留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

改良重症超声快速管理方案对非计划入ICU患者的评估价值

赵华 王小亭 刘大为 中国重症超声研究组

赵华, 王小亭, 刘大为, 中国重症超声研究组. 改良重症超声快速管理方案对非计划入ICU患者的评估价值[J]. 协和医学杂志, 2018, 9(5): 437-444. doi: 10.3969/j.issn.1674-9081.2018.05.012
引用本文: 赵华, 王小亭, 刘大为, 中国重症超声研究组. 改良重症超声快速管理方案对非计划入ICU患者的评估价值[J]. 协和医学杂志, 2018, 9(5): 437-444. doi: 10.3969/j.issn.1674-9081.2018.05.012
Hua ZHAO, Xiao-ting WANG, Da-wei LIU, Chinese Critical Ultrasound Study Group. Evaluating Value of Modified Critical Care Ultrasonic Examination Protocol for the Patients Unplanned Admission to the ICU[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(5): 437-444. doi: 10.3969/j.issn.1674-9081.2018.05.012
Citation: Hua ZHAO, Xiao-ting WANG, Da-wei LIU, Chinese Critical Ultrasound Study Group. Evaluating Value of Modified Critical Care Ultrasonic Examination Protocol for the Patients Unplanned Admission to the ICU[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(5): 437-444. doi: 10.3969/j.issn.1674-9081.2018.05.012

改良重症超声快速管理方案对非计划入ICU患者的评估价值

doi: 10.3969/j.issn.1674-9081.2018.05.012
详细信息
    通讯作者:

    刘大为  电话:010-69152300, E-mail:dwliu98@163.com

  • 中图分类号: R459.7, R445.1

Evaluating Value of Modified Critical Care Ultrasonic Examination Protocol for the Patients Unplanned Admission to the ICU

More Information
    Corresponding author: LIU Da-wei    Tel:010-69152300, E-mail:dwliu98@163.com
  • 摘要:   目的  探讨改良重症超声快速管理(modified critical care ultrasonic examination,M-CCUE)方案对非计划入ICU患者的评估价值,并分析其是否会影响医疗行为及预后判断。  方法  回顾性收集并分析2015年12月至2016年6月北京协和医院重症医学科非计划收治患者的相关临床资料,包括血流动力学指标、器官及组织灌注指标和预后评价指标。所有入选患者在入室30 min内完成初始M-CCUE评估,根据M-CCUE评分系统予以评分(M-CCUE score,MCS)。分析MCS与预后的相关性及对治疗策略的影响。  结果  共计272例符合入选和排除标准的非计划入ICU患者纳入本研究,其中仅3例(1.1%,3/272)患者在M-CCUE评估方案中未发现异常,139例(51.1%,139/272)因评估结果改变了药物治疗方案,81例(29.8%,81/272)进行了有创检查或治疗。MCS与患者28 d死亡率(r=0.432,P=0.020)、48 h死亡率(r=0.594,P=0.008)、机械通气时间(r=0.454,P=0.040)、ICU住院时间(r=0.563,P=0.003)均呈正相关。多因素回归分析显示,年龄、急性生理与慢性健康状况评分Ⅱ(acute physiology and chronic health evaluation Ⅱ,APACHE Ⅱ)、MCS和序贯性器官衰竭评分(sequential organ failure assessment,SOFA)是28 d死亡的独立危险因素,同时年龄、MCS和SOFA是48 h死亡的独立危险因素。  结论  M-CCUE能够实现早期床旁心肺功能评估,其量化评估结果可改进临床治疗方案,预测患者预后。
  • 图  1  M-CCUE方案重症心脏超声图像

    A.下腔静脉;B.剑突下四腔心;C.心尖四腔心切面; D.胸骨旁短轴; E.胸骨旁长轴; M-CCUE:改良重症超声快速管理方案

    图  2  M-CCUE方案重症肺部超声定位

    A.上蓝点、M点、膈肌点、PLAPS点;B.双侧后蓝点M-CCUE:同图 1

    表  1  M-CCUE评分标准

    超声部分 超声表现正常 超声表写异常
    左肺 0分 1分/项
        上蓝点 A B/C/P
        M点 A B/C/P
        膈肌点 A B/C/P
        PLAPS点 A B/C/P
        后蓝点 A B/C/P
        得分
    右肺 0分 1分/项
        上蓝点 A B/C/P
        M点 A B/C/P
        膈肌点 A B/C/P
        PLAPS点 A B/C/P
        后蓝点 A B/C/P
        得分
    明显心脏异常 0分 2分/项
        大量心包积液
        心包堵塞
        新的瓣膜毁损
        得分
    右心功能 0分 1分/项 2分/项
        室间隔形态 正常运动 室间隔抖动 矛盾运动
        右室室壁增厚 -
        右心室/左心室比例 <0.6 0.6~1.0 >1.0
        三尖瓣瓣环收缩期位移(cm) >1.8 ≤1.8 -
        得分
    左室功能
      左室收缩功能 0分 0.5分/项 1分/项 1.5分/项 2分/项
        LVEF (%) 51~57 >70 30~50 11~29 <10
        二尖瓣瓣环收缩期位移(cm) >1.2 - ≤1.2
      左室舒张功能 0分 - 1分/项 - -
        LVEF<50% - - -
        左室室壁增厚 - - -
        左房增大 - - -
      得分
    容量状态 0分 2分/项
        下腔静脉直径(cm) 1.5~2.0(机械通气) <1.5或2.0(机械通气)
    1.0~2.0(非机械通气) <1.0或2.0(非机械通气)
        下腔静脉直径呼吸变异度(%) <18(机械通气) ≥18(机械通气)
    <50(非机械通气) ≥50(非机械通气)
        得分
    总评分
    M-CCUE:同图 1
    下载: 导出CSV

    表  2  非计划入ICU患者入室后30 min内血流动力学参数

    参数 结果
    心率(x ±s, 次/分) 110±3 2
    平均动脉压(x±s, mm Hg) 62 ±21
    氧合指数(x±s) 176± 46
    机械通气/非机械通气(n) 221/51
    呼气末正压(x±s, cm H2o) 10± 6
    机械通气时间[M(Q), d] 4.2(0.9, 24)
    ICU住院时间[M(Q), d] 11(5, 19)
    住院时间[M(Q), d] 24(10, 28)
    血管活性药物使用时间[M(Q), h] 67(31, 197)
    28d死亡率(%) 17.6(48/272)
    48h死亡率(%) 13.6(36/272)
    下载: 导出CSV

    表  3  非计划入ICU患者病情评分与预后的相关性

    评分项目 28d死亡率 48h死亡率 机械通气时间(d) ICU住院时间(d)
    r p r p r p r p
    MCS 0.432 0.020 0.594 0.008 0.445 0.040 0.563 0.003
    APACHE 0.465 0.010 0.175 0.132 0.198 0.170 0.745 <0.001
    SOFA 0.523 0.005 0.342 0.030 0.542 0.030 0.416 0.084
    MCS:改良重症超声快速管理方案评分; APACHE Ⅱ :急性生理与慢性健康状况评分Ⅱ; SOFA:序贯性器官衰竭评分
    下载: 导出CSV

    表  4  MCS与非计划入ICU患者预后相关性

    分组 MCS 例数 28死亡率(%) ICU住院时间(d) 机械通气时间(d)
    低危组 0~10 67 11.9 7.6 5.2
    中危组 11~20 125 16.0 12.4 7.3
    高危组 21~32 80 25.0 19.3 14.2
    p 0.006 0.024 0.035
    MCS:同表 3
    下载: 导出CSV

    表  5  非计划入ICU患者28 d和48 h死亡风险单因素分析

    风险因素 28d死亡   48h死亡
    OR P   OR P
    MCS 1.450 0.017   1.967 0.003
    APACHE Ⅱ 1.087 0.023 - -
    SOFA 1.836 < 0.001 2.013 0.012
    年龄 1.031 0.042 1.125 0.037
    氧合指数 2.013 0.028 1.783 0.026
    平均动脉压 1.131 0.073 0.946 0.040
    心率 0.764 0.132 1.097 0.310
    性别 1.183 0.0231 0.853 0.425
    机械通气时间 1.473 0.076 1.218 0.079
    ICU住院时间 0.624 0.213   0.873 0.058
    MCS、APACHE Ⅱ、SOFA:同表 3
    下载: 导出CSV

    表  6  非计划入ICU患者28 d和48 h死亡独立危险因素分析

    风险因素 28d死亡   48h死亡
    OR P 95% CI   OR P 95% CI
    MCS 1.543 0.013 1.243~1.678   1.967 < 0.001 1.243~2.678
    APACHE Ⅱ 1.087 0.030 1.023~1.196 - - -
    SOFA 1.836 0.002 1.212~2.013 1.021 0.042 1.001~1.130
    年龄 1.031 0.021 1.002~1.217 1.125 0.020 1.002~1.310
    MCS、APACHE Ⅱ、SOFA:同表 3
    下载: 导出CSV
  • [1] Knaus WA, Draper EA, Wagner DP, et al. APACHE Ⅱ: a severity of disease classification system[J]. Crit Care Med, 1985, 13: 818-829. doi:  10.1097/00003246-198510000-00009
    [2] Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine [J]. Intensive Care Med, 1996, 22: 707-710. doi:  10.1007/BF01709751
    [3] Beaulieu Y. Bedside echocardiography in the assessment of the critically ill [J]. Crit Care Med, 2007, 35: S235-S249. doi:  10.1097/01.CCM.0000260673.66681.AF
    [4] Bataille B, Riu B, Ferre F, et al. Integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in ICU [J]. Chest, 2014, 146: 1586-1593. doi:  10.1378/chest.14-0681
    [5] Frankel HL, Kirkpatrick AW, Elbarbary M, et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part Ⅰ: General Ultrasonography [J]. Crit Care Med, 2015, 43: 2479-2502. doi:  10.1097/CCM.0000000000001216
    [6] Ha YR, Toh HC. Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review [J]. J Intensive Care, 2016, 4: 54. doi:  10.1186/s40560-016-0172-1
    [7] Karabinis A, Fragou M, Karakitsos D. Whole-body ultrasound in the intensive care unit: a new role for an aged technique [J]. J Crit Care, 2010, 25: 509-513. doi:  10.1016/j.jcrc.2009.07.001
    [8] Manno E, Navarra M, Faccio L, et al. Deep impact of ultrasound in the intensive care unit: the "ICU-sound" protocol [J]. Anesthesiology, 2012, 117: 801-809. doi:  10.1097/ALN.0b013e318264c621
    [9] Wang XT, Liu DW, Zhang HM, et al. Integrated cardiopulmonary sonography: a useful tool for assessment of acute pulmonary edema in the intensive care unit [J]. J Ultrasound Med, 2014, 33: 1231-1239. doi:  10.7863/ultra.33.7.1231
    [10] 王小亭, 赵华, 刘大为, 等.重症超声快速管理方案在ICU重症患者急性呼吸困难或血流动力学不稳定病因诊断中的作用[J].中华内科杂志, 2014, 53: 793-798. doi:  10.3760/cma.j.issn.0578-1426.2014.10.008
    [11] Wang X, Liu D, He H, et al. Using critical care chest ultrasonic examination in emergency consultation: a pilot study [J]. Ultrasound Med Biol, 2015, 41: 401-406. doi:  10.1016/j.ultrasmedbio.2014.09.010
    [12] 丁欣, 王小亭, 陈焕, 等.不同床旁肺部超声评估方案评估膈肌点位置与征象的研究[J].中华内科杂志, 2015, 54: 778-782. doi:  10.3760/cma.j.issn.0578-1426.2015.09.009
    [13] Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm [J]. Crit Care Med, 2007, 35: S150-S161. doi:  10.1097/01.CCM.0000260626.23848.FC
    [14] Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound [J]. J Am Soc Echocardiogr, 2014, 27: 683.e1-683.e33.
    [15] Delgado MK, Liu V, Pines JM, et al. Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system [J]. J Hosp Med, 2013, 8: 13-19. doi:  10.1002/jhm.1979
    [16] Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine [J]. Crit Care Med, 1999, 27: 633-638. doi:  10.1097/00003246-199903000-00048
    [17] Dahn CM, Manasco AT, Breaud AH, et al. A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure [J]. Am J Emerg Med, 2016, 34: 1505-1510. doi:  10.1016/j.ajem.2016.05.009
    [18] Wardi G, Wali AR, Villar J, et al. Unexpected intensive care transfer of admitted patients with severe sepsis [J]. J Intensive Care, 2017, 5: 43. doi:  10.1186/s40560-017-0239-7
    [19] Boerma LM, Reijners EPJ, Hessels R, et al. Risk factors for unplanned transfer to the intensive care unit after emergency department admission [J]. Am J Emerg Med, 2017, 35: 1154-1158. doi:  10.1016/j.ajem.2017.03.019
    [20] Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 [J]. Intensive Care Med, 2017, 43: 304-377. doi:  10.1007/s00134-017-4683-6
    [21] Huda AQ, Karim MR, Mahmud MA, et al. Use of Acute Physiology and Chronic Health Evaluation (APACHE)-Ⅱ and Red Cell Distribution Width (RDW) for Assessment of Mortality of Patients with Sepsis in ICU [J]. Mymensingh Med J, 2017, 26: 585-591.
    [22] Marcelino PA, Marum SM, Fernandes AP, et al. Routine transthoracic echocardiography in a general Intensive Care Unit: an 18 month survey in 704 patients [J]. Eur J Intern Med, 2009, 20: e37-42. doi:  10.1016/j.ejim.2008.09.015
    [23] Hamzaoui O, Monnet X, Teboul JL. Evolving concepts of hemodynamic monitoring for critically ill patients [J]. Indian J Crit Care Med, 2015, 19: 220-226. doi:  10.4103/0972-5229.154556
    [24] Heiberg J, El-Ansary D, Canty DJ, et al. Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care [J]. Anaesthesia, 2016, 71: 1091-1100. doi:  10.1111/anae.13525
    [25] Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department [J]. Intensive Care Med, 2013, 39: 1290-1298. doi:  10.1007/s00134-013-2919-7
    [26] Mok KL. Make it simple: enhanced shock management by focused cardiac ultrasound [J]. J Intensive Care, 2016, 4: 51. doi:  10.1186/s40560-016-0176-x
    [27] 王小亭, 刘大为, 张宏民.扩展的目标导向超声心动图方案对感染性休克患者的影响[J].中华医学杂志, 2011, 91: 1879-1883. doi:  10.3760/cma.j.issn.0376-2491.2011.27.003
    [28] Evans D, Ferraioli G, Snellings J, et al. Volume responsiveness in critically ill patients: use of sonography to guide management [J]. J Ultrasound Med, 2014, 33: 3-7. doi:  10.7863/ultra.33.1.3
    [29] Blaivas M. Lung ultrasound in evaluation of pneumonia [J]. J Ultrasound Med, 2012, 31: 823-826. doi:  10.7863/jum.2012.31.6.823
    [30] Chandraratna PA, Mohar DS, Sidarous PF. Role of echocardiography in the treatment of cardiac tamponade [J]. Echocardiography, 2014, 31: 899-910. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=10.1111/echo.12605
    [31] Krishnan S, Schmidt GA. Acute right ventricular dysfunction: real-time management with echocardiography [J]. Chest, 2015, 147: 835-846. doi:  10.1378/chest.14-1335
    [32] Tierney DM, Boland LL, Overgaard JD, et al. Pulmonary ultrasound scoring system for intubated critically ill patients and its association with clinical metrics and mortality: A prospective cohort study [J]. J Clin Ultrasound, 2018, 46: 14-22. doi:  10.1002/jcu.22526
    [33] Landesberg G, Gilon D, Meroz Y, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock [J]. Eur Heart J, 2012, 33: 895. doi:  10.1093/eurheartj/ehr351
    [34] Vallabhajosyula S, Kumar M, Pandompatam G, et al. Prognostic impact of isolated right ventricular dysfunction in sepsis and septic shock: An eight-year historical cohort study [J]. Ann Intensive Care, 2017, 7: 94. doi:  10.1186/s13613-017-0319-9
  • 加载中
图(2) / 表(6)
计量
  • 文章访问数:  281
  • HTML全文浏览量:  38
  • PDF下载量:  232
  • 被引次数: 0
出版历程
  • 收稿日期:  2018-06-12
  • 刊出日期:  2018-09-30

目录

    /

    返回文章
    返回

    【温馨提醒】近日,《协和医学杂志》编辑部接到作者反映,有多名不法人员冒充期刊编辑发送见刊通知,鼓动作者添加微信,从而骗取版面费的行为。特提醒您,本刊与作者联系的方式均为邮件通知或电话,稿件进度通知邮箱为:mjpumch@126.com,编辑部电话为:010-69154261,请提高警惕,谨防上当受骗!如有任何疑问,请致电编辑部核实。谢谢!