【罂粟摘要】肺保护性通气的小儿患者应用肺复张策略后液体反应性预估：一项前瞻性观察研究
中文摘要 肺保护性通气的小儿患者应用肺复张策略后液体反应性预估：一项前瞻性观察研究 贵州医科大学 高鸿教授课题组 翻译：佟睿 编辑：佟睿 审校：曹莹 01 基于压力的动态变化性，小儿的液体反应性并不很好预估，在低潮气量肺保护性通气期间，其可预测性可能会进一步降低。 我们假设肺复张策略(LRM)引起的动态变量的改变提高了预测小儿体液反应性的能力。 前瞻性观察研究。 三级护理儿童医院，时间在2017年6月到2019年5月的单中心研究。 我们纳入了7岁以下的接受心脏手术的小儿患者。排除新生儿和其中患肺动脉高压、明显心律失常、心室射血分数<30%或存在肺部疾病的患者。 所有患者均给予肺保护性容量控制通气(潮气量6ml·kg-1，呼气末正压6cmH2O)。LRM正压气道压为25cmH2O，持续20s。 通过受试对象术中特征曲线下面积(AUC)评价动态变量预测液体反应性的能力。液体反应性定义为给予晶体(10ml·kg-1)时心指数增加15%以上。 30名患者进入最终分析，其中19名有阳性反应。基础的脉搏变异性指数(PVI)(AUC 0.794，95%CI 0.608~0.919，P<0.001)和LRM引发的PVI(AUC 0.711，95%CI 0.517~0.861，P=0.026)可以预测液体反应性。无论是否进行LRM，脉搏血氧饱和度、光容积图波形和脉压变化的呼吸变化不能预测液体反应性。 无论是否进行LRM，PVI都可以有效地预测接受肺保护性通气的小儿患者的液体反应性。然而，LRM并没有提高其他动态变量预测这些患者体液反应性的能力。 Prediction of fluid responsiveness using lung recruitment manoeuvre in paediatric patients receiving lung-protective ventilation: A prospective observational study Abstract BACKGROUND Pressure-based dynamic variables are poor predictors of fluid responsiveness in children, and their predictability is expected to reduce further during lung-protective ventilation with a low tidal volume. OBJECTIVE We hypothesised that lung recruitment manoeuvre (LRM)-induced changes in dynamic variables improve their ability to predict fluid responsiveness in children. DESIGN Prospective observational study. SETTING Tertiary care children’s hospital, single-centre study performed from June 2017 to May 2019. PATIENTS We included patients less than 7 years of age undergoing cardiac surgery. Neonates and patients with pulmonary hypertension, significant dysrhythmia, ventricular ejection fraction of less than 30% or pulmonary disease were excluded. INTERVENTION All patients were provided with lung-protective volume-controlled ventilation (tidal volume 6 ml kg-1, positive end-expiratory pressure 6 cmH2O). A LRM was applied with a continuous inspiratory pressure of 25 cmH2O for 20 s. MAIN OUTCOME MEASURE The ability of dynamic variables to predict fluid responsiveness was evaluated by the area under the receiver operating characteristic curve [area under the curve (AUC)]. Fluid responsiveness was defined as an increase in the cardiac index by more than 15% with crystalloid administration (10 ml kg-1). RESULTS Thirty patients were included in the final analysis, of whom 19 were responders. The baseline pleth variability index (PVI) (AUC 0.794, 95% confidence interval 0.608 to 0.919, P<0.001) and LRM-induced PVI (AUC 0.711, 95% confidence interval 0.517 to 0.861, P=0.026) could predict fluid responsiveness. The respiratory variation of pulse oximetry photoplethysmographic waveform and pulse pressure variation did not predict fluid responsiveness regardless of the LRM. CONCLUSION The PVI is effective in predicting fluid responsiveness in paediatric patients with lung-protective ventilation regardless of a LRM. However, the LRM did not improve the ability of the other dynamic variables to predict fluid responsiveness in these patients. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier: NCT03184961.