背景:在机械通气患者中,呼气末正压(PEEP)可以通过减少心脏前负荷和/或增加右心室后负荷来减少心输出量。通过液体给药或被动抬腿(PLR)增加中心血容量可以通过增加心脏预负荷和/或重新开放封闭的肺微血管来逆转这些现象。我们假设PEEP的瞬时降低(PEEP测试)可以用作检测容量响应性的测试。
方法:前瞻性纳入PEEP≥10cmH2O(“高水平”)且无自主呼吸的机械通气患者。容量反应性通过阳性PLR测试评估,定义为PLR≥10%期间脉搏轮廓衍生心脏指数(CI)增加。PEEP测试包括将PEEP从高水平降低至5cmH2O持续1分钟。在PLR和PEEP测试期间监测脉冲轮廓衍生的CI(PiCCO2)。
结果:我们招募了64名患者,其中31名具有容量反应。PLR期间CI的中位数增加为14%(11-16%)。基线时的PEEP中位数为12(10-15)cmH2O,PEEP测试导致PEEP中位数降低7(5-10)cmH2O,容量敏感和无反应患者之间没有差异。在容量敏感的患者中,与容量无反应的患者相比,PEEP测试导致CI显著增加16%(12-20%)(从2.4±0.7到2.9±0.9L/min/m2,p<0.0001)。在容量反应迟钝的患者中,PLR和PEEP测试将CI提高了2%(1-5%)和6%(3-8%),分别。通过PEEP测试期间CI>8.6%的增加来预测体积反应性,灵敏度为96.8%(95%置信区间(95CI):83.3-99.9%),特异性为84.9%(95CI68.1-94.9%)。用于检测容量响应性的PEEP测试的受试者工作特征曲线下面积为0.94(95CI0.85-0.98)(p<0.0001vs.0.5).PLR引起的CI变化与PEEP检验之间的Spearman相关系数为0.76(95CI0.63-0.85,p<0.0001)。
结论:PEEP测试期间ACI增加>8.6%,包括将PEEP降低到5cmH2O,可靠地检测PEEP≥10cmH2O的机械通气患者的容量反应性。试验注册ClinicalTrial.gov(NCT04,023,786)。2019年7月18日注册。伦理委员会批准CPPEstIII(N°2018-A01599-46)。
In patients on mechanical ventilation, positive end-expiratory pressure (PEEP) can decrease cardiac output through a decrease in cardiac preload and/or an increase in right ventricular afterload. Increase in central blood volume by fluid administration or passive leg raising (PLR) may reverse these phenomena through an increase in cardiac preload and/or a reopening of closed lung microvessels. We hypothesized that a transient decrease in PEEP (PEEP-test) may be used as a test to detect volume responsiveness.
Mechanically ventilated patients with PEEP ≥ 10 cmH2O (\"high level\") and without spontaneous breathing were prospectively included. Volume responsiveness was assessed by a positive PLR-test, defined as an increase in pulse-contour-derived cardiac index (CI) during PLR ≥ 10%. The PEEP-test consisted in reducing PEEP from the high level to 5 cmH2O for one minute. Pulse-contour-derived CI (PiCCO2) was monitored during PLR and the PEEP-test.
We enrolled 64 patients among whom 31 were volume responsive. The median increase in CI during PLR was 14% (11-16%). The median PEEP at baseline was 12 (10-15) cmH2O and the PEEP-test resulted in a median decrease in PEEP of 7 (5-10) cmH2O, without difference between volume responsive and unresponsive patients. Among volume responsive patients, the PEEP-test induced a significant increase in CI of 16% (12-20%) (from 2.4 ± 0.7 to 2.9 ± 0.9 L/min/m2, p < 0.0001) in comparison with volume unresponsive patients. In volume unresponsive patients, PLR and the PEEP-test increased CI by 2% (1-5%) and 6% (3-8%), respectively. Volume responsiveness was predicted by an increase in CI > 8.6% during the PEEP-test with a sensitivity of 96.8% (95% confidence interval (95%CI): 83.3-99.9%) and a specificity of 84.9% (95%CI 68.1-94.9%). The area under the receiver operating characteristic curve of the PEEP-test for detecting volume responsiveness was 0.94 (95%CI 0.85-0.98) (p < 0.0001 vs. 0.5). Spearman\'s correlation coefficient between the changes in CI induced by PLR and the PEEP-test was 0.76 (95%CI 0.63-0.85, p < 0.0001).
A CI increase > 8.6% during a PEEP-test, which consists in reducing PEEP to 5 cmH2O, reliably detects volume responsiveness in mechanically ventilated patients with a PEEP ≥ 10 cmH2O. Trial registration ClinicalTrial.gov (NCT 04,023,786). Registered July 18, 2019. Ethics Committee approval CPP Est III (N° 2018-A01599-46).