重症医学科问题导向重症超声检查特征分析

Characteristics of ultrasonic patterns of problem based critical care ultrasound examination in patients in intensive care unit

目的对四川大学华西医院重症医学科问题导向重症超声检查的特征及构成进行统计分析,为临床实践及科研提供流行病学资料。方法回顾性分析四川大学华西医院问题导向检查重症超声数据库资料,对进行重症超声检查的临床问题进行分类,对重症超声检查发现的病理生理变化进行整理和分类,并结合临床信息阐明各类临床问题所反应的病理生理病因。结果本研究共纳入患者135例,平均年龄(51±18)岁。共进行问题导向检查386例次,人均2.85例次。启动检查的原因包括:急性循环障碍共271例次(70.2%),急性呼吸障碍共34例次(8.8%),急性呼吸障碍合并循环障碍76例次(19.7%),考虑需要检查膈肌及其他共5例次(1.2%)。单独和合并存在的急性循环障碍共347例次,重症超声检查发现存在的病理生理改变包括:容量不足55例次(15.9%),容量过负荷85例次(24.5%),心脏功能不全246例次(70.9%),外周阻力下降22例次(6.3%),右心后负荷增高15例次(4.3%);246例次心脏功能不全包括:左心收缩功能不全31例次(12.6%),左心舒张功能不全108例次(43.9%),左心收缩功能不全合并舒张功能不全49例次(19.9%),右心功能不全23例次(9.4%),全心功能不全35例次(14.2%)。单独和合并存在的急性呼吸障碍共110例次,主要超声表现为:肺实变40例次(36.4%),弥漫超声肺间质综合征27例次(24.5%),肺实变合并弥漫超声肺间质综合征18例次(16.4%),局限性超声肺间质综合征17例次(14.6%),其他9例次(8.2%)。病情恶化原因包括:心源性肺水肿、舒张功能障碍、右心功能障碍、急性瓣膜疾病或慢性瓣膜病失代偿等。结论重症超声检查以急性循环障碍、急性呼吸障碍为主要问题导向。重症超声检查能全面的显示患者的呼吸循环系统病理生理改变,并结合临床诊断病情恶化的原因,指导临床治疗。

Objective To provide epidemiological data as a reference for the coming research and clinical practice by analyzing the problem based critical care ultrasound（CCUS） examination database in Department of Critical Care Medicine,West China Hospital, Sichuan University. Methods A retrospective study of the database was performed. The clinical problems prompting the CCUS examination were classified, the ultrasonnic findings representing the pathophysiological changes were collected and gathered into categories, and the pathophysiological etiology for each classification of clinical problems was stated after referring to the clinical information. Results In the 135 cases with a mean age of（51±18） years, 386 times of problems based examinations were performed（2.85 times per patient）. The problems prompting the examinations were acute circulatory dysfunction（271 times, 70.2%）, acute respiratory dysfunction（34 times, 8.8%）, acute circulatory dysfunction combined with acute respiratory dysfunction（76 times, 19.7%）, and suspected diaphragm disorder and others（5 times, 1.2%）. In the 347 times of examination for acute circulatory dysfunction, the pathophysiological changes discovered by the CCUS examination included hypovolemia（55 times, 15.9%）, hypervolemia（85 times, 24.5%）, decreased systemic vascular resistance index（22 times, 6.3%）, and increased right ventricular（RV） afterload（15 times, 4.3%）. In the 246 times of examination for cardiac dysfunction, the underlying etiology detected included left ventricular（LV） systolic dysfunction（31 times, 12.6%）, LV diastolic dysfunction（108 times, 43.9%）, LV systolic dysfunction associated with diastolic dysfunction（49 times, 19.9%）, RV dysfunction（23 times, 9.4%）, and whole heart failure（35 times, 14.2%）. Acute respiratory disorders was identified 110 times in total, which consisted of lung consolidation（40 times, 36.4%）, diffuse ultrasonic interstitial syndrome（DIS; 27 times, 24.5%）, consolidation associated with DIS（18 times, 16.4%）, focal interstitial syndrome（17 times, 14.6%）, and others（9 times, 8.2%）. Causes of deterioration of the cases were cardiogenic pulmonary edema, diastolic dysfunction, RV failure, acute valve insult or chronic valve insufficiency and so on. Conclusions The main problems prompting the CCUS examinations are acute circulatory dysfunction and acute respiratory dysfunction. CCUS examination can provide physicians with valuable information on the full picture of the pathophysiology characteristics of hemodynamics and lung pathology to help diagnose the causes of the deterioration and guide clinical treatment.