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Objective:To investigate the value of partial pressure of end-tidal carbon dioxide (P ETCO 2) combined with passive leg raising test (PLR) in predicting volume responsiveness in patients with septic shock. Methods:A total of 43 patients with septic shock admitted to the second department of critical care medicine, People's Hospital of Xinjiang Uygur Autonomous Region from December 2019 to June 2021 were selected as the research subjects. P ETCO 2, cardiac index (CI), stroke volume variation (SVV), mean arterial pressure (MAP) and other hemodynamic indexes were monitored before and after PLR and volume stress test (VE). Subjects were grouped according to the CI variation rate (ΔCI) after VE test. Patients with ΔCI ≥ 15% were the responding group, and patients with ΔCI < 15% were the non-responding group. The receiver operator characteristic curve (ROC curve) was drawn to analyze the evaluation value of the change in P ETCO 2 after PLR on the evaluation value of fluid responsiveness. Results:Among the 43 patients, 22 cases were in the responding group, accounting for 51.2%; 21 cases were in the non-responding group, accounting for 48.8%. After the PLR test, the change values of MAP, SVV, CI and P ETCO 2 in the responding group were higher than those in the non-responding group, and the differences were statistically significant [MAP (mmHg): 3.8±2.1 vs. 1.4±2.0, SVV (%): -5.3±2.5 vs. 2.7±2.0, CI (mL·s -1·m -2): 0.48±0.13 vs. 0.14±0.18, P ETCO 2 (mmHg): 3.4±1.8 vs. 1.1±1.0, all P < 0.05, 1 mmHg≈0.133 kPa]. After the VE test, the changes of HR, MAP, SVV, CI and P ETCO 2 in the responding group were higher than those in the non-responding group [HR (times/min): -8.3±2.8 vs. -2.3±3.7, MAP (mmHg): 3.8±2.4 vs. 1.2±1.7, SVV (%): -6.3±3.1 vs. -3.3±2.0, CI (mL·s -1·m -2): 0.51±0.14 vs. 0.16±0.12, P ETCO 2 (mmHg): 3.3±1.2 vs. 1.3±1.1, all P < 0.05]. The area under the ROC curve (AUC) of the change in P ETCO 2 before and after the PLR test (ΔP ETCO 2 PLR) for evaluating fluid responsiveness was 0.881. When the critical value was 5.9%, the sensitivity was 76.7%, the specificity was 89.5%, and the correct index was 0.68; the AUC for SVV baseline assessment of fluid responsiveness was 0.835, and when the cut-off value was 12.8%, the sensitivity was 84.6%, the specificity was 80.0%, and the correct index was 0.65. The predictive value of ΔP ETCO 2 was not lower than the SVV baseline. Conclusion:After the PLR test, the change of P ETCO 2 can be used as a non-invasive, simple, safe and reliable indicator for predicting the volume responsiveness of patients with septic shock.
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Objective:To explore the value of severe ultrasound measurement of internal jugular vein dilation index (ΔIJV) combined with passive leg raising (PLR) in predicting the volume responsiveness of septic shock.Methods:Patients diagnosed with septic shock under complete mechanical ventilation in the ICU of Jinshan Hospital Affiliated to Fudan University from January 2020 to March 2021 were prospectively selected as the research objects. After 500 mL crystals were injected within 30 min, the patients having the "gold standard" left stroke volume (SV) increased by 15% were allocated to the volume response positive group, and patient having an SV increased by less than 15% to the volume response negative group. First, the maximum anterior posterior diameter (IJV max) and the minimum anterior posterior diameter (IJV min) in the respiratory cycle of internal jugular vein were measured by ultrasound, then SV before and after PLR was measured, and finally SV, IJV max and IJV min were measured again after rapid infusion of 500 mL crystals, and ΔIJV=(IJV max-IJV min)/(IJV mean)×100%. The Wilcoxon rank-sum test was used to compare the hemodynamic indexes before and after capacity expansion and PLR. Spearman rank method was used to analyze the change rate of SV (ΔSV) after PLR and the correlation between ΔIJV and ΔSV of the "gold standard". The sensitivity, specificity and relevant cut-off values were obtained by drawing the subject function curve to evaluate the value of ΔIJV and PLR in predicting the volume responsiveness of patients with sepsis. Results:A total of 56 patients were enrolled in the study, and they were divided into two groups: 32 patients in the volume response positive group and 24 patients in the volume response negative group. There was a positive correlation between ΔIJV and ΔSV after capacity expansion ( r=0.778, P<0.01). Taking ΔIJV>17.3% as the threshold, the area under the curve (AUC) was 0.846 (95% CI: 0.716~0.977), the sensitivity was 84.4% and the specificity was 83.3%. PLR was also positively correlated with ΔSV ( r=0.698, P<0.01). Taking ΔSV>15.5% after PLR as the threshold, the AUC was 0.895 (95% CI: 0.796~0.993), the sensitivity was 96.9%, and the specificity was 79.2%. When ΔIJV combined with PLR predicted volume reactivity, the AUC was 0.944 (95% CI: 0.862~1.000), the sensitivity was 99.8% and the specificity was 87.5%. Conclusions:The measurement of internal jugular vein respiratory dilation index by bedside ultrasound is a reliable index to predict volume responsiveness in patients with sepsis. When combined with PLR, the sensitivity and specificity of prediction can be improved.
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Objective:To evaluate the accuracy of variation of carotid artery hemodynamic parameters combined with passive leg raising (PLR) test in predicting supine hypotension syndrome (SHS) after spinal anesthesia in the patients undergoing cesarean section.Methods:Sixty-four parturients who were at full term with a singleton fetus, at 37-42 weeks of gestation, aged 18-40 yr, with body mass index of 18-30 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing elective cesarean section, were enrolled in this study.The variation of carotid artery diameter (ΔD), variation of velocity time integral (ΔVTI), and variation of carotid blood flow (ΔCBF) before and after PLR were measured using ultrasound.Patients were divided into SHS group and non-SHS group (NSHS group) according to whether SHS after spinal anesthesia occurred.Pearson correlation was used to analyze the correlation between ΔD, ΔVTI, ΔCBF and systolic blood pressure (SBP) after spinal anesthesia.The receiver operating characteristic curve was used to assess the accuracy of ΔD, ΔVTI and ΔCBF in predicting SHS. Results:ΔVTI was negatively correlated with SBP after spinal anesthesia ( r=-0.539, P<0.01), ΔCBF was negatively correlated with SBP after spinal anesthesia ( r=-0.475, P<0.05), and ΔD had no correlation with SBP after spinal anesthesia in group SHS ( P>0.05). The critical values of ΔCBF, ΔVTI, and ΔD combined with PLR in predicting SHS after spinal anesthesia were 15.5%, 10.1%, and 6.0%, respectively, the sensitivity was 92.9%, 57.1%, and 96.4%, respectively, and the specificity was 53.1%, 81.2%, and 75.0%, respectively, and the areas under the curve were 0.873, 0.681 and 0.846, respectively. Conclusion:The ultrasound-measured ΔCBF and ΔD of carotid artery combined with PLR can be used as a reliable method to predict SHS after spinal anesthesia in the patients undergoing cesarean section, and the ΔCBF combined with PLR has a higher accuracy.
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@#Objective To investigate the perioperative hemodynamic changes of off-pump coronary artery bypass grafting (OPCABG) patients monitored by pulse recorded analysis method (MostCare/PRAM devices) and its relationship with the prognosis. Methods A total of 89 patients who underwent OPCABG from October 2016 to January 2017 in Beiijng Anzhen Hospital were included, including 53 males and 36 females aged 60.50±8.40 years. The hemodynamic changes were recorded. The patients were divided into two groups (a major adverse cardiovascular events group and a stable group) according to whether major adverse cardiovascular events occurred or not. The difference of hemodynamic changes between the two groups was analysed. Results The mean percentage increases of stroke volume (SV) in the passive leg raising (PLR) test before opening chest and after chest closure were 23.00%±3.20% and 29.40%±3.70%, respectively. Hemodynamic data were analysed seven times, namely, anaesthesia, opening chest, heparin administration, coronary artery bypass grafting, protamine administration, thoracic closure and after operation. SV was significantly decreased during above periods, while systemic vascular resistance index (SVRI) was significantly increased. Cardiac circle efficiency (CCE) and maximum pressure gradient (dP/dT) were decreased after anaesthesia, and decreased to the lowest value during the procedure of bypass grafting, and then they began to increase gradually after the manipulation of bypass grafting was finished. Stroke volume variation (SVV) and pulse pressure variation (PPV) were slightly decreased during anaesthesia, then increased significantly through the whole surgery. Major adverse cardiovascular events occurred in 9 patients and 4 of them died. The basic mean values of SVRI, SVV and PPV of patients in the major adverse cardiovascular events group before opening chest were significantly higher than those of patients in the stable group. There was no significant difference in the mean values of CCE, dP/dT or SV between the two groups. There was no significant correlation between the prognosis and the mean values of SVRI, SVV, PPV, CCE, dP/dT or SV. Conclusion The hemodynamic indexes are not stable, thus, it is necessary to monitor the perioperative hemodynamic changes of OPCABG patients timely by MostCare/PRAM device and adjust treatment measures accordingly.
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Objective:To investigate the value of monitor carotid velocity time integral (VTI) and corrected flow time (FTc) by bedside ultrasound before and after passive leg raising (PLR) in predicting fluid responsiveness in critically ill patients.Methods:A prospective observational study was conducted. Fifty patients with critical illness admitted to the First People's Hospital of Fuyang Hangzhou from January 2020 to March 2021 were enrolled. The clinical data including the gender, age, body mass index (BMI), acute physiology and chronic health evaluationⅡ(APACHEⅡ) score, and the duration of mechanical ventilation were recorded. The changes of carotid VTI and FTc were measured by bedside ultrasound, and the values of heart rate, mean arterial pressure (MAP), central venous pressure (CVP), stroke volume index (SVI), and intrathoracic blood volume index (ITBVI) were measured by pulse indicated continuous cardiac output (PiCCO) monitor before and after PLR in all patients. According to the changes of SVI before and after PLR, the patients were divided into fluid responsiveness positive group with the change rate of SVI≥15% and fluid responsiveness negative group with the change rate of SVI < 15%. The differences in the values of VTI, FTc, CVP, and ITBVI obtained before and after PLR (ΔVTI, ΔFTc, ΔCVP and ΔITBVI) were calculated and then compared between the two groups. The predictive values of these indicators on fluid responsiveness in critically ill patients were analyzed by receiver operator characteristic curve (ROC curve), and their relationship with the difference in SVI (ΔSVI) obtained before and after PLR was evaluated by Pearson correlation analysis.Results:Fifty patients were all enrolled in this study, in which 27 patients were fluid response and 23 patients were fluid nonresponse. Basic clinical data were not different between the two groups. The values of ΔVTI, ΔFTc, ΔCVP, and ΔITBVI in fluid response were all significantly higher than those in fluid nonresponse [ΔVTI (cm): 2.07±1.16 vs. 0.67±0.86, ΔFTc (ms): 4.00±6.10 vs. 0.01±2.26, ΔCVP (cmH 2O, 1 cmH 2O = 0.098 kPa): 1.67±1.14 vs. 1.00±1.17, ΔITBVI (mL/m 2): 98±69 vs. 48±70, all P < 0.05]. ROC curve analysis showed that ΔVTI, ΔFTc, ΔCVP and ΔITBVI were all positive for predicting fluid responsiveness, their area under ROC curve (AUC) and 95% confidence interval (95% CI) were 0.870 (0.769-0.972), 0.694 (0.547-0.841), 0.684 (0.535-0.832) and 0.709 (0.564-0.855), respectively. When using ΔVTI 0.92 cm, ΔFTc 1.45 ms, ΔCVP 1.50 cmH 2O and ΔITBVI 44.50 mL/m 2 as the threshold values, the sensitivities were 96.3%, 63.0%, 44.4% and 81.5%, and the specificities were 65.2%, 78.3%, 82.6% and 56.5%, respectively, in which the predictive value of ΔVTI was the largest. Pearson correlation analysis indicated that ΔVTI, ΔFTc, ΔCVP, and ΔITBVI were positively associated with ΔSVI ( r values were 0.971, 0.334, 0.440, 0.650, P values were 0.000, 0.018, 0.001, 0.000, respectively). Conclusion:Carotid ΔVTI and ΔFTc monitored by bedside ultrasound before and after PLR could be as effective as conventional indicators in predicting fluid responsiveness in critically ill patients, and the predictive value of ΔVTI was better than others.
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Objective To assess the value of passive leg raising (PLR) combined with echocardiography in predicting volume responsiveness in patients with septic shock. Methods Thirty septic shock patients with spontaneous respiration admitted to intensive care unit (ICU) of Tianjin First Center Hospital from July 2016 to August 2018 were enrolled. PLR and volume expansion (VE) were performed successively. The hemodynamic parameters including left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), stroke volume (SV) and left ventricular ejection fraction (LVEF) before PLR (baseline level), after PLR, immediately after VE were examined by echocardiography, and the central venous pressure (CVP) was monitored. The patients with increase in SV after VE (ΔSV) ≥ 15% were served as reaction group, while ΔSV < 15% were served as non-reaction group. The changes in LVEDV, LVESV, SV, LVEF and CVP at baseline level, after PLR and after VE were compared between the two groups. Pearson correlation method was used to analyze the correlation between ΔSV, increase in LVEF (ΔLVEF) after PLR and ΔSV, and ΔLVEF after VE. Receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of ΔSV and ΔLVEF after PLR for volume responsiveness. Results PLR and VE were successfully performed in 30 patients, of which 23 patients (76.7%) were enrolled in the reaction group, and 7 patients (23.3%) in the non-reaction group. Compared with baseline levels, LVEDV, SV, and LVEF in the reaction group were significantly increased after PLR [LVEDV (mL): 83.5±9.6 vs. 77.1±6.2, SV (mL): 48.5±5.6 vs. 43.2±4.9, LVEF: 0.58±0.04 vs. 0.56±0.06, all P < 0.05], and CVP was significantly increased after VE [cmH2O (1 cmH2O = 0.098 kPa): 7.4±3.3 vs. 4.6±0.7, P < 0.01], however, there was no significant change in LVESV. In the non-reaction group, SV and LVEF were significantly increased after PLR as compared with those at baseline levels [SV (mL): 42.7±3.7 vs. 40.6±3.1, LVEF: 0.52±0.05 vs. 0.50±0.05, both P < 0.05], while LVEDV and CVP were significantly increased after VE as compared with those at baseline levels [LVEDV (mL): 84.4±4.1 vs. 80.6±5.9, CVP (cmH2O): 10.6±3.5 vs. 7.6±0.5, both P < 0.05], however, there was no significant change in LVESV. Pearson correlation analysis showed that ΔSV and ΔLVEF after PLR were positively correlated with ΔSV and ΔLVEF after VE (r1 = 0.86, r2 = 0.65, both P < 0.01). ROC curve analysis showed that the area under ROC curve (AUC) of PLR-induced ΔSV and ΔLVEF for predicting volume responsiveness was 0.85 and 0.66 respectively. When the cut-off value of ΔSV after PLR was 10.6%, the sensitivity was 78.2%, the specificity was 82.3%; when the cut-off value of ΔLVEF after PLR was 3.6%, the sensitivity was 78.2%, and the specificity was 73.2%. Conclusion ΔSV and ΔLVEF measured by PLR combined with echocardiography can be used to evaluate the volume responsiveness in patients with septic shock and can guide fluid therapy.
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Objective To explore the clinical value of early fluid resuscitation guided by passive leg-raising test (PLR) combined with transthoracic echocardiography (TTE) in patients with septic shock. Methods A prospective randomized controlled trial (RCT) was conducted. Seventy-four patients with septic shock admitted to China-Japan Friendship Hospital from January 2017 to October 2018 were enrolled. The patients were randomly divided into control group and experimental group with 37 patients in each group. Both groups of patients were treated with broad-spectrum antibiotics empirically, while received fluid resuscitation via the subclavian vein catheter. The patients of control group were given rapid fluid replacement, and those of experimental group received fluid replacement according to result of PLR combined with TTE. The stroke volume (SV) was measured by TTE before and after PLR, volumetric response of patients was judged by stroke volume variation (SVV). If the SVV≥15%, it was considered that there was a volume responsiveness, and fluid loading was given. If SVV﹤15%, it was considered that there was no volume shortage, and the restrictive fluid replacement was given. The goal of fluid resuscitation in both groups were to simultaneously meet the central venous pressure (CVP) of 8-12 mmHg (1 mmHg = 0.133 kPa), mean arterial pressure (MAP) ≥65 mmHg, urine volume ≥ 0.5 mL·kg-1·h-1, and central venous blood oxygen saturation (ScvO2) ≥ 0.70 within 6 hours. Vasoactive drugs were used when the patients could not achieve the treatment goals. The MAP, lactic acid (Lac), oxygenation index (PaO2/FiO2) and ScvO2 of the patients were determined at 6 hours of treatment, and serum C-reactive protein (CRP) and chest CT were reviewed at 48 hours of treatment, and compared with those before treatment. The total hospital stay and the mortality were recorded. Results There was no significant difference in gender, age, body weight and etiological structure between the two groups, which indicated that the baseline data were generally balanced. There was no statistical difference in MAP, Lac, PaO2/FiO2, ScvO2 and CRP before infusion between the two groups. After 6 hours of treatment, the MAP, Lac, PaO2/FiO2 and ScvO2 of the two groups were all better than those before infusion. Except for the difference in MAP between the experimental group and the control group (mmHg: 78.76±5.22 vs. 76.35±6.66, P > 0.05), the other three parameters in the experimental group were significantly better than those in the control group [Lac (mmol/L): 2.52±1.15 vs. 3.89±1.42, PaO2/FiO2 (mmHg):338.14±27.47 vs. 303.35±22.52, ScvO2: 0.70±0.04 vs. 0.63±0.05, all P < 0.01]. After 48 hours of treatment, CRP levels of both groups were lower than those before infusion, and the experimental group was better than the control group (mg/L: 110.12±39.80 vs. 137.98±31.23, P < 0.01). Chest CT showed that the incidence of pulmonary edema in the experimental group was significantly lower than that in the control group [13.5% (5/37) vs. 37.8% (14/37), P < 0.01]. The hospital stay of the experimental group was shorter than that of the control group (days: 21.47±5.58 vs. 28.33±4.93, P < 0.01), but no significant difference in mortality was found between the two groups [18.9% (7/37) vs. 18.9% (7/37), P > 0.05]. Conclusion Compared with the traditional rapid fluid replacement, early fluid resuscitation treatment strategies guided by the PLR combined with TTE, could better improve perfusion and oxygenation level of tissues and organs, avoid pulmonary edema caused by rapid fluid replacement, shorten the hospital stay in patients with septic shock, but had no significant effect on hospital mortality.
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Objective To evaluate the feasibility of using noninvasive ultrasonic cardiac output monitor USCOM velocity time integral (VTI) as the observation index of PLR.Methods This prospective study recruited 36 septic shock or acute pancreatitis patients from October 2014 to October 2016 in the resuscitation room and EICU of Peking Union Medical College Hospital.The change of VTI and plus pressure before and after PLR (⊿VTIplr and ⊿pp),and the change of VTI and stroke volume before and after 500 mL of volume expansion (⊿VTIve and ⊿SV) were recorded.Fluid response positive was defined as stroke volume increase more than 15％ after volume expansion.Results ⊿VTIplr was positively correlated with ⊿SV (Spearman correlation coefficient r=0.888,P＜0.01).The predicting value of⊿VTIve,⊿VTIplr and ⊿PP in fluid response were as follows:the sensitivity of ⊿VTIve in ＞15％ was 94.7％,the specificity was 94.1％,area under the ROC curve was 0.989;the sensitivity of⊿ VTIplr in ＞12％ was 84.2％,the specificity was 88.2％,area under the ROC curve was 0.916;and the sensitivity of⊿ PP in ＞10.5％ was 78.9％,the specificity was 88.2％,the area under the ROC curve was 0.870.Conclusions ⊿ VTIplr measured by USCOM before and after the PLR is a sensitive and specific index.It is better than the classic index ⊿ PP.⊿ VTIplr measured by USCOM is completely noninvasive,which has very good application prospect in the emergency department.
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Objective To investigate whether the change of cardiac output (CO) with bed head raising (BHR) combined with passive leg raising (PLR) can be used to assess volume overload in critical patients.Methods A prospective observational diagnostic trial was designed. The patients who underwent fluid resuscitation 6 hours or more, and admitted to intensive care unit (ICU) of Meizhou People's Hospital in Guangdong Province from January to December in 2016 were enrolled. Volume overload were identified with the criteria including the increasing of pulmonary rales, the higher levels of N-terminal brain natriuretic peptide (NT-proBNP) and new pulmonary exudates in chest radiograph. CO and heart rate (HR) were monitored with impedance cardiography at supine position and BHR by 30°(BHR30), 60° (BHR60), and PLR in all patients. The changes of CO (?CO30,?CO60,?COPLR) and HR (?HR30,?HR60,?HRPLR) were calculated at different positions. The receiver operating characteristic curve (ROC) was used to evaluate the predictive values of?CO30,?CO60 and combination of?CO60 and?COPLR on volume overload.Results A total of 62 patients were enrolled in this study, with 44 males and 18 females, age of (58.9±15.9) years, a body mass index of (22.7±2.4) kg/m2, and an acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score of 18.7±4.4. The CO of 32 patients with volume overload was significantly increased at BHR30 or BHR60 compared with supine position [?CO30 was (14.5±11.5)%,?CO60 was (26.9±17.5)%, bothP 0.05). There was no consistent change of CO at BHR30 or BHR60 compared with supine position in 30 patients without volume overload,?CO30 was (-3.4±9.1)% (P 0.05), while CO was significantly increased after PLR,?COPLR was (12.4±11.3)% (P < 0.01). There was no significant change of HR after BHR and PLR in patients with volume overload and non volume overload. ROC curve showed that when the cut-off value of ΔCO30≥3.3%, the area under ROC curve (AUC) was 0.903±0.039, the sensitivity was 90.6%, the specificity was 80.0%, and the accuracy was 85.5% for predicting volume overload; when the cut-off value of ΔCO60≥5.6%, the AUC was 0.911±0.036, the sensitivity was 96.9%, the specificity was 73.3%, and the accuracy was 85.5% for predicting volume overload. If volume overload was assessed by the increase of ΔCO60 combining with the decrease of ΔCOPLR, the AUC was 0.928±0.034, the optimal cut-off value for the new combined predictive indicator in predicting volume overload was -0.008, and the sensitivity, specificity, accuracy was 96.9%, 83.3%, 90.3%, respectively, and its evaluation effect is better than the use of ΔCO30 or ΔCO60 alone.Conclusion The change of CO with BHR combined with PLR can be used to accurately evaluate volume overload in patient with critically illness.
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Passive leg raising is widely used in clinic, but it lacks of specialized mechanical raise equipment. It requires medical staff to raise leg by hand or requires a multi-functional bed to raise leg, which takes time and effort. Therefore we have developed a new medical electric leg-raising machine. The equipment has the following characteristics: simple structure, stable performance, easy operation, fast and effective, safe and comfortable. The height range of the lifter is 50-120 cm, the range of the angle of raising leg is 10°-80°, the maximum supporting weight is 40 kg. Because of raising the height of the lower limbs and making precise angle, this equipment can completely replace the traditional manner of lifting leg by hand with multi-functional bed to lift patients' leg and can reduce the physical exhaustion and time consumption of medical staff. It can change the settings at any time to meet the needs of the patient;can be applied to the testing of PLR and dynamically assessing the hemodynamics; can prevent deep vein thrombosis and some related complications of staying in bed; and the machine is easy to be cleaned and disinfected, which can effectively avoid hospital acquired infection and cross infection; and can also be applied to emergency rescue of various disasters and emergencies.
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Objective To investigate the use of PLR induced VTI changes combined with P(cv-a)CO2 in sepsis shock early fluid resuscitation. Methods 54 patients with sepsis shock admitted in Chancheng district central hospital from March 2016 to May 2017 were randomly divided into the treatment group (n=26) and the control group (n=28). The treatment group were monitored by the PLR induced VTI changes combined with P(cv-a)CO2, while the control group were monitored by CVP. The changes of 6 h, 12 h, 24 h, CVP, BNP and LAC levels, the time of vasoactive drugs, the time of mechanical ventilation, ICU hospitalization time and mortality were compared between the two groups. Results There were no statistic difference in fluid infusion within 6h, CVP, BNP, and LAC levels in the two groups; Fluid infusion within 12 h and 24 h, CVP and BNP in the treatment group were lower than those in the control group (P<0.05); the two groups for the treatment of 12 h,24 h plasma, LAC levels were no significant difference; The application time of vasoactive drugs, the time of mechanical ventilation and the length of hospitalization in ICU in the treatment group were shorter than those in the control group (P<0.05); The 28 day mortality was not statistically different between the two groups. Conclusion PLR induced VTI changes combined with P (cv-a) CO2 in septic shock early fluid resuscitation monitoring is superior to CVP, which has the important research significance.
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Objective To investigate whether mixed venous-arterial carbon dioxide difference (Pv-aCO2) combined with passive leg raising (PLR) could better guide volume management for patients post off-pump coronary artery bypass grafting (OPCABG).Methods Eighty patients experienced OPCABG, and admitted to Tianjin Chest Hospital from June 1st to October 1st in 2016 were enrolled. They were randomly divided into two groups: observation group given Pv-aCO2 combined with PLR directed therapy and control group given central venous pressure (CVP) directed therapy, 40 cases in each group. The difference in body temperature (T), heart rate (HR), mean arterial pressure (MAP), CVP, oxygenation index (PaO2/FiO2), mixed venous oxygen saturation (SvO2), Pv-aCO2, blood lactate (Lac), fluid intake, scores of the vasoactive agents at 6 hours post-operation, sequential organ failure assessment (SOFA) of 24 hours, mechanical ventilation time, the length of intensive care unit (ICU) stay, and hospitalization time were compared. The correlation between Pv-aCO2 and cardiac index (CI), Pv-aCO2 and Lac were analyzed by Spearman analysis in observation group.Results The T, HR, MAP, CVP, PaO2/FiO2, SvO2 and Lac at 6 hours post-operation were higher than those at admission in two groups, and Pv-aCO2 were significantly decreased. The SvO2 and fluid intake in observation group were higher than those in control group [SvO2: 0.671±0.068 vs. 0.634±0.052, fluid intake (mL): 454±151 vs. 304±106, bothP < 0.05], Pv-aCO2, Lac and scores of the vasoactive agents were lower than those in control group [Pv-aCO2 (mmHg, 1 mmHg = 0.133 kPa): 6.1±1.8 vs. 7.0±1.8, Lac (mmol/L): 1.7±0.5 vs. 2.8±0.6, scores of the vasoactive agents: 3.18±1.01 vs. 4.48±1.50, allP < 0.05], mechanical ventilation time and the length of ICU stay were less than those in the control group (hours: 16.52±6.41 vs. 21.96±9.00, 45.51±9.36 vs. 51.76±13.66, bothP< 0.05). There was no significant difference in SOFA, hospitalization time between the two groups. There was negative correlation with Pv-aCO2 and CI (r = -0.752,P < 0.01), and no correlation with Pv-aCO2 and Lac (r = -0.154,P = 0.171).Conclusion Pv-aCO2 combined with PLR can better guide volume management in the patients post OPCABG, reduce the usage of vasoactive agents and decrease the mechanical ventilation time and the length of ICU stay.
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Objective To explore the value of predicting fluid responsiveness using velocity time index variation (△VTI) and stroke volume variation (△SV) before and after passive leg raising (PLR)monitored by bedside temporary test equipment (TTE).Methods A cohort of 42 patients supported with mechanical ventilation in our hospital admitted from October 2014 to October 2015 were prospectively selected.The hemodynamic variables including heart rate (HR),mean arterial pressure (MAP),central venous pressure (CVP),VTI,SV and other parameters were monitored before and after after undergoing PLR.Fluid resuscitation volume expansion test was carried out after stroke volume index (SVI) monitored by pulse indicator continuous cardiac output monitoring (PICCO).Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to presence or absence of SVI ≥ 15％ after fluid resuscitation volume expansion.Results Of 42 patients,22 belonged to fluid responsiveness positive group,20 got into fluid responsiveness negative group.There were no significant differences in basic clinical data between two groups.Before and after PLR,there were no distinct changes in HR and CVP (P ＞ 0.05),while MAP,VTI and SV increased significantly (P ＜ 0.05) after PLR in fluid responsiveness positive group.Contrarily,there were no noticeable changes in MAP and SV after PLR (P ＞ 0.05),but HR,CVP and VTI increased significantly (P ＜ 0.05) in fluid responsiveness negative group.The degrees of △VTI and △SV in fluid responsiveness positive group were much higher than those in fluid responsiveness negative group (P ＜0.05).According to SVI ≥ 15％ monitored by PICCO after fluid resuscitation volume expansion test as a standard,the area under the ROC (AUC) of △VTI between prePLR and post-PLR was 0.75 (95％ CI:O.593-0.907,P ＜ 0.01),the sensitivity and specificity were 63.6％ and 95％ respectively using △VTI 15.6％ as threshold value.The AUC of △SV was 0.844 (95％CI:O.716-0.972,P ＜0.01),the sensitivity and specificity were 81.8％ and 85.0％ respectively using △SV 10.5％ as threshold value.Conclusion △VTI and △SV monitored by TTE before and after PLR could be employed for predicting fluid responsiveness of critical patients under the status of spontaneous respiration.Their value for prediction of critical patients could be further improved by combined employment of these two indexes of variation.
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Objective To assess the value of end-tidal carbon dioxide partial pressure (PETCO2) combined passive leg raising (PLR) test on volume responsiveness assessment in shocked patients post cardiac operation.Methods A prospective,self-controlled,and observational study was conducted.The shocked patients post cardiac operation undergoing complete mechanical ventilation admitted to Department of Critical Care Medicine of First Affiliated Hospital of College of Medicine,Zhejiang University from June 2014 to October 2015 were enrolled.PETCO2 and hemodynamic parameters including stroke volume variation (SVV),cardiac index (CI),mean arterial pressure (MAP) monitored by a pulse indicator continuous cardiac output (PiCCO) were determined before and after PLR and volume expansion (VE).Volume responsiveness was defined as an increase in CI (△ CI) of 15％ or greater after VE,namely response group (△ CI ≥ 15％) and non-response group (△ CI ＜ 15％).The value of PLR-induced PETCO2 change (△PETCO2 PLH) to predict volume responsiveness was evaluated by receiver operating.characteristic curves (ROC).Results Among the 41 patients enrolled,21 had volume responsiveness (response group),and 20 had no responsiveness (non-response group).After PLR,the changes in CI and PETCO2 were both significantly increased in the response group compared with non-response group [△ CI:(13.5 ± 4.6)％ vs.(3.6± 3.5)％,△ PETCO2:(7.4 ± 3.4)％ vs.(2.8 ± 2.5)％,both P ＜ 0.05].△ PETCO2 PLR and baseline SVV were positively correlated with PLR-induced CI change (△ CI PLR) (r1 =0.50,r2 =0.38,both P ＜ 0.05).VE-induced PETCO2 change (△ PETCO2 VE),baseline SVV and △ CI PLR were positively correlated with VE-induced CI (△ CI VE) (r1 =0.58,r2 =0.56 and r3 =0.84,all P ＜ 0.01).The area under ROC curve (AUC) of △ PETCO2 PLR was 0.875±0.054 [95％ confidence interval (95％CI) =0.769-0.981,P ＜ 0.05].△ PETCO2 PLR ≥ 5.8％ predicted volume responsiveness with sensitivity of 76.2％ and specificity of 90.0％.AUC of △CI PLR was 0.933±0.036 (95％CI =0.862-1.000,P ＜ 0.05).△CI PLR ≥ 10.4％ predicted volume responsiveness with sensitivity of 81.0％ and specificity of 90.0％.AUC of baseline SVV was 0.831 ±0.066 (95％CI =0.702-0.960,P ＜ 0.05).Baseline SVV ≥ 12.5％ predicted volume responsiveness with sensitivity of 85.7％ and specificity of 75.0％.Conclusion The change in PETCO2 induced by PLR is a convenient,reliable and non-invasive indicator to predict volume responsiveness in shocked patients post cardiac operation with mechanical ventilation.
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Objective Using Doppler ultrasound measured in femoral artery flow velocity variation rate method to predict fluid responsiveness.Methods 80 patients were measured femoral artery flow velocity variation rate (△Vpeak)by mastering the ultrasound skills of the attending physician.Passive leg raising test (PLR)stroke vol-ume variation (△SV)was used to analyze the peak value of the femoral artery flow velocity,rate of femoral artery peak velocity of respiratory changes,and the results were compared with results of PICCO monitoring to predict patients with their response to the treatment capacity,to evaluate clinical feasibility.Results Reactive groups in the PLR test before the experiment and hemodynamic changes:PLR test reaction group in before the test and test process, HR,MAP,CAP index changes were not obvious (P >0.05),but ultrasonic detection and PICCO detection showed SV and CO varied significantly (t =15.24,P =0.00;t =13.64,P =0.00),the two kinds of methods to forecast results was consistent.In the absence of the anti should patients in PLR test before the experiment and hemodynamic chan-ges:PLR test unreacted group in before the test and test process,HR,MAP,CAP,SV and CO index change were not obvious (all P >0.05).Conclusion By ultrasonic method for measuring femoral artery flow speed variation rate can exactly evaluate the capacity status of critically ill patients,and effectively predict fluid responsiveness,the prediction results and PICOO monitoring results are highly consistent.It is a safe and efficient prediction method,which is worthy of promotion in clinical intensive observation.
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Objective To evaluate the role ofpleth variability index (PVI) by passive leg raising (PLR) test in volume responsiveness and volume status prediction in patients with septic shock.Methods A prospective randomized controlled trial (RCT) was conducted.Eighty-seven patients suffering from septic shock undergoing mechanical ventilation in Department of Critical Care Medicine of Subei People's Hospital from June 2012 to September 2014 were enrolled.The hemodynamic changes before and after PLR were monitored by pulse indicated continuous cardiac output (PiCCO) and PVI monitoring.Responsive group:positive fluid response was defined as an increase in cardiac index (CI) ≥ 10％ after PLR.Unresponsive group:negative fluid response was defined as an increase in CI ＜ 10％ after PLR.The hemodynamic parameters,including heart rate (HR),mean arterial pressure (MAP),central venous pressure (CVP),stroke volume variation (SVV),CI and PVI,and the changes in cardiac parameters (△ HR,△ MAP,△ CVP,△ SVV,△ CI,and △ PVI) before and after PLR were determined.The relations between hemodynamic parameters and their changes with △ CI were analyzed by the Pearson analysis.The role of the parameters for volume responsiveness prediction was evaluated by receiver operating characteristic (ROC) curves.Results 145 PLRs in 87 patients with septic shock were conducted,with 67 in responsive group and 78 in unresponsive group.There were no statistically significant differences in HR,MAP,CVP and CI before PLR between the responsive and unresponsive groups.SVV and PVI in responsive group were significantly higher than those in the unresponsive group [SVV:(16.9± 3.1)％ vs.(8.4±2.2) ％,t =9.078,P =0.031; PVI:(20.6±4.3)％ vs.(11.1 ±3.2)％,t =19.189,P =0.022].There were no statistically significant differences in HR,MAP,CVP,SVV,and PVI after PLR between the responsive group and unresponsive group.CI in the responsive group was significantly higher than that in the unresponsive group (mL·s-1·m-2:78.3±6.7 vs.60.0±8.3,t =2.902,P =0.025).There were no statistically significant differences in △HR,△MAP,△ CVP between responsive group and unresponsive group.△ SVV,△ CI and △ PVI in responsive group were significantly higher than those in the unresponsive group [△ SVV:(4.6 ± 1.5)％ vs.(1.8 ± 0.9)％,t =11.187,P =0.022;△ CI (mL·s-1·m-2):18.3 ± 1.7 vs.1.7 ± 0.5,t =3.696,P =0.014; △ PVI:(6.4 ± 1.1)％ vs.(1.3 ± 0.2)％,t =19.563,P =0.013].No significant correlation between HR,MAP or CVP before PLR and △ CI was found.SVV (r =0.850,P =0.015) and PVI (r =0.867,P =0.001) before PLR were correlated with △ CI.It was shown by ROC curve that the area under ROC curve (AUC) for SVV fluid responsiveness prediction was 0.948,and cut-off of SVV was 12.4％,the sensitivity was 85.4％,and specificity was 86.6％.The AUC for PVI fluid responsiveness prediction was 0.957,and cut-off was 14.8％,the sensitivity was 87.5％,and specificity was 84.8％.It was higher than other hemodynamic parameters (HR,MAP,CVP).Conclusions PVI and SVV can better predict fluid responsiveness in mechanically ventilating patients with septic shock after PLR.PVI as a new continuous,noninvasive and functional hemodynamic parameter has the same accuracy as SVV.
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ObjectiveTo assess the value of passive leg raising (PLR) test in predicting fluid responsiveness in patients with sepsis-induced cardiac dysfunction.Methods A prospective observational cohort study was conducted. Thirty-eight patients under mechanical ventilation suffering from sepsis-induced cardiac dysfunction admitted to Department of Surgical Intensive Care Unit of First Affiliated Hospital of Sun Yat-Sen University from September 2013 to July 2014 were enrolled. The patients were studied in four phases: before PLR (semi-recumbent position with the trunk in 45°), PLR (the lower limbs were raised to a 45° angle while the trunk was in a supine position), before volume expansion (VE, return to the semi-recumbent position), and VE with infusing of 250 mL 5% albumin within 30 minutes. Hemodynamic parameters were recorded in every phase. The patients were classified into two groups according to their response to VE: responders (at least a 15% increase in stroke volume,ΔSVVE≥15%), and non-responders. The correlations among all changes in hemodynamic parameters were analyzed by linear correlation analysis, and the receiver operating characteristic curve (ROC) was plotted to assess the value of hemodynamic parameters before and after PLR in predicting fluid responsiveness.Results Of 38 patients, 25 patients were responders, and 13 non-responders. There was no significant difference in the baseline and hemodynamic parameters at semi-recumbent position between the two groups. The changes in SV and cardiac output (CO) after PLR (ΔSVPLR andΔCOPLR) were significantly higher in responders than those of non-responders [ΔSVPLR: (14.7±5.7)%vs. (6.4±5.3)%,t = 4.304,P = 0.000;ΔCOPLR: (11.2±7.5)% vs. (3.4±2.3)%,t = 3.454,P = 0.001], but there was no significant difference in the changes in systolic blood pressure, mean arterial pressure, pulse pressure, and heart rate after PLR (ΔSBPPLR,ΔMAPPLR,ΔPPPLR andΔHRPLR) between two groups.ΔSVVE in responders was significantly higher than that of the non-responders [(20.8±5.5) % vs. (5.0±3.7) %,t = 8.347,P = 0.000]. It was shown by correlation analysis thatΔSVPLR was positively correlated withΔSVVE (r = 0.593,P = 0.000),ΔCOPLR was positively correlated withΔSVVE (r = 0.494,P = 0.002). The area under ROC curve (AUC) ofΔSVPLR≥8.1% for predicting fluid responsiveness was 0.860±0.062 (P = 0.000), with sensitivity of 92.0% and specificity of 70.0%; the AUC ofΔCOPLR≥5.6% for predicting fluid responsiveness was 0.840±0.070 (P = 0.000), with sensitivity of 84.0%and specificity of 76.9%; the AUC ofΔMAPPLR≥6.9% for predicting fluid responsiveness was 0.662±0.089, with sensitivity of 68.0% and specificity of 76.9%; the AUC ofΔSBPPLR≥6.4% for predicting fluid responsiveness was 0.628±0.098, with sensitivity of 76.0% and specificity of 61.5%; the AUC ofΔPPPLR≥6.2% for predicting fluid responsiveness was 0.502±0.094, with sensitivity of 56.0% and specificity of 53.8%; the AUC ofΔHRPLR≥-1.7%for predicting fluid responsiveness was 0.457±0.100, with sensitivity of 56.0% and specificity of 46.2%.Conclusion In patients with sepsis-induced cardiac dysfunction, changes in SV and CO induced by PLR are accurate indices for predicting fluid responsiveness, but the changes in HR, MAP, SBP and PP cannot predict the fluid responsiveness.
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Objective To discuss the clinical significance of fluid management of severe patients according to arterial pressure-based cardiac output (APCO) monitoring volume responsiveness index.Methods A retrospective cohort study was conducted.The severe patients were selected from the intensive care unit (ICU) of the First Hospital of Jilin University from June 1st,2012 to December 31st,2013.The hemodynamic parameters were monitored by APCO,and the fluid resuscitation was managed by stroke volume variation (SVV) and passive leg-raising test (PLR) when the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score ≥ 15,heart rate ＞ 100 bpm with the result that the preload and heart function could not be evaluated.The heart rate,SVV,lactic acid (Lac) and central venous pressure (CVP) and curative effect were recorded before and after carrying out fluid management strategy.The criteria of clinical effective was defined as heart rate decreased and (or) stroke volume (SV) increased ≥ 10％,accompanied by blood Lac and SVV decreased,other than,the cases did not meet above criteria were considered ineffective.Results Sixty-eight patients were enrolled in the study.① Before carrying out fluid management strategy:40 cases with CVP＞ 12 cmH2O (1 cmH2O=0.098 kPa),and 16 cases with 5-12 cmH2O,12 with ＜5 cmH2O.SVV＞13％ in 35 cases,SVV ＜ 13％ in 9 cases.PLR positive in 18 cases,and PLR negative in 6 cases.It was implicated that the patients with poor preload (SVV ＞ 13％ and PLR positive) accounted by 77.9％ (53/68).② There were 49 effective cases and 19 ineffective cases 4 hours after carrying out fluid management strategy,and the effective rate was 72.06％ (49/68).While there were 56 effective cases and 12 ineffective cases after 12 hours,and the total effective rate was 82.35％ (56/68).③ In effective group,heart rate,SVV,Lac after fluid management strategy were significantly lower than those before fluid management strategy [4 hours after fluid management strategy:heart rate (bpm) 112.45 ± 13.53 vs.129.55 ± 15.49,SVV (15.47 ± 6.32)％ vs.(21.20 ± 7.40)％,Lac (mmol/L) 4.16 ± 3.12 vs.6.21 ± 4.11 ; 12 hours after fluid management strategy:heart rate (bpm) 110.02 ± 13.92 vs.129.61 ± 14.93,SVV (14.61 ± 15.52)％ vs.(20.66 ± 7.40)％,Lac (mmol/L) 3.35 ± 2.26 vs.6.11 ± 4.02,P＜0.05 or P＜0.01],while there was no significant difference in those markers between before and after fluid management strategy in ineffective group [4 hours after fluid management strategy:heart rate (bpm) 119.53 ± 11.68 vs.125.79 ± 11.58,SVV (16.95 ±6.48)％ vs.(18.47 ±4.96)％,Lac (mmol/L) 5.55 ± 3.80 比 6.54 ± 3.72 ; 12 hours after fluid management strategy:heart rate (bpm) 115.92 ± 11.71 vs.123.40 ± 11.59,SVV (17.17 ± 6.09)％ vs.(19.42 ± 8.25)％,Lac (mmol/L) 6.33 ± 3.40 vs.7.21 ± 3.81,all P＞ 0.05].CVP only at 12 hours after fluid management strategy in effective group was significantly higher than that before fluid management strategy (cmH2O:12.88 ± 3.38 vs.11.27 ± 4.97,P＜0.05).Conclusion SVV monitored by APCO is a good indicator of volume responsiveness index,which can be used as an important reference combined with PLR for fluid management of severe patients.
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Objective To evaluate the value of PLR-△SVV for the septic shock patients with autonomous breathing. Methods 60 patients were included in the study. Hemodynamic data of PICCO were collected before and after treatment. After rehydration, the group (△SV≥10%) was defined volume responder group, and then the predictive value of PLR-△SVV was analyzed. Results Compared with the nonresponders group, PLR-△SVV was increased significantly in response group[(10 ± 4)mL vs (14 ± 6)mL,P<0.05]. The ROC curve for PLR-△SVV were 0.881, and the sensitivity was 85.7%, the specificity was 92.0%. Conclusion PLR-△SVV can be used to predict fluid responsiveness for septic shock patients with spontaneously breathing.
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Objective To compare the procotol of EGDT +Pt (cv-a ) CO2 with EGDT in fluid resuscitation and management after evaluate fluid responsiveness in shock patients by Vigileo and passive leg raising test.Metheds Prospectively collect patients who meet the criteria between 2013.5.1-2013.1 1.30 in our ICU.Randomly (random number)divided into Vigileo group (first evaluate the fluid responsiveness then give EGDT +Pt (cv-a) CO2 ) and CVP group (give EGDT).Compare the hospital mortality and morbility of MODS,the volume given in the first 6 hours and the first 7 days,consume of blood products , the ICU and hospital stay.Results Collected 46 patients,Vigileo group (21 )and CVP group (25 ). There’s no significant difference between groups at baseline.In the first 6 hours the CVP group had received more fluids (3656.281678.57 vs. 2639.141326.59 ) mL, P =0.03;and more blood products (573.00172.57 vs. 190.4770.82)mL,P=0.04,respictivily.Vigileo group significantly short the ICU stay ,(6.384.34 vs. 12.165.77)d,P=0.04.But there’s no significant difference in hospital motality and the morbility of MODS.The ROC of Age ,the accumulative volume of balance in 7 days,APACHEⅡscore in the first day to predict death is 0.84 (0.68-0.99)、0.82 (0.69-0.95)、0.80 (0.66-0.94),all P>0.05,respectively.By 7 days the accumulative volume of balance 3454.51mL as cutoff to predict death with the sensitivity of 0.67,specificity of 0.84.Conclusions 1.Given EGDT +Pt (cv-a) CO2 after evaluate the fluid responsiveness can reduce fluid and blood products given in the first 6 hours,significantly short the ICU stay,without worsen the tissue flow or increase the morbility of MODS;2.Consecutive positive fluid balance is a risk factor about poor prognosis,and also a sensitive indicator to predict death.