中国危重病急救医学
中國危重病急救醫學
중국위중병급구의학
CHINESE CRITICAL CARE MEDICINE
2013年
1期
14-18
,共5页
常平%彭升%周健%谢海庭%刘占国%王华
常平%彭升%週健%謝海庭%劉佔國%王華
상평%팽승%주건%사해정%류점국%왕화
肾源性脓毒性休克%肺毛细血管渗漏%液体复苏%脉搏指示连续心排血量监测技术
腎源性膿毒性休剋%肺毛細血管滲漏%液體複囌%脈搏指示連續心排血量鑑測技術
신원성농독성휴극%폐모세혈관삼루%액체복소%맥박지시련속심배혈량감측기술
Septic shock following urinary infection%Pulmonary capillary leakage%Fluid resuscitation%Pulse induced continuous cardiac output monitoring
目的 分析肾源性脓毒性休克合并严重肺毛细血管渗漏的疾病特点,探讨液体复苏对休克治疗的影响以及脉搏指示连续心排血量(PiCCO)监测的意义.方法 采用回顾性分析方法,选择8例在重症监护病房(ICU)进行PiCCO监测并成功复苏的肾、输尿管碎石手术后并发肾源性脓毒性休克伴严重肺毛细血管渗漏患者,均以入院为起点,休克纠正或转出为终点,记录全心舒张期末容积指数(GEDVI)、血管外肺水指数(EVLWI)、液体出入量、液体净平衡、氧合指数(PaO2/FiO2)、动脉血乳酸水平和X线胸片等指标,分析其内在联系,探讨肾源性脓毒性休克疾病的特点和PiCCO监测在休克液体复苏治疗中的意义.结果 8例患者手术后4.5 d(中位数)出现脓毒性休克,均伴有不同程度的肺毛细血管渗漏和低氧血症.入ICU时EVLWI均值为(22±7)ml/kg,PaO2/FiO2为(164±82) mm Hg(1 mm Hg=0.133 kPa)；液体复苏均采用保守性策略,平均液体入量为(2412±1121) ml/d,液体净平衡-553 ml/d;中心静脉压(CVP)和GEDVI分别维持在(9±3)mm Hg和(749±236) ml/m2.其中6例使用呋塞米利尿,平均剂量(264± 133) mg;7例需要血管活性药物维持血压,去甲肾上腺素/多巴胺平均使用天数为(4±1)d；7例需要机械通气,通气时间(8±6)d.8例患者治疗后脓毒性休克均纠正,EVLWI下降至(11±3) ml/kg,肺部渗出吸收好转,平均住ICU天数(17±11)d.相关分析显示:EVLWI与PaO2/FiO2和动脉血乳酸水平显著相关,相关系数(r)值分别为-0.91和0.70(均P＜0.05).结论 准确评估血容量状态尤其是血管外肺水程度,参照血流动力学指标采取保守性液体复苏策略以及强调控制血管外肺水是成功救治肾源性脓毒性休克的关键,PiCCO是判断患者容量状态、指导液体复苏和评价治疗效果的有用工具.
目的 分析腎源性膿毒性休剋閤併嚴重肺毛細血管滲漏的疾病特點,探討液體複囌對休剋治療的影響以及脈搏指示連續心排血量(PiCCO)鑑測的意義.方法 採用迴顧性分析方法,選擇8例在重癥鑑護病房(ICU)進行PiCCO鑑測併成功複囌的腎、輸尿管碎石手術後併髮腎源性膿毒性休剋伴嚴重肺毛細血管滲漏患者,均以入院為起點,休剋糾正或轉齣為終點,記錄全心舒張期末容積指數(GEDVI)、血管外肺水指數(EVLWI)、液體齣入量、液體淨平衡、氧閤指數(PaO2/FiO2)、動脈血乳痠水平和X線胸片等指標,分析其內在聯繫,探討腎源性膿毒性休剋疾病的特點和PiCCO鑑測在休剋液體複囌治療中的意義.結果 8例患者手術後4.5 d(中位數)齣現膿毒性休剋,均伴有不同程度的肺毛細血管滲漏和低氧血癥.入ICU時EVLWI均值為(22±7)ml/kg,PaO2/FiO2為(164±82) mm Hg(1 mm Hg=0.133 kPa)；液體複囌均採用保守性策略,平均液體入量為(2412±1121) ml/d,液體淨平衡-553 ml/d;中心靜脈壓(CVP)和GEDVI分彆維持在(9±3)mm Hg和(749±236) ml/m2.其中6例使用呋塞米利尿,平均劑量(264± 133) mg;7例需要血管活性藥物維持血壓,去甲腎上腺素/多巴胺平均使用天數為(4±1)d；7例需要機械通氣,通氣時間(8±6)d.8例患者治療後膿毒性休剋均糾正,EVLWI下降至(11±3) ml/kg,肺部滲齣吸收好轉,平均住ICU天數(17±11)d.相關分析顯示:EVLWI與PaO2/FiO2和動脈血乳痠水平顯著相關,相關繫數(r)值分彆為-0.91和0.70(均P＜0.05).結論 準確評估血容量狀態尤其是血管外肺水程度,參照血流動力學指標採取保守性液體複囌策略以及彊調控製血管外肺水是成功救治腎源性膿毒性休剋的關鍵,PiCCO是判斷患者容量狀態、指導液體複囌和評價治療效果的有用工具.
목적 분석신원성농독성휴극합병엄중폐모세혈관삼루적질병특점,탐토액체복소대휴극치료적영향이급맥박지시련속심배혈량(PiCCO)감측적의의.방법 채용회고성분석방법,선택8례재중증감호병방(ICU)진행PiCCO감측병성공복소적신、수뇨관쇄석수술후병발신원성농독성휴극반엄중폐모세혈관삼루환자,균이입원위기점,휴극규정혹전출위종점,기록전심서장기말용적지수(GEDVI)、혈관외폐수지수(EVLWI)、액체출입량、액체정평형、양합지수(PaO2/FiO2)、동맥혈유산수평화X선흉편등지표,분석기내재련계,탐토신원성농독성휴극질병적특점화PiCCO감측재휴극액체복소치료중적의의.결과 8례환자수술후4.5 d(중위수)출현농독성휴극,균반유불동정도적폐모세혈관삼루화저양혈증.입ICU시EVLWI균치위(22±7)ml/kg,PaO2/FiO2위(164±82) mm Hg(1 mm Hg=0.133 kPa)；액체복소균채용보수성책략,평균액체입량위(2412±1121) ml/d,액체정평형-553 ml/d;중심정맥압(CVP)화GEDVI분별유지재(9±3)mm Hg화(749±236) ml/m2.기중6례사용부새미이뇨,평균제량(264± 133) mg;7례수요혈관활성약물유지혈압,거갑신상선소/다파알평균사용천수위(4±1)d；7례수요궤계통기,통기시간(8±6)d.8례환자치료후농독성휴극균규정,EVLWI하강지(11±3) ml/kg,폐부삼출흡수호전,평균주ICU천수(17±11)d.상관분석현시:EVLWI여PaO2/FiO2화동맥혈유산수평현저상관,상관계수(r)치분별위-0.91화0.70(균P＜0.05).결론 준학평고혈용량상태우기시혈관외폐수정도,삼조혈류동역학지표채취보수성액체복소책략이급강조공제혈관외폐수시성공구치신원성농독성휴극적관건,PiCCO시판단환자용량상태、지도액체복소화평개치료효과적유용공구.
Objective To characterize septic shock following urinary infection with severe pulmonary capillary leakage,and to evaluate the fluid therapy on treatment of hypovolemic shock and the role of transpulmonary thermodilution technique with pulse induced continuous cardiac output (PiCCO) monitoring.Methods A retrospective study was conducted.Eight patients surviving septic shock following urinary infection with severe pulmonary capillary leakage were enrolled,and all of them underwent PiCCO monitoring in the intensive care unit (ICU) when the diagnosis was established.The monitoring started at admission,and ended when shock was corrected or transferred from ICU.The clinical data including general end diastolic volume index (GEDVI),extravascular lung water index (EVLWI),input and output volume of fluid,net fluid balance,oxygenation index (PaO2/FiO2),the level of arterial blood lactic acid,and chest X ray were collected and analyzed retrospectively the characteristics of septic shock following urinary infection,and the role of PiCCO monitoring in fluid resuscitation.Results Septic shock following urinary infection occurred in a median of 4.5 days in 8 patients after renal and ureteric calculi lithotripsy,accompanied with severe pulmonary vessel effusion and hypoxemia in different degrees.The mean value of EVLWI was (22 ± 7) ml/kg,and the PaO2/FiO2 (164 ± 82) mm Hg (1 mm Hg=0.133 kPa) at the time of admission to ICU.Conservative fluid resuscitation strategy was adopted in management of septic shock with severe pulmonary capillary leakage,the mean fluid input in 8 patients was (2412 ± 1121) ml/d,and the net fluid balance-553 ml/d,and the central venous pressure (CVP) and GEDVI were maintained at levels of (9 ± 3) mm Hg and (749 ± 236) ml/m2 respectively.Diuretics were administered to 6 patients and the mean dosage of fursemide was (264± 133)mg.Norepinephrine and dobutamine infusion were given to 7 patients to maintain blood pressure at normal range for (4 ± 1) days.Seven patients were mechanically ventilated,and the mean length of ventilation was (8 ± 6) days.All of the 8 patients survived from septic shock after fluid resuscitation therapy,with the mean level of EVLWI decreased gradually to (11 ± 3) ml/kg,and the lung effusion was absorbed significantly as shown in chest X ray.The mean length of ICU stay was (17 ± 11) days.Pearson correlate analysis showed EVLWI was significantly correlated with PaO2/FiO2 and the levels of artery blood serum lactate,with r-0.91 and 0.70 respectively (both P＜0.05).Conclusions Successful management of septic shock following urinary infection with severe pulmonary vascular leakage is based on accurate assessment of blood volume status,especially the degree of EVLWI,emphasis on prevention of EVLWI increase,and adoption of conservative fluid resuscitation strategies according to hemodynamic monitoring parameters.PiCCO monitoring is a useful tool in assessment of the blood volume status and management of fluid resuscitation in patients with urinary lithotripsy-associated septic shock complicated with severe pulmonary edema.
