血管外肺水导向的危重病患者容量管理策略

Extravascular lung water oriented capacity management strategies in critically ill patients

目的评价联合应用血管外肺水(EVLW)调整危重病患者液体管理和血管活性药物及其短期临床效果。方法选择江苏省苏北人民医院2011年1月至2012年9月入住重症医学科(ICU)的低血压和低氧患者,共24例低血压和19例低氧患者纳入研究,经过早期(入ICU时间>24 h)积极液体复苏,留置(PICCO)监测EVLW,记录监测EVLW前后起始治疗调整情况,包括液体管理调整和血管活性药物应用的调整,液体管理策略调整最多方案为限制液体+应用利尿剂(11/25)。结果监测EVLW后,25例(58.1%,25/43)患者起始治疗方案均作调整,包括25例(100%)对液体管理策略均进行调整和5(20%)例对血管活性药物应用有所调整。起始治疗调整组EVLW[(13.58±5.9)mL/kg]显著高于起始治疗未调整组[(9.5±2.4)mL/kg],但2组间中心静脉压(CVP)、全心舒张末期容积(GEDI)差异均无统计学意义(P>0.05)。限制液体复苏+利尿剂组患者CVP、GEDI与扩容组和限制液体复苏组患者比较差异均无统计学意义(P>0.05),但限制液体复苏+利尿剂组EVLW[(16.2±3.8)mL/kg]显著高于扩容组和限制液体复苏组EVLW[分别为(7.2±1.5)、(10.1±2.4)mL/kg,P<0.05],24 h液体平衡显著低于扩容组和限制液体复苏组(P<0.05)。25例患者起始治疗调整后20例(80%)患者调整治疗有效,低血压及低氧情况有所改善。结论危重病患者后期复苏阶段,监测EVLW调整危重病患者容量管理策略,避免过多液体复苏,有利于改善低血压和低氧血症。

Objective To evaluate the efficacy of extravascular lung water （EVLW） in changing the fluid management of critically ill patients, and to assess the short- term clinical effect. Methods Patients with hypotension or hypoxemia in the postresuscitation phase （ICU stay 〉 24 h） admitted between January 2011 and September 2012 in the intensive care units （ICU） of Subei People＇s hospital were analyzed prospectively, including 24 cases of hypotension and 19 cases of hy- poxemia. After early aggressive fluid resuscitation （ICU time ）24 h）, PICCO monitoring of EVLW, recording and monitoring EVLW before and after initial treatment adjustment, including fluid management adjustment and vasoactive drug application adjustment, it was found that the most frequently- changed fluid management strategy was limited fluid ± diuretics（ 11/25 ）. Results After knowing the EVLW, 58.1% （25/43） of initial therapeutic plans were changed, modifying fluid therapy in all of these cases and vasoactive therapy in 5 of them. EVLW value [ （13.58 ± 5.9） mL/kg] of patients with change of therapeutic plan was obviously higher than those with no change [ （9.5 ± 2.4） mL/kg]. No differences were found in preload parameters （CVP, GEDI） as a func- tion of change/no change （ P ） 0.05 ）. The most frequent decision change was to fluid reduction plus diuretic administration , and patients with this modification had significantly higher EVLW [ （16.2 ± 3.8） mL/kg]values compared with patients of volume load [ （7.2 ± 1.5） mL/kg] and volume infusion reduced [ （10.1 ± 2.4） mL/kg] （P〈 0.05）, thus there were no differences in preload parameters. Out of the 25 patients with a modified therapeutic decision, the therapy proved effective in improving hypotension or hypoxemia in 20 patients （80 % ）. Conclusion Quantification of EVLW in patients in the postresuscitation phase induces important modifications in fluid and vasoactive therapy. These changes generally resulted in a lower volume loading and a positive outcome for patients.