【摘要】 目的 探讨呼气末正压（PEEP）调节对血流动力学参数的影响及其在液体反应性评估中的应用价值。方法 采用前瞻性观察性研究设计,纳入67例脓毒性休克及低血容量性休克患者。所有患者均接受机械通气和脉搏指示连续心输出量监测（PICCO）,通过将PEEP提高3 cm H₂O（1 cm H₂O=0.098 kPa）观察心脏指数（CI）、每搏指数（SVI）、每搏量变异度（SVV）、脉压变异度（PPV）等指标变化,分析PEEP上调3 cm H₂O前后血流动力学指标变化。当CI、SVI下降>10%且SVV、PPV上升>10%时判定为液体反应性阳性,给予500 ml晶体液输注后再次评估指标变化,分析PEEP调节对液体反应性的预测价值。结果 患者CI、SVI、SVV、PPV基础值分别为（2.8±0.6）L/（min·m²）、（35.2±7.4）ml/m²、（9.1±2.3）%、（8.7±2.1）%, PEEP上调3 cm H₂O后分别为（2.5±0.5）L/（min·m²）、（31.4±6.8）ml/m²、（14.6±3.1）%、（13.9±2.9）%。PEEP上调3 cm H₂O后,患者的CI、SVI均呈现出10.7%～10.8%的下降趋势, SVV、PPV则显著上升,增幅60%左右（P<0.01）。67例患者的PEEP调节试验中,有58例患者展现出了对补液措施的积极反应,而剩余的9例患者则未出现明显反应。CI下降≥10%、SVI下降≥10%、SVV上升>10%、PPV上升>10%及CI下降≥10%且SVV上升>10%预测液体反应性的敏感度分别为91.4%、93.1%、96.6%、94.8%、87.9%,特异度分别为44.4%、44.4%、33.3%、33.3%、88.9%,准确度分别为85.1%、86.6%、88.1%、86.6%、88.1%, CI下降≥10%且SVV上升>10%预测液体反应性的敏感度最低,但特异度和准确度最高。结论 将PEEP提高3 cm H₂O可安全、有效地评估休克患者的液体反应性。该方法操作简便,结果可靠,可作为临床液体管理的重要参考,且联合CI和SVV指标判断能显著提高预测准确性。更多还原

【Abstract】 Objective To investigate the effect of positive end-expiratory pressure（PEEP） regulation on hemodynamic parameters and its application value in evaluating fluid responsiveness. Methods A total of 67 patients with septic shock or hypovolemic shock were enrolled in this prospective observational study. All patients received mechanical ventilation and pulse indicator continous cardiac output（PICCO） monitoring. The changes of cardiac index（CI）, stroke volume index（SVI）, stroke volume variation（SVV） and pulse pressure variation（PPV） were observed by increasing PEEP by 3 cm H₂O（1 cm H₂O=0.098 kPa）. Hemodynamic parameters were analyzed before and after PEEP was increased by 3 mm Hg. Positive fluid responsiveness was defined when CI/SVI decreased by >10% and SVV/PPV was >10%. After 500 ml crystalloid infusion, the index changes were evaluated again to evaluate the predictive value of PEEP adjustment for fluid responsiveness. Results The baseline values for CI, SVI, SVV, and PPV were（2.8±0.6） L/（min·m²）,（35.2±7.4） ml/m²,（9.1±2.3）%, and（8.7±2.1）%, respectively. After increasing PEEP by 3 cm H₂O, the values were（2.5±0.5） L/（min·m²）,（31.4± 6.8） ml/m²,（14.6±3.1）%, and（13.9±2.9）%, respectively. After increasing PEEP by 3 cm H₂O, CI and SVI were significantly decreased by 10.7%-10.8%, and SVV and PPV were significantly increased by about 60%（P<0.01）. In the PEEP regulation test of 67 patients, 58 cases demonstrated a positive response to fluid administration, while the remaining 9 cases showed no significant response. The sensitivity of predicting liquid reactivity with CI decrease ≥10%, SVI decrease ≥10%, SVV increase >10%, PPV increase >10%, and CI decrease ≥10% and SVV decrease >10% were 91.4%, 93.1%, 96.6%, 94.8%, and 87.9%, respectively. The specificity were 44.4%, 44.4%, 33.3%, 33.3%, and 88.9%, and the accuracy were 85.1%, 86.6%, 88.1%, 86.6%, and 88.1%, respectively. The sensitivity of predicting liquid response with CI decrease ≥10% and SVV decrease >10% was the lowest, but the specificity and accuracy were the highest. Conclusion An increase of PEEP by 3 cm H₂O can safely and effectively evaluate fluid responsiveness in patients with shock. This method is simple and reliable, which can be used as an important reference for clinical fluid management, and the combination of CI and SVV can significantly improve the prediction accuracy.更多还原