Update on the assessment of fluid responsiveness
Update on the assessment of fluid responsiveness
复制标题
液体反应性评估的更新
DOI：
10.1007/s00540-019-02731-4
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发表时间：
2020
影响因子：
2.8
通讯作者：
Suehiro Koichi
中科院分区：
文献类型：
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作者：
Mukai Akira;Suehiro Koichi;Kimura Aya;Fujimoto Yohei;Funao Tomoharu;Mori Takashi;Nishikawa Kiyonobu;Suehiro Koichi
全身麻醉期间经常发生血液动力学波动，包括低血压和心输出量（CO）减少，并可导致急性循环衰竭。在这种情况下，液体负荷是一线治疗方法。然而，过度的液体体积膨胀可能是有害的，特别是在心脏病患者中。由于急性循环衰竭患者通常不会通过增加CO对液体负荷作出反应，因此进行了大量研究[1-3]，以开发预测“液体反应性”的试验。虽然传统上使用静态指标（如中心静脉压和肺毛细血管楔压）评估患者的容量状态，但这些指标用于识别液体反应者的可靠性较差[4]。最近使用了动态指标，包括脉压变异度（PPV）和每搏输出量变异度（SVV），它们为液体反应性提供了更好的预测性[5，6]。微创血流动力学监测的最新进展增加了这些指标的临床适用性[7-10]。在各种临床条件下，使用动态指标的目标导向治疗可降低术后发病率[11-13]。然而，某些情况（包括心律失常和自主呼吸）对动态指标的临床使用造成了一些限制[14]。特别是，这些指标对低潮气量（< 8 ml/kg）或低驱动气道压力（< 20 cm H2O）患者的液体反应性预测性较差[15，16]。根据正压通气引起的胸内压的周期性变化计算动态指标，包括SVV和PPV。当低潮气量通气时胸内压的变化很小时，左右心室前负荷的呼吸变化程度也变小。因此，在这种情况下，每搏输出量（SV）和脉压的呼吸变化对评估容量状态的用途有限。这意味着，由于在手术期间采用低潮气量（6-7 ml/kg）和呼气末正压治疗（5-10 cmH 2 O）的肺保护性通气已变得很常见，因此围手术期不常使用动态指标[14]。考虑到动态指标的这些弱点，需要新的干预措施来评估液体反应性。在此，作者简要总结了目前开发的一些干预措施，以预测液体反应性。
Hemodynamic fluctuations, including hypotension and decreases in cardiac output (CO), frequently occur during general anesthesia and can lead to acute circulatory failure. Under these circumstances, fluid loading is the firstline therapeutic method. However, excessive fluid volume expansion can be harmful, especially in patients with heart disease. As patients with acute circulatory failure do not usually respond to fluid loading by increasing their CO, numerous studies [1–3] have been conducted to develop tests that predict “fluid responsiveness”. Although static indices, such as central venous pressure and pulmonary capillary wedge pressure, have been traditionally used for assessing patients’ volume status, these indices have poor reliability for identifying fluid responders [4]. Dynamic indices, including pulse pressure variation (PPV) and stroke volume variation (SVV), have been recently used, and they provide better predictability for fluid responsiveness [5, 6]. Recent advances in minimally invasive hemodynamic monitoring allow for an increased clinical applicability of these indices [7–10]. Goaldirected therapy using dynamic indices decreases postoperative morbidity under various clinical conditions [11–13]. However, certain conditions, including arrhythmias and spontaneous breathing, impose some limitations for the clinical use of dynamic indices [14]. In particular, these indices have poor predictability for fluid responsiveness in patients with low tidal volumes (< 8 ml/kg) or low driving airway pressures (< 20 cm H2O)[15, 16]. Dynamic indices, including SVV and PPV, are calculated based on cyclic changes in intrathoracic pressure induced by positive pressure ventilation. When the change in intrathoracic pressure with low tidal volume ventilation is very small, the degree of respiratory variation of the preload in the right and left ventricles also becomes small. Thus, respiratory variations in stroke volume (SV) and pulse pressure are of limited use to assess volume status under this condition. This means that as lung-protective ventilation with low tidal volume (6–7 ml/kg) and positive end-expiratory pressure therapy (5–10 cmH2O) has become common during surgery, dynamic indices are less frequently used in the perioperative period [14]. Considering these weaknesses of dynamic indices, new interventions for assessing fluid responsiveness are required. Herein, the author briefly summarizes some currently developed interventions to predict fluid responsiveness.