CCO技术在ARDS诊断和治疗中的应用

PiCCO在ARDS诊断和治疗中的应用(病例分析),男性，62岁，退休干部因右腹股沟不可回纳包块伴恶心呕吐四天入院6月4日急诊全麻行剖腹探查术术中循环不稳定，心率40170次/分术中见小肠部分坏死，给予回肠部分切除大量补液（7050ml)+Daba、DobuNE转ICU既往有冠心病史,无明确高血压病史T36HR160BP88/45mmHgCVP16mmHgPAWP22mmHg(PEEP10cmH2O)球结膜水肿，两肺呼吸音粗，腹膨,全腹压痛、反跳痛尿少,Casereport:腹痛伴恶心呕吐4天,辅助检查,血常规：WBC3.6109/LGRA25%PLT35109/L血气：pH7.429PO286.4mmHg(FiO250%)Lac6.5mmol/L生化：ALB15g/LCR330umol/L心电图：窦性心律,ST-T异常,主要诊断：右腹股沟疝绞窄性肠梗阻回肠部分切除术后弥漫性腹膜炎感染性休克急性肾衰急性呼吸衰竭(病因?)ARDS心源性肺水肿,急性呼吸衰竭的病因?,NEnglJMed2005;353:2788-96,ARDS诊断标准,急性起病PaO2/FiO25.3L/min/m2),IntensiveCareMed,2002,28(8):1073-7,PAWP18mmHgiscommoninARDS,NEnglJMed2006,354:2213-24,29pats：PAWP18mmHg97%patswithPAWP18mmHghadanormalorelevatedCI,1001patients,513assignedtoPAC,488toCVC,ObjectiveCriteriaforARDS,PAWP18mmHg不应作为ARDS的诊断标准肺毛细血管通透性明显增加ARDS区别于心源性肺水肿的特征性改变应在诊断标准中体现，使诊断标准更具特征性,SchusterDP.Thesearchfor“objective”criteriaforARDS.IntensiveCareMed,2007,33:400-402.WareLB,.MatthayMA.AcutePulmonaryEdema.NEnglJMed,2005;353:2788-96.,ARDS高通透性肺水肿vs急性左心衰竭高静水压性肺水肿试图依据病史、临床特征、X线胸片的特征血管外白蛋白的漏出量AlbinBAL/Plasma无创性核医学技术热稀释技术计算肺内血容量(PBV)与血管外肺水(EVLW)肺血管通透性指数(PVPI),可用来反映肺毛细血管通透性,ObjectiveCriteriaforARDS,2002年Schuster以双肺水肿、病程24h的危重患者为研究对象99mTc-Alb示踪肺血管通透性的改变临床诊断为ARDS(21例)和急性左心衰竭(7例)肺部同位素放射强度并无显著差别高静水压性肺水肿也有少量白蛋白漏出肺泡II型上皮细胞对肺泡中液体的主动清除核示踪技术的敏感性不足,ObjectiveCriteriaforARDS,SchusterDP,StarkT,StephensonJ,etal.Detectinglunginjuryinpatientswithpulmonaryedema.IntensiveCareMed,2002,28:1246-1253.,PiCCO的临床应用,肺水指标：ExtravascularLungWater:EVLWPulmonaryVascularPermeabilityIndex:PVPI(EVLW/PBV),ObjectiveCriteriaforARDS,ARDS与心源性肺水肿的鉴别诊断,心源性肺水肿：EVLW、PBV均明显增加，PVPI降低或正常ARDS性肺水肿：EVLW明显增加、PBV不增加，PVPI明显升高,Design:RetrospectivereviewofcasesPatients:48criticallyillpatsventilatedforARFbilateralinfiltratesonchestradiographPaO2/FiO2300mmHgEVLWI12ml/kg,Intervention:Pulmonarypermeability：PVPIandEVLWi/GEDViCauseofpulmonaryedema：determinedby3experts,EVLWi/GEDVi3.01021.21021.41020.4102*,ObjectiveCriteriaforARDS,PVPIcanbehelpfulfordistinguishinghydrostaticpulmonaryedemaandARDS,Cut-offvalue=3Se=85%Sp=100%,ROC-PVPI:0.920.04,ObjectiveCriteriaforARDS,肺水指标可协助鉴别肺内/外原因ARDS,10pats,4withdirectand6withindirect(sepsisinduced)GEDV,ITBVandEVLWweremeasuredPI(permeabilityindex)(EVLW/ITBV),CriticalCare2006,10(Suppl1):P326,EVLWI20ml/kg:肺水肿PVPI3.8%:ARDSEVLWI/GEDI0.31:ARDSindirectEKG:sepsisinduced心肌损害,PiCCO：(Dopa5ug/kg.min，Dobu10ug/kg.min)CO4.1L/minCI2.44L/min/m2SVV30%GEDI641ml/m2EVLWI20ml/kgPVPI3.8,ObjectiveCriteriaforARDS,下一步治疗A、去甲肾上腺素B、加肾上腺素C、IABPD、CRRTE、补液,PiCCO：(Doba5ug/kg/min，Dobu10ug/kg/min)CO4.1L/minCI2.44L/min/m2CVP16mmHgPAWP22mmHgSVV30%GEDI641ml/m2EVLWI20ml/kgPVPI3.8%,ManagementofARDS,Prospective,nonrandomized,nonblindedinterventionalstudy.Cardiaccatheterizationandechocardiographylaboratories.NormalhealthyvolunteersGroups:Group1:Pulmonarycatheterizationandradionuclidecineangiographyn=12Group2:volumetricechocardiographyn=32Volumeload:3Lsalinivover3hrs,CritCareMed.2004;32:691699.,CritCareMed2004;32:691699,CVP/PAWP对容量试验的反应,择期心脏手术患者n=20监测GEDVI:PiCCOCEDVIPAC:PACLVpreloadassessment:TEEHemodynamicmeasurements:before(T0)and20min(T1)and40min(T2)afteravolumeloadVolumeload:HES10ml/kgover20min,BritishJournalofAnaesthesia.2005,94(6):748755.,BritishJournalofAnaesthesia94(6):74855(2005),容量状态评估,SVV、PPV:predictingfluidresponsiveness,40patientsundergoingelectiveOPCABG,Chest2005,128:848854,SVV、GEDV、ITBV:Cardiacpreload,感染导致的ARDS患者如何补液？,重症感染、感染性休克：需要积极液体复苏CritCareMed2008,36(1):296-327ARDS：通透性增加容量控制NEnglJMed2006,354:2564-75复苏液体种类的选择,胶体渗透压对肺水肿的影响,CircRes1959,7:649-57,主要处理：大量血浆、白蛋白输注，循环稳定下间断利尿(前3日液体平衡：2000ml，50ml,800ml)泰能、替考拉宁、替硝唑联合大扶康抗感染呼吸机(BiPAP模式，PEEP1015cmH2O,MAP20cmH2O,VT420ml左右),间断行SI,6-07PiCCO：(多巴胺4ug/kg/min，血压120/80mmHg)CO6.56L/minCI3.62L/min/m2SVV10%GEDI1310ml/m2EVLWI12ml/kgPVPI2.0,ManagementofARDS,6-07SBTPSV:PEEP5cmH2O，PS10cmH2O30min后SBT通过，血气Lac1.0mmol/L脱机拔管1h后两肺湿罗音，SPO2下降至80，而再次气管插管,拔管失败可能的原因？,ManagementofARDS,再插管前一天胸片再插管后胸