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1、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、Dobu NE 转ICU 既往有冠心病史, 无明确高血压病史 T 36 HR 160 BP88/45mmHg CVP 16mmHg PAWP 22 mmHg (PEEP 10cmH2O) 球结膜水肿，两肺呼吸音粗，腹膨, 全腹压痛、反跳痛 尿少,Case report: 腹痛伴恶心呕吐4天,辅助检查,血常规： WBC 3.6109/L GRA 25% PLT 35109/L 血气： pH
2、 7.429 PO2 86.4mmHg (FiO2 50%) Lac 6.5mmol/L 生化： ALB 15g/L CR 330umol/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?,N Engl J Med 2005;353:2788-96,ARDS 诊断标准,急性起病 PaO2/FiO2 200mm Hg (不管PEEP水平) 正位X 线胸片显示双肺均有斑片状阴影 PAWP18 mm Hg, 或无LAP增高的临床证据,Am J Re
3、spir Crit Care Med, 1994,149:818-824,缺乏反映其病理生理特征的血管通透性指标,ARDS与心源性肺水肿的鉴别诊断,对于有基础心脏病史，合并感染、休克时鉴别诊断非常困难,支持ARDS的依据 急性起病 感染、休克病史 胸片 氧合(200mm Hg) 支持心源性肺水肿的依据 既往有冠心病史 急性起病 术中心率40170次/分 大量输液 胸片 CVP 16 mmHg/PAWP 22 mmHg 氧合,ARDS vs cardiogenic pul edema,CVP/PAWP增高 排除 ARDS/一定就是左心衰?,高水平PEEP或气道平台压 针对休克的早期大量液体复苏
4、感染对心肌的抑制 腹内压的增高 肺血管阻力的增加(如COPD, ARDS) 测量不当,该患者可能因素？,High PAWP in pats with ARDS,120 pats with or at high risk of ARDS The mean maximum PAWP reading among patients was 22.5 mmHg and mean median was 16.6 mmHg Patients who met standard criteria for ARDS were more likely to develop a high PAWP. （30 18mm
5、 Hg，CI 5.3 L/min/m2),Intensive Care Med, 2002,28(8):1073-7,PAWP18mmHg is common in ARDS,N Engl J Med 2006,354:2213-24,29 pats ：PAWP 18mm Hg 97% pats with PAWP 18mm Hg had a normal or elevated CI,1001 patients, 513 assigned to PAC, 488 to CVC,Objective Criteria for ARDS,PAWP18 mmHg不应作为ARDS的诊断标准 肺毛细血管
6、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,Schuster DP. The search for “objective” criteria for ARDS. Intensive Care Med, 2007, 33:400-402. Ware LB,. Matthay MA. Acute Pulmonary Edema. N Engl J Med, 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 Alb in BAL/Plasm
7、a 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,Objective Criteria for ARDS,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,Objective Criteria for ARDS,Schuster DP, Stark T, S
8、tephenson J, et al. Detecting lung injury in patients with pulmonary edema. Intensive Care Med, 2002, 28: 1246-1253.,PiCCO的临床应用,肺水指标： Extravascular Lung Water: EVLW Pulmonary Vascular Permeability Index: PVPI (EVLW/PBV),Objective Criteria for ARDS,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 ARD
9、S性肺水肿： EVLW明显增加、PBV不增加，PVPI明显升高,Design: Retrospective review of cases Patients: 48 critically ill pats ventilated for ARF bilateral infiltrates on chest radiograph PaO2/FiO2 300 mm Hg EVLWI 12 ml/kg,Intervention: Pulmonary permeability：PVPI and EVLWi/GEDVi Cause of pulmonary edema：determined by 3 ex
10、perts,EVLWi/GEDVi 3.01021.2102 1.41020.4102*,Objective Criteria for ARDS,PVPI can be helpful for distinguishing hydrostatic pulmonary edema and ARDS,Cut-off value = 3 Se=85% Sp=100%,ROC-PVPI: 0.920.04,Objective Criteria for ARDS,肺水指标可协助鉴别肺内/外原因ARDS,10 pats, 4 with direct and 6 with indirect (sepsis
11、induced) GEDV, ITBV and EVLW were measured PI (permeability index) (EVLW/ITBV ),Critical Care 2006, 10(Suppl 1):P326,EVLWI 20 ml/kg: 肺水肿 PVPI 3.8%: ARDS EVLWI/GEDI 0.31: ARDS indirect EKG: sepsis induced 心肌损害,PiCCO：(Dopa 5ug/kg.min，Dobu 10ug/kg.min) CO 4.1 L/min CI 2.44 L/min/m2 SVV 30% GEDI 641 ml/
12、m2 EVLWI 20 ml/kg PVPI 3.8,Objective Criteria for ARDS,下一步治疗 A、去甲肾上腺素 B、加肾上腺素 C、IABP D、CRRT E、补液,PiCCO：(Doba 5ug/kg/min，Dobu 10ug/kg/min) CO 4.1 L/min CI 2.44 L/min/m2 CVP 16mmHg PAWP 22mmHg SVV 30% GEDI 641 ml/m2 EVLWI 20 ml/kg PVPI 3.8%,Management of ARDS,Prospective, nonrandomized, nonblinded int
13、erventional study. Cardiac catheterization and echocardiography laboratories. Normal healthy volunteers Groups: Group 1: Pulmonary catheterization and radionuclide cineangiography n = 12 Group 2: volumetric echocardiography n=32 Volume load: 3 L salin iv over 3 hrs,Crit Care Med. 2004; 32:691699.,Cr
14、it Care Med 2004; 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: PiCCO CEDVIPAC: PAC LV preload assessment: TEE Hemodynamic measurements: before (T0) and 20 min (T1) and 40 min (T2) after a volume load Volume load: HES10 ml/kg over 20min,British Journal of Anaesthesia. 2005, 94 (6): 748755.,Brit
15、ish Journal of Anaesthesia 94 (6): 74855 (2005),容量状态评估,SVV、PPV: predicting fluid responsiveness,40 patients undergoing elective OPCABG,Chest 2005, 128:848854,SVV 、 GEDV、ITBV: Cardiac preload,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 Crit Care Med 2008, 36(1):296-327 ARDS：通透性增加 容量控制 N Engl J Med 2006, 354
16、:2564-75 复苏液体种类的选择,胶体渗透压对肺水肿的影响,Circ Res 1959, 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，PEEP 1015cmH2O, MAP 20cmH2O, VT 420ml左右),间断行SI,6-07 PiCCO：(多巴胺4ug/kg/min，血压120/80mmHg) CO 6.56 L/min CI 3.62 L/min/m2 SVV 10% GEDI 1310 ml/m2 EVLWI 12 ml/
17、kg PVPI 2.0,Management of ARDS,6-07 SBT PSV: PEEP 5cmH2O，PS 10cmH2O 30min后SBT通过，血气Lac 1.0mmol/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？,Management of ARDS,再插管前一天胸片 再插管后胸片,CVP 3cmH2O PAWP8cmH2O CI 4.0 EVLWI 15 ml/kg 进一步处理？,6-076-10期间负平衡1500ml1000ml/d 6-11 EVLWI 6ml/kg 成功脱机,Management of ARDS,PiCCO for ARDS,肺水及血管通透性相关指标有助于肺水肿类型的鉴别及ARDS诊断 容量指标可更好的指导ARDS患者前负荷的评价 血管外肺水指标可指导ARDS患者容量管理和脱机判断,谢谢你的阅读,知识就是财富 丰富你的人生,