脉搏指示连续心排血量监测技术救治重症胰腺炎并发急性呼吸窘迫综合征患儿二例

Pulse indicator continuous cardiac output measurement-guided treatment aids two pediatric patients with severe acute pancreatitis complicated with acute respiratory distress syndrome

目的 探讨脉搏指示连续心排血量监测（PiCCO）在指导儿童重症胰腺炎（SAP）并发急性呼吸窘迫综合征（ARDS）治疗中的作用.方法 对2例SAP合并ARDS患儿在综合治疗的同时进行PiCCO监测,根据心脏指数、全心舒张末期容积指数（GE DVI）、血管外肺水指数（EVLWI）指导液体管理.结果 例1男,14岁,因“确诊急性淋巴细胞白血病12个月”入院行第6次化疗,应用培门冬酶、米托蒽醌1周后并发SAP伴ARDS.除给予支持、抗生素等基础治疗外,持续床旁血液透析＋滤过（CVVHDF）去除炎症介质,应用PiCCO指导治疗指导液体管理.PiCCO监测初始数值提示GEDVI450 ml/m2（参考值680 ～ 800 ml/m2）,心脏指数3.65 L/（min·m2）[参考值3.0～5.0 L/（min·m2）],EVLWI 7 ml/kg（参考值3.0 ～ 7.0 ml/kg）.床旁胸X线片提示右肺透过度良好,左肺透过度不佳,氧合指数223 mmHg（l mmHg =0.133 kPa）,增加心排量提高组织灌注,设置CVVHDF脱水速度70 ml/h.2h后氧合指数下降至155 mmHg,胸X线片示右肺透过度降低,呈弥漫性渗出改变,呼吸机呼吸末正压达5 cmH2O（1 cmH2O=0.098 kPa）,出现ARDS,PiCCO示GEDVI上升至600 ml/m2,ELVWI上升至10 ml/kg,立即停止补液,提高CVVHDF脱水速度（100～200 ml/h）.入PICU第3天,氧合指数上升至182 mmHg,PiCCO示EVLWI下降至6 ml/kg,GEDVI下降至370 ml/m2.入PICU 8 d后成功脱离呼吸机,9d后继发感染再次呼吸机辅助通气治疗,30 d后放弃治疗出院,出院1d后死亡.例2男,11岁,因暴饮暴食诱发SAP入院,入PICU第2天,患儿出现呼吸困难,血氧饱和度下降至80％,立即给予机械通气,CVVHDF去除炎症介质,应用PiCCO指导液体管理.PiCCO初始数值提示EVLWI9 ml/kg,GEDVI 519 ml/m2,氧合指数298 mmHg,床旁胸X线片可双肺见透过度降低,同时呼气末正压达5 cmH2O,考虑并发ARDS.设置CVVHDF脱水速度50 ml/h以减少循环负荷.2h后氧合指数下降至140 mmHg,PiCCO示GEDVI 481 ml/m2,EVLWI9 ml/kg,进一步增加CVVHDF脱水速度（最高达100 ml/h）.入PICU第4天,氧合指数上升至394 mmHg,EVLWI 9 ml/kg,GEDVI 430ml/m2,复查床旁胸X线片双肺透过度良好.入PICU第5天撤离PiCCO,30 d后好转出院.结论 PiCCO监测有助于实时了解SAP合并ARDS患儿心功能、心脏前后负荷以及血管外肺水情况,对ARDS及休克的抢救具有重要的指导意义.

Objective To evaluate the clinical value of the pulse indicator continuous cardiac output （PiCCO） system in patients with severe acute pancreatitis （SAP） complicated with acute respiratory distress syndrome （ARDS）.Method Two cases of SAP with ARDS were monitored using PiCCO during comprehensive management in the Pediatric Intensive Care Unit （PICU） of Shengjing Hospital,China Medical University.To guide fluid management,the cardiac index （CI） was measured to assess cardiac function,the global end-diastolic volume index （GEDVI） was used to evaluate cardiac preload,and the extravascular lung water index （EVLWI） was used to evaluate the pulmonary edema.Result Case 1 was diagnosed with type L2 acute lymphoblastic leukemia （intermediate risk） and received the sixth maintenance phases of chemotherapy this time.After a 1-week dosage of chemotherapeutic drugs （pegaspargase and mitoxantrone）,he suffered SAP combined with ARDS.Except comprehensive treatment （life supporting,antibiotic,etc.） and applying continuous veno-venous hemodiafiltration （CVVHDF） to remove inflammatory mediators.PiCCO monitor was utilized to guide fluid management.During the early stage of PiCCO monitoring,the patient showed no significant manifestations of pulmonary edema in the bedside chest X-ray （bedside ultrasound showed left pleural effusion）,and had an oxygenation index 223 mmHg （1 mmHg =0.133 kPa）,GEDVI 450 ml/m2,and ELVWI 7 ml/kg.We increased cardiac output to increase tissue perfusion and dehydration speed of CVVHDF was set at 70 ml/h.Two hours later,GEDVI significantly increased to 600 ml/m2 and ELVWI significantly increased to 10 ml/kg,the oxygenation index declined to 155 mmHg,the bedside chest X-ray showed a significant decrease of permeability （right lung） and PEEP was adjusted to 5 cmH2O （1 cmH2O =0.098 kPa）,indicating circulating overload.ARDS subsequently occurred,upon which the fluid infusion was halted,the dehydration rate of CVVHDF raised （adjusted to 100-200 ml/h）.On day 3 in the PICU,EVLWI dropped to 6 ml/kg,GEDVI dropped to 370 mL/m2,and the oxygenation index increased to 180 mmHg.On day 8,the patient was successfully weaned from the ventilator.However,on day 9,the patient reverted to mechanical ventilation due to secondary infection.On day 30,the patient was discharged for voluntarily giving up treatment.Late follow-up results showed that the patient was dead one day after giving up treatment.Case 2 was admitted due to SAP induced by overeating one day before admission.On day 2,the patient showed dyspnea and oxygen saturation decreased to 80％.We applied mechanical ventilation,CVVHDF to remove inflammatory mediators and PiCCO to guide fluid management.According to the initial data of PiCCO,EVLWI was 9 m[/kg,GEDVI was 519 ml/m2,the oxygenation index was 298 mmHg,the bedside chest X-ray showed decreased permeability and PEEP was adjusted to 5 cmH2O,suggesting the existence of ARDS.During treatment,the dehydration speed of CVVHDF was set at 50 ml/h to maintain the balance of fluid input and output.Two hours after PiCCO monitoring,the oxygenation index decreased to 140 mmHg,GEDVI 481 ml/m2,EVLWI 9 ml/kg,thus the dehydration speed of CVVHDF was increased （up to 100 ml/h）.On day 4 in the PICU,EVLWI was 9 ml/kg,GEDVI was 430 ml/m2,oxygenation index was 394 mmHg,and the bedside chest X-ray showed that permeability was higher.On day 5,the patient was transferred from PiCCO.On day 30,the patient recovered and was discharged.Conclusion PiCCO monitoring can provide real-time surveillance of cardiac function,cardiac preload and afterload,and extravascular lung water in pediatric patients with SAP combined with ARDS.These results are clinically significant for the rescue of critically ill patients with ARDS or shock.