《CCO技术在ARDS诊断和治疗中的应用.ppt》由会员分享，可在线阅读，更多相关《CCO技术在ARDS诊断和治疗中的应用.ppt（36页珍藏版）》请在三一办公上搜索。
1、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、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 3510
2、9/L血气：pH 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 Respir Crit
3、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感染对心肌的抑制腹内压的增高肺血管
4、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 ARDSThe mean maximum PAWP reading among patients was 22.5 mmHg and mean median was 16.6 mmHgPatients who met standard criteria for ARDS were more likely to develop a high PAWP.（30 18mm Hg，CI 5.3 L/min/m2),Int
5、ensive 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
6、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/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
7、(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,Stephenson J,et al.Detecting lung injury in patients with pu
8、lmonary 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ARDS性肺水肿：EVLW明显增加、PBV不增加，PVPI明显升高,Design:Retrospective review of cases Pat
9、ients: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 experts,EVLWi/GEDVi 3.01021.2102 1.41020.4102*,Objective Criteria for ARDS,PV
10、PI 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 induced)GEDV,ITBV and EVLW were measured PI(permeability index)(EVLW/ITBV),Critic
11、al Care 2006,10(Suppl 1):P326,EVLWI 20 ml/kg:肺水肿PVPI 3.8%:ARDSEVLWI/GEDI 0.31:ARDS indirectEKG: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/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
12、,PiCCO：(Doba 5ug/kg/min，Dobu 10ug/kg/min)CO 4.1 L/min CI 2.44 L/min/m2CVP 16mmHgPAWP22mmHgSVV 30%GEDI 641 ml/m2 EVLWI 20 ml/kg PVPI 3.8%,Management of ARDS,Prospective,nonrandomized,nonblinded interventional study.Cardiac catheterization and echocardiography laboratories.Normal healthy volunteersGro
13、ups:Group 1:Pulmonary catheterization and radionuclide cineangiography n=12 Group 2:volumetric echocardiography n=32Volume load:3 L salin iv over 3 hrs,Crit Care Med.2004;32:691699.,Crit 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:PiCCOCEDVIPAC:PACLV preload assessment:TEEHemodynami
14、c measurements:before(T0)and 20 min(T1)and 40 min(T2)after a volume loadVolume load:HES10 ml/kg over 20min,British Journal of Anaesthesia.2005,94(6):748755.,British Journal of Anaesthesia 94(6):74855(2005),容量状态评估,SVV、PPV:predicting fluid responsiveness,40 patients undergoing elective OPCABG,Chest 20
15、05,128:848854,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):296-327ARDS：通透性增加 容量控制 N Engl J Med 2006,354:2564-75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 1015cmH
16、2O,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/kg PVPI 2.0,Management of ARDS,6-07 SBTPSV:PEEP 5cmH2O，PS 10cmH2O30min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 4.0EVLWI 15 ml/kg 进一步处理？,6-076-10期间负平衡1500ml1000ml/d6-11 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,
