbEIQOOA==, tableContent=null), ArticleFig(id=1208791317501571072, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=EN, label=Tab. 1, caption=

Comparison of basic data of patients with septic shock between the two groups

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)t/χ2P
年龄(岁，$\bar{x}±s$)64.5±13.466.6±11.90.5170.608
男性[例次(%)]13(59.1)10(55.6)0.0510.822
BMI(kg/m2，$\bar{x}±s$)20.69±3.8422.86±3.411.8410.074
感染部位[例次(%)]  2.3150.314
 腹腔5(22.7)8(44.4)
 血流7(31.8)5(27.8)
 其他10(45.5)5(27.8)
SOFA评分(分，$\bar{x}±s$)8.15±3.269.14±3.140.9420.353
APACHEⅡ评分(分，$\bar{x}±s$)14.06±3.8415.86±3.591.4840.147
机械通气[例次(%)]16(72.7)11(61.1)0.6090.435
压力支持(cmH2O，$\bar{x}±s$)15.45±3.5813.81±3.081.4770.148
呼气末正压(cmH2O，$\bar{x}±s$)6.57±1.985.73±1.191.2400.227
使用去甲肾上腺素[例次(%)]10(45.5)12(66.7)1.8000.180
去甲肾上腺素使用量[μg/(kg·min)，$\bar{x}±s$]0.44±0.210.38±0.210.8130.424
), ArticleFig(id=1208791317572874244, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=CN, label=表1, caption=

两组脓毒性休克患者基线资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)t/χ2P
年龄(岁，$\bar{x}±s$)64.5±13.466.6±11.90.5170.608
男性[例次(%)]13(59.1)10(55.6)0.0510.822
BMI(kg/m2，$\bar{x}±s$)20.69±3.8422.86±3.411.8410.074
感染部位[例次(%)]  2.3150.314
 腹腔5(22.7)8(44.4)
 血流7(31.8)5(27.8)
 其他10(45.5)5(27.8)
SOFA评分(分，$\bar{x}±s$)8.15±3.269.14±3.140.9420.353
APACHEⅡ评分(分，$\bar{x}±s$)14.06±3.8415.86±3.591.4840.147
机械通气[例次(%)]16(72.7)11(61.1)0.6090.435
压力支持(cmH2O，$\bar{x}±s$)15.45±3.5813.81±3.081.4770.148
呼气末正压(cmH2O，$\bar{x}±s$)6.57±1.985.73±1.191.2400.227
使用去甲肾上腺素[例次(%)]10(45.5)12(66.7)1.8000.180
去甲肾上腺素使用量[μg/(kg·min)，$\bar{x}±s$]0.44±0.210.38±0.210.8130.424
), ArticleFig(id=1208791317665148935, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=EN, label=Tab. 2, caption=

Changes of hemodynamic parameters of patients with septic shock before and after PLR between the two groups ($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)tP
HR(次/min)
 PLR前90.62±16.1793.38±17.510.4600.648
 PLR后88.54±14.2790.33±18.300.3010.765
MAP(mmHg)
 PLR前67.50±5.3268.17±8.610.2390.813
 PLR后69.30±6.0872.50±7.961.1800.248
CVP(mmHg)
 PLR前6.75±1.606.69±1.400.1100.913
 PLR后7.42±1.317.63±1.360.4070.687
CO(L/min)
 PLR前4.69±1.234.98±1.120.7800.440
 PLR后5.16±1.22(1)6.01±1.28(1)2.1460.038
), ArticleFig(id=1208791317765812234, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=CN, label=表2, caption=

两组脓毒性休克患者PLR前后血流动力学指标的变化($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)tP
HR(次/min)
 PLR前90.62±16.1793.38±17.510.4600.648
 PLR后88.54±14.2790.33±18.300.3010.765
MAP(mmHg)
 PLR前67.50±5.3268.17±8.610.2390.813
 PLR后69.30±6.0872.50±7.961.1800.248
CVP(mmHg)
 PLR前6.75±1.606.69±1.400.1100.913
 PLR后7.42±1.317.63±1.360.4070.687
CO(L/min)
 PLR前4.69±1.234.98±1.120.7800.440
 PLR后5.16±1.22(1)6.01±1.28(1)2.1460.038
), ArticleFig(id=1208791317879058445, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=EN, label=Tab. 3, caption=

Changes of hemodynamic parameters of patients with septic shock before and after VE between the two groups ($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)tP
HR(次/min)
 VE前92.85±13.4892.10±14.670.1490.882
 VE后89.69±14.6888.76±13.120.1920.849
MAP(mmHg)
 VE前66.83±5.4969.17±6.800.9910.330
 VE后69.58±5.2174.61±9.591.6540.109
CVP(mmHg)
 VE前7.08±1.626.50±1.550.9670.343
 VE后8.75±1.54(1)8.19±1.72(1)0.8930.380
CO(L/min)
 VE前4.71±1.295.03±1.190.8200.418
 VE后5.15±1.39(1)6.31±1.33(1)2.6760.011
ΔCOPLR(%)10.76±4.9421.21±8.544.843<0.001
ΔCOVE(%)9.44±3.4526.32±8.648.399<0.001
VE前PPV(%)13.41±5.6814.00±5.980.3200.751
), ArticleFig(id=1208791317992304657, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208791312359355199, language=CN, label=表3, caption=

两组脓毒性休克患者VE前后血流动力学指标的变化($\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
项目无反应组(n=22)有反应组(n=18)tP
HR(次/min)
 VE前92.85±13.4892.10±14.670.1490.882
 VE后89.69±14.6888.76±13.120.1920.849
MAP(mmHg)
 VE前66.83±5.4969.17±6.800.9910.330
 VE后69.58±5.2174.61±9.591.6540.109
CVP(mmHg)
 VE前7.08±1.626.50±1.550.9670.343
 VE后8.75±1.54(1)8.19±1.72(1)0.8930.380
CO(L/min)
 VE前4.71±1.295.03±1.190.8200.418
 VE后5.15±1.39(1)6.31±1.33(1)2.6760.011
ΔCOPLR(%)10.76±4.9421.21±8.544.843<0.001
ΔCOVE(%)9.44±3.4526.32±8.648.399<0.001
VE前PPV(%)13.41±5.6814.00±5.980.3200.751
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每搏连续无创血压监测系统结合被动抬腿试验对脓毒性休克患者容量反应性的预测价值
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薛贻敏 1, 2 , 陈美琪 1, 2 , 黄廷烽 1, 2 , 陈明光 1, 2 , 陈茜 1, 2 , 陈锋 1, 3, *
解放军医学杂志 | 论著 2021,46(11): 1112-1117
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解放军医学杂志 | 论著 2021, 46(11): 1112-1117
每搏连续无创血压监测系统结合被动抬腿试验对脓毒性休克患者容量反应性的预测价值
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薛贻敏1, 2, 陈美琪1, 2, 黄廷烽1, 2, 陈明光1, 2, 陈茜1, 2, 陈锋1, 3, *
作者信息
  • 1福建医科大学省立临床医学院，福州 350001
  • 2福建省立医院重症医学四科，福州 350001
  • 3福建省立医院急诊科/福建省急诊医学重点实验室，福州 350001

    • 薛贻敏，医学硕士，副主任医师，主要从事危重症患者血流动力学监测与治疗方面的研究

通讯作者:

陈锋，E-mail:
Predictive value of continuous non-invasive arterial pressure monitor combined with passive leg raising test for volume responsiveness assessment in patients with septic shock
Yi-Min Xue1, 2, Mei-Qi Chen1, 2, Ting-Feng Huang1, 2, Ming-Guang Chen1, 2, Qian Chen1, 2, Feng Chen1, 3, *
Affiliations
  • 1Provincial Clinical Medical College of Fujian Medical University, Fuzhou 350001, China
  • 2The Fourth Department of Intensive Care Unit, Fujian Provincial Hospital, Fuzhou 350001, China
  • 3Department of Emergency/Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Hospital, Fuzhou 350001, China
出版时间: 2021-11-28 doi: 10.11855/j.issn.0577-7402.2021.11.08
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摘要
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目的 探讨每搏连续无创血压监测系统(CNAP)结合被动抬腿试验(PLR)对脓毒性休克患者容量反应性的预测价值。方法 前瞻性观察福建省立医院重症医学四科2019年7月—2020年7月收治的脓毒性休克患者36例，置入锁骨下静脉导管后，先进行PLR，再行容量负荷试验(VE)。研究过程采用CNAP监测，每个试验前后均监测心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心排量(CO)及脉压变异度(PPV)，记录PLR前后CO的变化率(ΔCOPLR)及VE前后CO的变化率(ΔCOVE)。将ΔCOVE≥15%定义为有容量反应性并纳入有反应组，ΔCOVE<15%者纳入无反应组。采用Pearson检验分析ΔCOPLR、VE前PPV与ΔCOVE的相关性；采用受试者工作特征(ROC)曲线评估ΔCOPLR、VE前PPV对容量反应性的预测价值。结果 36例脓毒性休克患者共进行40例次VE，其中有反应组18例次，无反应组22例次。两组患者PLR及VE前的血流动力学指标差异均无统计学意义(P>0.05)。两组患者PLR及VE后HR、MAP均无明显变化(P>0.05)；两组PLR后CVP无明显变化(P>0.05)，VE后CVP均明显增加(P<0.05)，但组间差异无统计学意义(P>0.05)。两组患者PLR及VE后CO均明显增加(P<0.05)，有反应组PLR及VE后CO明显高于无反应组[(6.01±1.28) L/min vs. (5.16±1.22) L/min、(6.31±1.33) L/min vs. (5.15±1.39) L/min，P<0.05]。有反应组ΔCOPLR、ΔCOVE明显高于无反应组(21.21%±8.54% vs.10.76%±4.94%、26.32%±8.64% vs. 9.44%±3.45%，P<0.05]。ΔCOPLR与ΔCOVE呈正相关(r=0.820，P<0.05)，而VE前PPV与ΔCOVE无相关性(r=0.194，P>0.05)。ΔCOPLR预测脓毒性休克患者容量反应性的曲线下面积(AUC)为0.855(95%CI 0.707~0.946，P<0.05)，最佳截断值为13.95%，敏感度为83.3%，特异度为81.8%；VE前PPV预测容量反应性的AUC仅为0.525(95%CI 0.362~0.685，P>0.05)。结论 CNAP监测ΔCOPLR可用于预测脓毒性休克患者的容量反应性，指导临床液体治疗。

每搏连续无创血压监测系统  /  被动抬腿试验  /  脓毒症  /  容量反应性

Objective To investigate the predictive value of continuous non-invasive arterial pressure monitor (CNAP)combined with passive leg raising (PLR) test for volume responsiveness assessment in patients with septic shock. Methods Prospective and observational study was performed in the patients with septic shock admitted to the Fourth Department of Intensive Care Unit (ICU) of Fujian Provincial Hospital from July 2019 to July 2020. Subclavian venous catheter was indwelled in each patient, then the hemodynamic parameters including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP),cardiac output (CO) and pulse pressure variability (PPV) were measured non-invasively by CNAP before and after PLR and volume expansion (VE) test. The changes of CO during PLR test (ΔCOPLR) and VE test (ΔCOVE) were calculated respectively. Patients were classified as responder group or non-responder group according to the ΔCOVE increased ≥15% or not after VE test. Moreover,Pearson's test was used for the correlation analysis. The roles of ΔCOPLR and PPV before VE test in predicting volume responsiveness were evaluated by receiver operating characteristic (ROC) curve. Results A total of 40 VE tests in these 36 patients were evaluated and resulting in 18 responder group and 22 non-responder group. There was no significant difference between two groups in the hemodynamics parameters before PLR and VE test (P>0.05). Both in responder group and non-responder group, there was no significant change in HR and MAP after PLR and VE test (P>0.05). After PLR, CVP did not change significantly in the two groups(P>0.05). CVP after VE test increased significantly in the two groups (P<0.05), but there was no significant difference between the two groups (P>0.05). CO was obviously increased after PLR and VE test in the two groups (P<0.05). In responder group, CO after PLR and VE test were significantly higher than those in non-responder group [(6.01±1.28) L/min vs. (5.16±1.22) L/min,(6.31±1.33) L/min vs. (5.15±1.39) L/min, P<0.05]. Besides, the ΔCOPLR and ΔCOVE in responder group were significantly higher than those in non-responder group (21.21%±8.54% vs. 10.76%±4.94%, 26.32%±8.64% vs. 9.44%±3.45%, P<0.05).Correlation analysis showed that the ΔCOPLR was positively related to ΔCOVE (r=0.820, P<0.05), while the PPV before VE test was unrelated to ΔCOVE (r=0.194, P>0.05). Furthermore, the area under the ROC curve (AUC) of ΔCOPLR and PPV predicting volume responsiveness were 0.855 (95%CI 0.707-0.946, P<0.05) and 0.525 (95%CI 0.362-0.685, P>0.05) respectively. The sensitivity and specificity of ΔCOPLR ≥13.95% to predict volume responsiveness in patients with septic shock were 83.3% and 81.8%, respectively. Conclusion ΔCOPLR measured by CNAP can predict the volume responsiveness in patients with septic shock and it is reliable to guide further fluid resuscitation.

continuous non-invasive arterial pressure monitor  /  passive leg raising  /  sepsis  /  volume responsiveness
薛贻敏, 陈美琪, 黄廷烽, 陈明光, 陈茜, 陈锋. 每搏连续无创血压监测系统结合被动抬腿试验对脓毒性休克患者容量反应性的预测价值. 解放军医学杂志, 2021 , 46 (11) : 1112 -1117 . DOI: 10.11855/j.issn.0577-7402.2021.11.08
Yi-Min Xue, Mei-Qi Chen, Ting-Feng Huang, Ming-Guang Chen, Qian Chen, Feng Chen. Predictive value of continuous non-invasive arterial pressure monitor combined with passive leg raising test for volume responsiveness assessment in patients with septic shock[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (11) : 1112 -1117 . DOI: 10.11855/j.issn.0577-7402.2021.11.08
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液体复苏是脓毒性休克患者的一线治疗措施，可以快速增加有效循环血量，改善器官及组织的灌注[1]，而不恰当的液体治疗可能会加重患者的容量负担，导致预后不良，故临床医师需对患者的容量反应性做出准确判断[2-3]。被动抬腿试验(passive leg raising，PLR)可模拟内源性液体冲击，且几乎不受患者自主呼吸、心律失常的影响，是可靠且安全的容量反应性评估手段。但PLR预测容量反应性的效应短暂，需要联合能快速、持续监测心排量(cardiac output，CO)变化的方法[4]。传统的有创血流动力学监测技术通常存在操作难度高、监测费用昂贵等缺点，使PLR在临床的应用受到一定限制。每搏连续无创血压监测系统(continuous non-invasive arterial pressure monitor，CNAP)是无创动脉波轮廓分析技术的代表，具有快速、准确、无创及连续监测等特点，目前主要用于监测围术期麻醉患者的血流动力学指标，指导液体管理[5]，但其在脓毒性休克患者中的应用少见报道。本研究采用CNAP实时监测PLR前后的CO变化，评估其对脓毒性休克患者容量反应性的预测价值。
1 资料与方法
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1.1 研究对象
前瞻性观察2019年7月—2020年7月就诊于福建省立医院重症医学四科的脓毒性休克的患者。纳入标准：(1)符合《中国脓毒症/脓毒性休克急诊治疗指南(2018)》[6]中关于脓毒性休克的诊断标准；(2)年龄>18岁。排除标准：(1)孕妇；(2)严重出血性疾病者；(3)严重心律失常或严重心功能不全无法进行容量负荷试验(volume expansion，VE)者；(4)先天性心脏病或合并严重心脏瓣膜病者；(5)行主动脉内球囊反搏治疗者；(6)下肢截肢、下肢静脉血栓形成或腹腔内高压无法完成PLR者；(7)严重上肢动脉硬化或CNAP监测末梢灌注信号(perfusion index，PI)无法通过者；(8)严重水肿或手指缺失无法使用指套者。PLR或VE过程中出现严重容量过负荷表现(如患者出现气促，听诊肺部出现新的湿啰音或原有湿啰音增加，末梢血氧饱和度降低等)者予以剔除。根据纳入及排除标准，共有37例脓毒性休克患者入选，1例在VE过程中出现明显气促、肺部湿啰音增多表现，予以剔除，最终纳入36例患者。本研究通过福建省立医院伦理委员会审核批准(批号：K2019-06-015)，所有监测及治疗均得到患者或家属的知情同意。
1.2 研究方法
1.2.1 监测前准备
所有患者均给予床旁心电监护(SolarTM 8000M/i Patient Monitor，美国GE公司)监测生命体征，记录患者年龄、性别、体重指数(body mass index，BMI)、感染部位、感染相关器官功能衰竭(sepsis-related organ failure assessment，SOFA)评分、急性生理学与慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluation Ⅱ，APACHEⅡ)评分、机械通气及呼吸机参数(压力支持和呼气末正压)、去甲肾上腺素使用剂量等。患者入科后均留置锁骨下静脉导管(FV-3766，广东百合医疗科技股份有限公司)，在呼气末测定中心静脉压(central venous pressure，CVP)(DPT-248，浙江辰和医疗设备有限公司)。呼吸机参数及去甲肾上腺素使用剂量在PLR、VE前后均维持恒定，仪器操作及数据收集均由同一位熟练应用CNAP(CNSystems Medizintechnik AG，奥地利)技术的重症医学科(intensive care unit，ICU)主治医师负责。
1.2.2 PLR、VE及CNAP监测
采用CNAP监测PLR、VE前后血流动力学指标的变化，连接CNAP控制器及测压袖带，将合适的袖带依据箭头标记安置在患者右上臂，在患者右手相邻的两个手指根部套入双指套(试验前后双指套位置不变)，输入患者的性别、年龄、身高、体重及测得的CVP，PI显示通过后，序贯进行PLR及VE[7]。PLR前：抬高患者躯干45°，下肢置水平位；PLR：患者取仰卧位，抬高双下肢45°，持续1 min；VE前：完成PLR后恢复45°的半坐卧位，休息5 min；VE：10 min内快速输注乳酸钠林格注射液(浙江天瑞药业有限公司)10 ml/kg。PLR及VE前后均用CNAP主机测量无创血压，校准后收集心率(heart rate，HR)、平均动脉压(mean arterial pressure，MAP)、CVP和CO，并测量VE前的脉压变异率(PPV)，均重复测量3次，取平均值。记录PLR前后CO的变化率(ΔCOPLR)及VE前后CO的变化率(ΔCOVE)。ΔCOPLR=(PLR后CO—PLR前CO)/PLR前CO×100%。ΔCOVE=(VE后CO—VE前CO)/VE前CO×100%。将ΔCOVE≥15%定义为有容量反应性[8]并纳入有反应组，ΔCOVE<15%者纳入无反应组。另外，若患者在治疗后再次出现脓毒性休克，可重复进行VE试验，2次试验的间隔时间至少为24 h。
1.3 统计学处理
采用SPSS 21.0软件进行统计分析。对各组数据进行正态性检验(Shapiro-Wilk test)，符合正态分布的计量资料以$\bar{x}±s$表示，两组间比较采用独立样本t检验，组内血流动力学指标的比较采用配对t检验；计数资料以例次(%)表示，组间比较采用χ2检验；相关性分析采用Pearson检验。通过受试者工作特征(ROC)曲线分析ΔCOPLR和VE前PPV对脓毒性休克患者容量反应性的预测价值。P<0.05为差异有统计学意义。
2 结果
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2.1 一般资料
36例脓毒性休克患者中，男20例，女16例，年龄(65.8±12.1)岁，BMI (21.12±3.51) kg/m2；感染部位：腹腔感染12例，血流感染10例，肺部感染8例，泌尿系感染3例，其他3例；SOFA评分(8.92±3.20)分，APACHEⅡ评分(14.73±3.72)分；使用呼吸机辅助呼吸25例，其中采用同步间歇指令通气模式16例，自主通气模式9例；压力支持(14.33±3.25) cmH2O (1 cmH2O=0.098 kPa)，呼气末正压(5.86±1.73) cmH2O；22例患者使用去甲肾上腺素，剂量为(0.42±0.19) μg/(kg·min)。
36例脓毒性休克患者共进行40例次VE(4例患者重复进行了2次试验)，其中有反应组18例次，无反应组22例次；两组患者的年龄、性别、BMI、感染部位、SOFA评分、APACHEⅡ评分、呼吸机使用情况及去甲肾上腺素使用情况等基线资料差异均无统计学意义(P>0.05，表1)。
2.2 PLR前后患者的血流动力学变化
PLR前两组患者的HR、MAP、CVP及CO差异均无统计学意义(P>0.05)。PLR后两组患者的CO均较PLR前明显增高，且有反应组高于无反应组，差异均有统计学意义(P<0.05)；两组患者的HR、MAP、CVP与PLR前比较均无明显变化，且两组间差异均无统计学意义(P>0.05)(表2)。
2.3 VE前后患者的血流动力学变化
VE前两组患者的HR、MAP、CVP、CO及PPV差异均无统计学意义(P>0.05)。VE后两组患者的CVP、CO与VE前比较均明显增高(P<0.05)，且有反应组CO明显高于无反应组(P<0.05)，但两组CVP比较差异无统计学意义(P>0.05)。两组患者VE前后HR、MAP均无明显变化，且组间差异均无统计学意义(P>0.05)。有反应组ΔCOPLR、ΔCOVE高于无反应组，差异有统计学意义(均P<0.05)，两组VE前PPV差异无统计学意义(P>0.05，表3)。
2.4 ΔCOPLR、VE前PPV与ΔCOVE的相关性分析
相关性分析显示，ΔCOPLR与ΔCOVE呈正相关(n=40，r=0.820，P<0.05)，VE前PPV与ΔCOVE无相关性(n=40，r=0.194，P>0.05)。
2.5 ΔCOPLR、VE前PPV对患者容量反应性的预测效能分析
采用ROC曲线评估ΔCOPLR预测脓毒性休克患者容量反应性的曲线下面积(AUC)为0.855(95%CI 0.707~0.946，P<0.05)，其最佳截断值为13.95%，敏感度为83.3%，特异度为81.8%，约登指数为0.652。VE前PPV预测脓毒性休克患者容量反应性的AUC为0.525(95%CI 0.362~0.685，P>0.05)，其最佳截断值为15.01%，敏感度为44.4%，特异度为68.2%，约登指数为0.126。ΔCOPLR预测脓毒性休克患者容量反应性的效能优于VE前PPV(图1)。
3 讨论
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有容量反应性表明脓毒性休克患者对快速补液具有应答能力，补液后才可以明显增加CO，从而尽快稳定循环，改善机体组织灌注[9]。既往研究表明，仅约50%的危重症患者具有容量反应性[10]；本研究36例脓毒性休克患者共进行40例次VE，有容量反应性者仅18例次(45.0%)。脓毒性休克患者合并心功能不全时行传统VE易诱发心力衰竭、肺水肿等严重并发症，增加患者的死亡风险[11]，故临床应用需谨慎。PLR被认为是安全可逆的自体VE，PLR期间引起的容量增加可以通过放平下肢得到快速恢复，从而避免相关并发症的发生。目前研究认为PLR可以较准确地预测ICU内具有自主呼吸的重症患者的容量反应性，但其可监测的血流动力学变化在90 s以内[4]。本研究结果显示，两组患者PLR及VE前后HR、MAP均无明显变化，提示传统指标HR及MAP无法有效预测容量反应性，其原因可能与HR、MAP水平受多种因素影响有关，包括应用血管活性药物、镇静水平、机械通气、血管弹性等[12]。此外，两组患者VE后CVP亦无明显变化，提示作为静态指标的CVP亦不能用于预测容量反应性。
临床上常用的脉搏指示连续心排血量监测(pulse indicated continuous cardiac output，PiCCO)技术已被证实与经典Swan-Ganz导管法的相关性良好，结合PLR可对患者血流动力学变化进行更全面的评估，然而其为有创操作，并发症多，技术要求高，且价格昂贵，故临床应用受到一定的限制[13-14]。床旁经胸超声心动图(transthoracic echocardiography，TTE)是快速评估血流动力学的无创方法，Bou Chebl等[15]证实，TTE引导PLR可用于评估急诊科患者的容量反应性；El Hadouti等[16]发现，应用TTE监测ΔCOPLR可用于预测具有自主呼吸的术后患者的容量反应性，其敏感度为68%，特异度为100%；但TTE的专业性较强，需依赖高质量的超声图像，易受体位、透声情况及操作技术等因素的影响，且无法进行长时间连续监测。
CNAP是近年来在临床应用范围较广的无创血流动力学监测设备，采用上臂袖带压定标及双指套交替采集信号体系，并基于血管卸载原理绘制动脉血压波形及脉搏趋势图，从而实现连续无创血流动力学监测[17]。目前临床多以VE前后PiCCO测得CO变化≥15%作为有容量反应性的金标准[8]，Wagner等[18]应用CNAP及PiCCO分别监测38例ICU患者(其中7例行机械通气)的CO，发现二者的一致性良好，平均差值仅为0.2 L/min，故本研究中以CNAP测得ΔCOVE≥15%定义为具有容量反应性；结果显示，CNAP监测的ΔCOPLR与ΔCOVE呈正相关；且ROC曲线分析发现，当ΔCOPLR截断值为13.95%时，其预测脓毒性休克患者容量反应性的敏感度为83.3%，特异度为81.8%，提示CNAP监测ΔCOPLR可以较好地预测脓毒性休克患者的容量反应性，指导液体复苏治疗。与PiCCO及TTE相比，CNAP操作简单、技术要求低、无一次性耗材，与PLR结合能进一步扩大应用范围，弥补有创连续与无创间断监测技术的局限性。
基于心肺交互的指标PPV或每搏量变异度(stroke volume variation，SVV)也是预测容量反应性的常用指标。但有研究指出，只有在完全机械通气、无心律失常及无严重心脏瓣膜病的患者中，PPV或SVV才有较高的预测价值[19]。Michard等[20]发现，在机械通气脓毒性休克患者中，以PPV=13%为截断值预测容量反应性的敏感度为94%，特异度为96%。然而受上述特定条件的限制，实际临床工作中PPV或SVV在危重症患者中的适用性并不高。Preau等[21]研究发现仅约17%的危重症患者适用PPV来预测容量反应性。本课题组前期研究发现，在完全机械通气、无心律失常及无严重心脏瓣膜病的患者中，应用CNAP与PiCCO测得的PPV一致性良好[22]。但在本研究中，以VE前PPV预测容量反应性的AUC仅为0.525，提示CNAP监测的PPV对脓毒性休克患者容量反应性的预测价值不高，其原因可能与本研究入选的研究对象均为完全自主呼吸或部分自主呼吸的患者，潮气量不恒定有关。
综上所述，CNAP监测ΔCOPLR可用于预测脓毒性休克患者的容量反应性，其敏感度和特异度均较高，对进一步液体治疗具有指导意义，且操作简单、易于掌握，具有临床推广价值。本研究尚存在局限之处：(1)为单中心研究，且样本量较小，个别患者重复试验可能存在变异性，需要在今后工作中进一步实践以验证本结论；(2)研究以CNAP测得的ΔCOVE≥15%定义为有容量反应性，使用CNAP采集的CO仍存在一定偏差；(3)以该方法为导向的液体复苏策略对脓毒性休克患者的容量平衡及预后影响尚需进一步明确。
基金
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  • 福建省重症医学中心建设项目(2017-510)
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2021年第46卷第11期
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doi: 10.11855/j.issn.0577-7402.2021.11.08
  • 接收时间：2021-01-28
  • 首发时间：2025-12-19
  • 出版时间：2021-11-28
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  • 收稿日期：2021-01-28
  • 修回日期：2021-05-20
基金
Critical Care Medical Center Construction Projects of Fujian Province(2017-510)
福建省重症医学中心建设项目(2017-510)
作者信息
    1福建医科大学省立临床医学院，福州 350001
    2福建省立医院重症医学四科，福州 350001
    3福建省立医院急诊科/福建省急诊医学重点实验室，福州 350001

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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