颈内静脉变异度和下腔静脉变异度评估成人心脏术后容量状态

Assessment of fluid responsiveness by variability index of internal jugular vena cava and variability index of inferior vena cava in adult petients with cardiosurgery

摘要:

目的： 探索超声测量颈内静脉变异度（variability index of internal jugular vena cava，VJVC）、下腔静脉变异度（variability index of inferior vena cava，VIVC）评估心脏术后容量状态。方法： 前瞻性连续纳入中国科学院大学重庆医院心血管外科成人心脏术后76例患者。超声测量被动抬腿实验（passive leg raising，PLR）前后患者心排指数，心排指数增加10%为标准，增加≥10%为容量有反应者（fluid responders，FR）；反之则为容量无反应者（fluid unresponders，FN）。同时记录患者PLR前后心率、收缩压、舒张压、平均压。在PLR前，查氨基末端脑利钠肽（N-terminal pro-brain natriuretic peptide，NT-proBNP），超声测量VIVC和左侧VJVC。结果： 对比PLR前后，FR组中心静脉压在PLR前后无统计学差异［（7.6±1.9）mmHg vs.（10.1±11.4）mmHg，P=0.154］，心率［（83.0±8.9）次/min vs.（75.3±7.5）次/min，P=0.000］、收缩压［（91.1±9.4）mmHg vs.（94.9±9.1）mmHg，P=0.000］、舒张压［（52.8±9.8）mmHg vs.（58.9±8.2）mmHg，P=0.000］、平均压［（65.6±9.2）mmHg vs.（70.7±8.0）mmHg，P=0.000］均有明显变化。FN组PLR后收缩压的变化无统计学差异［（90.0±7.4）mmHg vs.（92.3±6.7）mmHg，P=0.076］，心率［（83.5±9.1）次/min vs.（80.7±7.4）次/min，P=0.005］、舒张压［（50.0±7.1）mmHg vs.（55.2±5.7）mmHg，P=0.000］、平均压［（63.3±6.8）mmHg vs.（67.6±5.0）mmHg，P=0.000］、中心静脉压［（7.9±1.6）mmHg vs.（10.2±1.4）mmHg，P=0.000］均有明显变化。对比FR组和FN组患者被动抬腿实验前（T₀），心率、收缩压、舒张压、平均压、中心静脉压无统计学差异；被动抬腿实验后（T₁），心率明显下降，FR组与FN组比较有统计学差异［（75.3±7.5）次/min vs.（80.7±7.4）次/min，P=0.001］，舒张压和平均压变化有统计学差异［（58.9±8.2）mmHg vs.（55.2±5.7）mmHg，P=0.014；（70.7±8.0）mmHg vs.（67.6±5.0）mmHg，P=0.024］，收缩压和中心静脉压无统计学差异［（94.9±9.1）mmHg vs.（92.3±6.7）mmHg，P=0.075；（10.1±11.4）mmHg vs.（10.2±1.4）mmHg，P=0.474］，2组间血浆NT-proBNP无统计学差异［（1 144.6±9 92.1）pg/mL vs.（1 243.6±1 095.0）pg/mL，P=0.335］。FR组和FN组VIVC有统计学差异［（15.2±3.9）% vs.（12.5±4.2）%，P=0.003］，FR组和FN组VJVC有统计学差异［（17.7±4.3）% vs.（13.9±4.0）%，P=0.000］。VIVC诊断容量有反应的临界值为11.5%，敏感性为87.8%，特异性为55%（曲线下面积为0.7，95% CI=0.575~0.826，P=0.003）。VJVC诊断容量有反应的临界值为15.5%，敏感性为68.3%，特异性为77.1%（曲线下面积为0.764，95% CI=0.654~0.874，P=0.000）。结论： 颈内静脉变异度和下腔静脉变异度都能较好、及时地预测心脏术后患者容量状态，准确指导临床补液治疗。且颈内静脉比下腔静脉更容易测量，位置更加表浅，更加恒定，不受患者肥胖影响，不受腹压影响，无心脏术后引流管影响，重复性更好。临床工作中更推荐使用VJVC评估心脏术后容量状态。

Abstract:

Objective: To evaluate the variability index of internal jugular vena cava (VJVC) and variability index of inferior vena cava (VIVC) through ultrasound in predicting fluid responsiveness in adult petients with cardiosurgery. Methods: Prospectively, 76 adult pa tients who had cardiosurgery in the Department of Cardiovascular Surgery, Chongqing General Hospital were collected in the study, and the passive leg raising (PLR) tests were carried out on them of intensive monitoring in the intensive care unit (ICU) ward. Patients with elevated cardiac output index≥10% after PLR were included in the fluid responders (FR) group, while patients with elevated cardiac output index<10% were included in the fluid unresponders (FN) group. Meanwhile, the hemodynamic parameters of heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure were all recorded before and after PLR tests in both groups. The N-terminal pro-brain natriuretic peptide (NT-proBNP), VJVC, and VIVC were recorded before PLR tests. Results: After PLR tests, in FR group, there were no significant differences in central venous pressure［ (7.6±1.9) mmHg vs. (10.1±11.4) mmHg, P=0.154］; there were significant differences in heart rate［ (83.0±8.9) bpm vs. (75.3±7.5) bpm, P=0.000］, systolic blood pressure［ (91.1±9.4) mmHg vs. (94.9±9.1) mmHg, P=0.000］, diastolic blood pressure［ (52.8±9.8) mmHg vs. (58.9±8.2) mmHg, P=0.000］, and mean blood pressure［ (65.6±9.2) mmHg vs. (70.7±8.0) mmHg, P=0.000］. In FN group after PLR, there were no significant differences in systolic blood pressure［ (90.0±7.4) mmHg vs. (92.3±6.7) mmHg, P=0.076］, and there were significant differences in heart rate［ (83.5±9.1) bpm vs. (80.7±7.4) bpm, P=0.005］, diastolic blood pressure［ (50.0±7.1) mmHg vs. (55.2±5.7) mmHg, P=0.000］, mean blood pressure［ (63.3±6.8) mmHg vs. (67.6±5.0) mmHg, P=0.000］, and central venous pressure［ (7.9±1.6) mmHg vs. (10.2±1.4) mmHg, P=0.000］. There were no significant differences in heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure and central venous pressure between FR goup and FN group before PLR tests. After PLR, there were no significant differences in systolic pressure［ (94.9±9.1) mmHg vs. (92.3±6.7) mmHg, P=0.075］and central venous pressure［ (10.1±11.4) mmHg vs. (10.2±1.4) mmHg, P=0.474］between the two groups, and there were significant differences in heart rate［ (75.3±7.5) bpm vs. (80.7±7.4) bpm, P=0.001］, diastolic blood pressure［ (58.9±8.2) mmHg vs. (55.2±5.7) mmHg, P=0.014］, and mean blood pressure［ (70.7±8.0) mmHg vs. (67.6±5.0) mmHg, P=0.024］. In addition, There was no significant difference in plasma NT-proBNP between the two groups［ (1 144.6±992.1) pg/mL vs. (1 243.6±1095.0) pg/mL, P=0.335］, and there were significant differences in VIVC［ (15.2±3.9) % vs. (12.5±4.2) %, P=0.003］and VJVC［ (17.7±4.3) % vs. (13.9±4.0) %, P=0.000］. The cutoff value of VIVC diagnostic capacity was 11.5%, the sensitivity was 87.8%, and the specificity was 55% (AUC=0.7, 95% CI=0.575-0.826, P=0.003) . The cutoff value of VJVC diagnostic capacity was 15.5%, the sensitivity was 68.3%, and the specificity was 77.1% (AUC=0.764, 95% CI=0.654-0.874, P=0.000) . Conclusion: VIVC and VJVC can easily predict the noninvasive parameter of fuid responsiveness in patients with cardiosurgery and accurately guide the clinical rehydration therapy. Moreover, the internal jugular vein is easier to measure than the inferior vena cava, its position is shallower and more constant, and it is not affected by the obesity of patients, abdominal pressure and drainage tube after cardiosurgery, so the repeatability is better. It is more recommended to use the VJVC to evaluate the fluid responsiveness after cardiosurgery in clinical work.