【作者】 刘亚晶；

【导师】 张玉想； 胡振杰；

【作者基本信息】 河北医科大学 ， 急诊医学， 2010， 硕士

【摘要】 目的:急性呼吸窘迫综合征(ARDS)是重症患者发生呼吸衰竭的主要原因。目前认为感染、创伤、休克、大量输血、大量输液后的过度炎症反应是导致ARDS的根本原因。过度的炎症反应损伤肺泡上皮和内皮细胞导致肺毛细血管通透性增加,富含蛋白的水肿液进入肺间质甚至肺泡,形成肺水肿。肺血管内皮通透性(PPI)增加是ARDS重要病理生理特点。PPI增加又导致血管外肺水(EVLW)增加,肺水肿的严重程度与ARDS预后密切相关。因此如何对ARDS患者进行容量管理尤为重要。然而ARDS最佳的容量管理仍未明确,研究显示对于创伤导致的ALI/ARDS病人液体正平衡使危重患者病死率明显增加,液体负平衡与感染性休克患者病死率的降低显著相关,因此推荐容量管理目标为保证心输出量基础上的最低肺动脉楔压(PAWP)。但是,最近的临床研究证实利用压力(CVP和PAWP)反映容量的方法是不准确的。胸腔内血容量(ITBV)/全新舒张末容积(GEDV)是反映危重病患者循环血容量更好的指标。脉搏指示剂心排血量(PICCO)可直接提供两个重要的血流动力学信息—EVLW和心脏前负荷(ITBV/GEDV),本研究以PICCO指导ARDS容量管理,保证容量充足的基础上尽量减少血管外肺水的产生,早期达到液体负平衡,以期改善预后。方法:食管癌术后ARDS患者24例,随机分为2组:①CVP监测治疗组:根据CVP及尿量,心率、平均动脉压等传统临床表现给与开放性液体管理;②PICCO监测治疗组:根据PICCO监测血流动力学数据结合患者尿量、心率,平均动脉压等临床表现给与限制性液体管理;记录前7天每天液体入量,出量,液体平衡,血管外肺水指数(EVLWI)变化,氧合指数(PaO2/FiO2),机械通气时间,ICU住院时间,观察28天死亡率。数据统计分析采用SPSS13.0版软件包进行;数据均以均数±标准差(mean±s)表示,两组均数的比较行两组独立样本t检验,多个样本均数间比较采用单因素方差分析,两样本率的比较采用卡方检验,EVLWI与GEDVI、ITBVI、PVPI、LIS、PaO2/FiO2、CI、SVRI及CVP相关性分析应用直线相关分析。P<0.05为差异有统计学意义。结果1两组28天死亡率比较无差异(18%VS18%,P>0.05)。PICCO组与CVP组入选后7天累计液体入量分别为(27851.8±4578.6ml VS 33247±4524.2ml, P<0.05);累计7天液体净平衡两组比较(PICCO组4584±3615ml;CVP组8402±4248ml,P<0.05);达到液体负平衡(>500ml)的时间分别为(PICCO组4.17±1.64d;CVP组6.75±2.63d,P<0.01);PICCO组较CVP组显著改善了第5天的氧合指数(248±21 VS 200±22,P<0.05),缩短了机械通气天数(6.1±1.6d VS 8.0±2.4d,P<0.05)及ICU住院天数(8.4±2.5d VS 10.5±2.2d, P<0.05);PICCO组较CVP组未增加休克及急性肾功能衰竭的发生率。机械通气天数与达到液体负平衡的时间存在正相关性(r=0.61,P<0.01);中心静脉压均值CVP组较PICCO组高(13±0.7mmHg VS 9±0.5mmHg,P<0.05)。2 EVLWI与其他指标的相关性EVLWI与ITBVI存在正相关性(r=0.512,P<0.01);EVLWI与GEDVI存在正相关性(r=0.573,P<0.05);EVLWI变化与液体平衡改变存在正相关性(r=0.439,P<0.05);EVLWI与肺血管通透指数(PVPI)(r=0.767,P<0.01)以及肺损伤评分(LIS)(r=0.613,P<0.01)存在正相关性。EVLWI与氧合指数整体存在负相关性(r=0.48,P<0.01),EVLWI越高,氧合指数越差(r=0.65,P<0.01);EVLWI与CI、SVRI及CVP不存在直接相关性(P>0.05);CVP与GEDVI、ITBVI亦无相关性。3实验室指标监测1、3、5天pH值、BE值、Cr、BUN变化PICCO组与CVP组各时间点组间比较均无差异。但ALB水平PICCO组较CVP组改善显著,第5天PICCO组高于CVP组(24.74±2.51 VS 1.68±3.06,P<0.05)。结论:PICCO监测血流动力学指导ARDS限制性液体管理较CVP监测下的传统液体管理有好的临床结果。虽然没有改善患者的死亡率,但PICCO组能够减少容量负荷,减轻肺水肿的发生,缩短机械通气时间及ICU住院时间,且不增加肺外脏器的损伤。更多还原

【Abstract】 Objective: The acute respiratory distress syndrome(ARDS)is the major cause of acute respiratory failure in the critically ill patient.Currently,it is believed that ARDS result from the extensive and excessive inflammatory reaction in the lung due to serious strikes such as serious infection,trauma, shock,massive blood transfusion,high-dose infusion.Excessive inflammatory injury the alveolar epithelial and endothelial barriers of the lung and increse pulmonary capillary permeability,which brings about protein rich fliud accumulated in alveolar and interstitial and than causes pulmonary edema further.Increase in pumonary vascular endothelial permeability(PPI)incresae is an important pathophysiological feature of ARDS,which would lead to increase in extravascular lung water(EVLW)and that increased the severity of pumonary edema,which is closely related to the prognosis of ARDS.Unfortunately there is still a controversy that how to keep a fliud balance in this patient population.Recent data indicated that consistent positive fluid gain was associated with a worse outcome in patients with ARDS or after major surgery and a negative fluid balane was correlation with the mortality decrease of septic shock patients.Recommendated fluid management goal is the lowest possible pulmonary wedge pressure consistent with an adequate cardiac output.However,recent clinical studies confirmed that it was not accurate to reflect cardic volume by pressure(CVP and PAWP).May be Intrathoracic Blood Volume(ITBV)/Global End Diastolic Volume(GEDV)was a better indicater of circulation blood volume in critical ill patient.Pulse indicator cardiac output (PICCO) would provide two important haemodynamics information-EVLW and cardic preload(ITBV/GEDV).In this study,PICCO was used to guide ARDS capacity management in order to ensure adequate capacity on the basis of minimizing extravasclar lung water and achieve an early negative fluid balance for improvement of patients’prognosis.Methods:Twenty-four patients with ARDS after esophagectomy were randomly divided into 2 groups(n=12each):①C VP monitoring-treated group,in which the traditional liberty fliud management strategy was given according to the CVP,urine output,heart rate and mean arterial pressure;②PICCO monitoring-treated group,in which a restrictive fliud management was given according to the PICCO monitoring of hemodynamic data in conbination with urine output,heart rate,mean arterial pressure.Then the amount of liqud into and out volume,fliud balance,extravascular lung water index(EVLWI)changes and oxygenation index(PaO2/FiO2)were record during study days 1 to 7,ventilator days,length of stay and the 28-days mortality were record too.Statistical analysis was performed using SPSS 13.0 software package. Data were expressed as mean±SD;Compared two-sample using Student’s t-tests.The means of each group were analysed with ANOVA;Compared two-sample rate use chi-square test;The relationship bettween EVLWI with GEDVI,ITBVI,PVPI,LIS,PaO2/FiO2 ratio,CI,SVRI and CVP were analyzed by linea correlation analysis.A statistical significant was P-value<0.05.Results:1 No statistical difference developed to the overall 28-day mortality beteen the two groups(18.0%VS18.0%,P>0.05).The mean cumulative fluid input during 1 to 7 day was 27851.8±4578.6ml in PICCO group and 33247±4524.2 ml in cvp group,respectively(P<0.05).The net balance of the two groups of liquid was 4584.0±3615.0ml in the PICCO group,and 8402.0±4248.0ml in the cvp group(P<0.05)during the first seven days;The time by which a nagative fliuld balance(>500mL)was achieved was earlier in the PICCO group than in the cvp group(4.17±1.64d VS 6.75±2.63d,P=0.009);The oxygenation index of Day 5 was better in the PICCO group than in cvp group(248±21 VS 200±22, P<0.05).The PICCO group reduce the number of ventilator days (6.1±1.6d VS 8.0±2.4d,P<0.05) and ICU length of stay(8.4±2.5d VS 10.5±2.2d,P<0.05). The shock and acute kidney falure incidenc was not increased in the PICCO group than in the cvp group.There was a positive correlation between ventilator days and the achievement of negative fluid balance of the time(r=0.61,P<0.01);The mean CVP was high in CVP group compared with PICCO group(13±0.7mmHg VS 9±0.5mmHg,P<0.05).2 Correlation with extravascular lung water index(EVLWI)There was a positive correlation between EVLWI and ITBVI(r=0.512, P<0.01);EVLWI was well correlated with the GEDVI(r=0.573,P<0.05);The change in EVLWI has positive correlation with the change in fliud balance (r=0.439,P<0.05);EVLWI was also well correlated with the pumonary vascular endothelial permeability index(PVPI)(r=0.767,P<0.01)and lung injury score(LIS)(r=0.613,P<0.01);EVLWI was negative correlation with oxygenation index(r=0.48,P<0.01).There was a signifacant correlation between the highest EVLWI and the lowest PaO2/FiO2 ratio(r=0.65,P<0.01);There was no correlation between EVLWI with CI, SVRI,and CVP(P>0.05); There was also no correlation between CVP and GEDVI or ITBVI,either.3 Lab IndexThere was no statistical difference in pH value,acid-base status,serum urea nitrogen levels and serum creatinine levels between the PICCO group and the CVP group at each time point.But the ALB level was improved significantly in PICCO group compared with CVP group.The ALB level was 24.74±2.51g/l in PICCO group and 21.68±3.06g/l in CVP group at day 5,P<0.05.Conclusions:Conservative-strategy with PICCO seystem moniter hemodynamic of patients with ARDS after esophagectomy has better outcome compared to liberal-strategy with CVP.Though there was no reduction in overall mortality, PICCO group can reduce the volume overload, reduce the incidence of acute pulmonary edema, improved the oxygenation index and decreased the number of ventilator days and ICU length of stay,without increse the extrapulmonary organ damage.更多还原