How to detect a positive response to a fluid bolus when cardiac output is not measured?
How to detect a positive response to a fluid bolus when cardiac output is not measured?
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DOI：
10.1186/s13613-019-0612-x
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发表时间：
2019-12-16
影响因子：
8.1
通讯作者：
Monnet, Xavier
中科院分区：
文献类型：
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作者：
Ait-Hamou, Zakaria;Teboul, Jean-Louis;Monnet, Xavier
容量扩张的目的是增加心输出量（CO），但这一变量并不总是直接测量。我们评估了动脉压、脉压变异（PPV）和心率（HR）的变化或它们的组合检测心输出量（CO）对液体给药的阳性反应的能力。方法回顾性分析491例循环衰竭患者的临床资料。在500-mL生理盐水输注前后，我们测量了CO（PiCCO装置）、HR、收缩压（SAP）、舒张压（DAP）、平均动脉压（MAP）和脉搏（PP）、PPV、休克指数（HR/SAP）和PP/HR比值。结果液体诱导的HR变化与液体诱导的CO变化不相关。HR变化的受试者工作特征曲线下面积（AUROC）作为阳性液体反应（CO增加≥ 15%）的检测器，与0.5无差异。液体诱导的SAP、MAP、PP、PPV、休克指数（HR/SAP）和PP/HR比值的变化与液体诱导的CO变化相关，但r < 0.4。最好的检测是通过PP的增加来提供的，但它是粗略的（AUROC = 0.719 +/- 0.023，最佳阈值：增加>= 10%，灵敏度= 72 [66-77]%，特异性= 64 [57-70]%）。无论是休克指数的降低还是其他指数的变化，结合HR、休克指数、PPV和PP的变化，都不能比PP的变化更好地检测阳性液体反应。结论PP的变化可粗略地检测出对液体的阳性反应，而HR的变化则不能检测出对液体的阳性反应，休克指数和PP/HR比值等综合指标的变化并不能提供更好的诊断准确性。
Background Volume expansion is aimed at increasing cardiac output (CO), but this variable is not always directly measured. We assessed the ability of changes in arterial pressure, pulse pressure variation (PPV) and heart rate (HR) or of a combination of them to detect a positive response of cardiac output (CO) to fluid administration. Methods We retrospectively included 491 patients with circulatory failure. Before and after a 500-mL normal saline infusion, we measured CO (PiCCO device), HR, systolic (SAP), diastolic (DAP), mean (MAP) and pulse (PP) arterial pressure, PPV, shock index (HR/SAP) and the PP/HR ratio. Results The fluid-induced changes in HR were not correlated with the fluid-induced changes in CO. The area under the receiver operating characteristic curve (AUROC) for changes in HR as detectors of a positive fluid response (CO increase >= 15%) was not different from 0.5. The fluid-induced changes in SAP, MAP, PP, PPV, shock index (HR/SAP) and the PP/HR ratio were correlated with the fluid-induced changes in CO, but with r < 0.4. The best detection was provided by increases in PP, but it was rough (AUROC = 0.719 +/- 0.023, best threshold: increase >= 10%, sensitivity = 72 [66-77]%, specificity = 64 [57-70]%). Neither the decrease in shock index nor the changes in other indices combining changes in HR, shock index, PPV and PP provided a better detection of a positive fluid response than changes in PP. Conclusion A positive response to fluid was roughly detected by changes in PP and not detected by changes in HR. Changes in combined indices including the shock index and the PP/HR ratio did not provide a better diagnostic accuracy.