| Part I Comparative studies on fluid responsiveness evaluation of ultrasound dynamic and a variety of traditional hemodynamic monitoring indexesPurpose:To compare the consistence of transthoracic echocardiography (TTE) and B-type natriuretic peptide (BNP), central venous pressure (CVP), pulse indicator continuous cardiac output monitoring (PICCO).Methods:We prospectively selected 46 patients with mechanical ventilation in our hospital from June 2012 to January 2014, measuring BNP, CVP, and placing PICCO device to monitor stroke volume variation (SVV) and global end diastolic volume index (GEDVI), and using bedside hand-carried ultrasound to measure SVV and the dispensability index of the inferior vena cava (dIVC). Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to the increase of stroke volume index (SVI)≥15% monitored by PICCO after fluid infusion. ROC curve analysis evaluated the value of the fluid responsiveness and the consistence of different methods to predict the fluid responsiveness.Results:Of the forty six patients, twenty-four patients belonged to fluid responsiveness positive group, twenty-two patients belonged to fluid responsiveness negative group. ROC curve showed that area under curve (AUC) of BNP was 0.894 (95%CI:0.807～0.981,P<0.01), the sensitivity and specificity were 81.8% and 79.2% respectively using BNP 157.5 ng/L before fluid resuscitation volume expansion as threshold value. The AUC of CVP was 0.859 (95%CI:0.752～0.965, P<0.01), the sensitivity and specificity were 81.8% and 79.2% respectively using CVP7.5 mmHg before fluid resuscitation volume expansion as threshold value. The AUC of GEDVI measured by PICCO was 0.772 (95%CI:0.628-0.915, P<0.01), the sensitivity and specificity were 72.7% and 75% respectively using GEDVI 549 mL/m2 before fluid resuscitation volume expansion as threshold value. The AUC of SVV measured by PICCO was 0.965 (95%CI:0.922～1.008, P<0.001), the sensitivity and specificity were 95.8% and 81.8% respectively using SVV10.5% before fluid resuscitation volume expansion as threshold value. The AUC of SVV measured by TTE was 0.940 (95%CI: 0.874-1.006, P<0.001), the sensitivity and specificity were 91.7% and 86.4% respectively using SVV 11.7% before fluid resuscitation volume expansion as threshold value. The AUC of △subaortic velocity time index (VTI) measured by TTE was 0.958 (95%CI:0.909～1.008, P<0.001), the sensitivity and specificity were 87.5% and 90.9% respectively using AVTI 16.7% before fluid resuscitation volume expansion as threshold value. The AUC of dIVC measured by TTE was 0.964 (95%CI: 0.920-1.008, P<0.001), the sensitivity and specificity were 83.3% and 95.5% respectively using dIVC14.0% before fluid resuscitation volume expansion as threshold value. Kappa test consistency analysis revealed the Kappa coefficient of △VTI measured by TTE and SVV measured by PICCO were 0.743, P<0.001 and 0.826, P<0.001, respectively. Using Bland-Altman analysis to detect the consistency of SVV results measured by PICCO and TTE, demonstrated that the both had a good consistency (mean deviation 0.2093,95%CI:-2.967-3.385, P<0.05). Conclusion:The values of the assessment of fluid responsiveness using SVV, △VTI, dIVC measured by TTE were better than BNP and CVP. And these indexes had a good consistency as PICCO monitoring.Part Ⅱ The application of bedside ultrasonic combined with passive leg raising in fluid responsiveness evaluation of critical patientsPurpose:To explore the value of predicting fluid responsiveness using △VTI and △SV before and after passive leg raising (PLR) measured by bedside TTE.Methods:We prospectively selected 46 patients with mechanical ventilation in our hospital from October 2014 to June 2015, monitoring heart rate (HR), mean arterial pressure (MAP), CVP, VTl, SV and other hemodynamic parameters, monitoring these indexes again after undergoing PLR. Fluid resuscitation volume expansion test was carried out after SVI monitored by PICCO. Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to SVI whether or not≥15% after fluid resuscitation volume expansion.Results:Of the forty four patients, twenty-two patients belonged to fluid responsiveness positive group, twenty patients belonged to fluid responsiveness negative group. Comparing the basic clinical indexes, there was no difference between two groups. Before and after PLR, HR and CVP had no differences (P>0.05), MAP, VTI and SV increased significantly (P<0.05) in fluid responsiveness positive group. Whereas, MAP and SV had no differences (P>0.05), HR, CVP and VTI increased significantly (P<0.05) in fluid responsiveness negative group. △VTI and △SV of fluid responsiveness positive group were higher significantly than fluid responsiveness negative group (P<0.05). According to SVI> 15% monitored by PICCO after fluid resuscitation volume expansion test as the standard, the AUC of △VTI before and after PLR was 0.75 (95%CI:0.593～0.907, P<0.001), 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:0.716-0.972, P<0.001), 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 applied to predict fluid responsiveness of critical patients under the status of spontaneous respiration. Combined application of the two indexes could further improve the value.Part III Effects of different levels of intra-abdominal pressure on the ability of the application of ultrasound and PiCCO to determine the fluid responsivenessPurpose:To evaluate the effects of intra-abdominal pressure (IAP) on TTE and PICCO monitoring the fluid responsiveness of patients with mechanical ventilation.Methods:We prospectively selected 46 patients with mechanical ventilation in our hospital from January 2013 to June 2015, measuring IAP through routine urinary bladder, recording pressure, PiCCO monitoring, recording GEDVI, SVV, SVI and other indexes, meanwhile measuring maximum diameter of inferior vena cava (IVCdmax) and dVIC via bedside ultrasonic. After fluid resuscitation volume expansion test, patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to the increase of SVI≥15%. And according to the value of IAP, these patients were divided into A group (IAP<15mmHg) and B group (IAP>15mmHg). ROC curve analyzed the values of predicting fluid responsiveness using GEDVI, SVV monitored by PICCO and IVCdmax, dIVC measured by TTE, and compared the results obtained by the two methods.Results:Of the eighty six patients, forty-one patients (A group:21 cases, B group:20 cases) belonged to fluid responsiveness positive group, forty-five patients belonged to fluid responsiveness negative group (A group:22 cases, B group:23 cases). In A group, the AUC of SVV measured by PICCO was 0.921 (95%CI:0.842～1, P<0.01) and the sensitivity, specificity were 85.7% and 85% respectively using SVV12.5% before fluid resuscitation volume expansion as threshold value. The AUC of GEDVI measured by PICCO was 0.918 (95%CI:0.838-0.997, P<0.01), the sensitivity and specificity were 70% and 93.2% respectively using GEDVI 1574.5 mL/m2 before fluid resuscitation volume expansion as threshold value. The AUC of dIVC measured by TTE was 0.908 (95%CI:0.811～1, P<0.001), the sensitivity and specificity were 100% and 80% respectively using dIVC 12.64% before fluid resuscitation volume expansion as threshold value. The AUC of IVCdmax measured by TTE was 0.87 (95%CI: 0.761-0.979, P<0.001), the sensitivity and specificity were 70% and 93.2% respectively using IVCdmax 1.825cm before fluid resuscitation volume expansion as threshold value. In B group, the AUC of SVV was 0.984 (95%CI:0.956-1, P<0.01), the sensitivity and specificity were 95.5% and 95.7% respectively using SVV21.5% before fluid resuscitation volume expansion as threshold value. The AUC of GEDVI was 0.931 (95%CI:0.862-0.999, P<0.01), the sensitivity and specificity were 95.7% and 77.3% respectively using GEDVI 1566 mL/m2 before fluid resuscitation volume expansion as threshold value. The AUC of dIVC measured by TTE was 0.887 (95% CI: 0.793～0.982, P<0.001), the sensitivity and specificity were 81.8% and 82.6% respectively using dIVC 8.97% before fluid resuscitation volume expansion as threshold value. The AUC of IVCdmax measured by TTE was 0.817 (95%CI:0.697-0.938, P<0.001), the sensitivity and specificity were 73.9% and 77.3% respectively using IVCdmax2.25 cm before fluid resuscitation volume expansion as threshold value. In this group, IAP increased, IVCdmax and SVV raised significantly, dIVC decreased obviously and GEDV1 had no significantly change.Conclusion:The increase of IAP had effects on the fluid responsiveness evaluated by the indexes of IVCdmax, dIVC measured by TTE and SVV, GEDV1 monitored by PICCO. The indexes above could be used to evaluate the fluid responsiveness under high IAP status after adjusting threshold.Part IV Effects of positive end-expiratory pressure on inferior vena cava diameter and the dispensability index of the inferior vena cava of patients with mechanical ventilation measured by ultrasonicPurpose:To explore the effects of positive end-expiratory pressure (PEEP) on the evaluation of the fluid responsiveness via IVC and dIVC monitored by bedside TTE.Methods:We prospectively selected 40 patients with mechanical ventilation, when PEEP=0, measuring and calculating IVCdmax, IVCdmin and dIVC using bedside hand-carried ultrasound. Patients were divided into fluid responsiveness positive group and fluid responsiveness negative group according to the increase of cardiac output (CO)≥15% after fluid resuscitation volume expansion test. The value of the fluid responsiveness was predicted via ROC curve analysis of IVCdmax and dlVC. Then setting PEEP as 5,10,15 cmH2O, measuring and calculating IVCdmax and dIVC, and we analyzed the relevance of the indexes above and PEEP, variation trend of different PEEP values.Results:Of 40 patients, twenty-two patients belonged to fluid responsiveness positive group, eighteen patients belonged to fluid responsiveness negative group. The AUC of ax measured by TTE was 0.85 (95%CI:0.79-0.91, P<0.001), the sensitivity and specificity were 68.1% and 94.3% respectively using IVCdmax 2.03 cm before fluid resuscitation volume expansion as threshold value. The AUC of dlVC was 0.95 (95%C1: 0.91-0.98, P<0.001), the sensitivity and specificity were 80.7% and 98.6% respectively using dIVC 12.4% before fluid resuscitation volume expansion as threshold value. In fluid responsiveness positive group, with PEEP increasing, there were overall differences among groups about Ppeak, Pmcan, CO, and dlVC (P< 0.05). IVCdmax increasing with PEEP, there were no significant differences in comparison among groups (P>0.05), while there were significant differences in linear trend (P<0.01). There were positive correlation between PEEP and CO (r=-0.59, P=0.000), IVCdmax (r=0.35,P=0.001) and dIVC (r=-0.59,P=0.000). In fluid responsiveness negative group, with PEEP increasing, there were overall differences among groups about Ppeak, Pmcan, and CO (P<0.05). IVCdmax increasing with PEEP, there were no significant differences in comparison among groups (P> 0.05), while there were significant differences in linear trend (P< 0.05). dlVC increasing with PEEP, there were no significant differences in comparison among groups and linear trend (P>0.05). There are positive correlation between PEEP and the CO (r=-0.54, P=0.000), IVCdmax (r=0.28, P=0.019), and no relevance between PEEP and dlVC (r=-0.04, P=0.771).Conclusion:The indexes, IVCdmax and dIVC measured by bedside ultrasound, could be applied to evaluate the fluid responsiveness of patients, and the prediction value of dlVC was higher. PEEP could influence these two indexes, especially fluid responsiveness positive group. |
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