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1、PiCCO在ARDS诊断和治疗中的应用(病例分析)男性，男性，6262岁，退休干部岁，退休干部 因右腹股沟不可回纳包块伴恶心呕吐四天入院因右腹股沟不可回纳包块伴恶心呕吐四天入院6 6月月4 4日急诊全麻行剖腹探查术日急诊全麻行剖腹探查术术中循环不稳定，心率术中循环不稳定，心率4017040170次次/分分术中见小肠部分坏死，给予回肠部分切除术中见小肠部分坏死，给予回肠部分切除大量补液（大量补液（7050ml)+Daba7050ml)+Daba、Dobu NEDobu NE转转ICUICU既往有冠心病史既往有冠心病史,无明确高血压病史无明确高血压病史T 36T 36 HR 160 BP88/45
2、mmHg HR 160 BP88/45mmHg CVP 16mmHg PAWP 22 mmHg(PEEP 10cmHCVP 16mmHg PAWP 22 mmHg(PEEP 10cmH2 2O)O)球结膜水肿，两肺呼吸音粗，腹膨球结膜水肿，两肺呼吸音粗，腹膨,全腹压痛、反跳痛全腹压痛、反跳痛尿少尿少Case report:腹痛伴恶心呕吐腹痛伴恶心呕吐4天天辅助检查血常规：WBC 3.6109/L GRA 25%PLT 35109/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,S
3、T-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;353:2788-96N Engl J Med 2005;353:2788-96ARDS 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 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缺乏反映其病理生理特征的血管通透性指
4、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支持ARDSARDS的依据的依据 急性起病急性起病 感染、休克病史感染、休克病史 胸片胸片 氧合氧合(200mm Hg)(18mm Hg 18mm Hg，CI 5.3 L/min/mCI 5.3 L/min/m2 2)Intensive Care Med,2002,28(8):1073-7PAWP18mmHg is common in ARDSN Engl J Med 2006,354:2213-24n 29 pats：PAWP 18mm Hgn 97%
5、pats with PAWP 18mm Hg had a normal or elevated CI1001 patients,513 assigned to PAC,488 to CVCObjective Criteria for ARDSPAWP18 mmHg不应作为ARDS的诊断标准肺毛细血管通透性明显增加ARDSARDS区别于心源性肺水肿的特征性改变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
6、Care Med,2007,33:400-402.Ware LB,.Matthay MA.Acute Pulmonary Edema.N Engl J Med,2005;353:2788-96.ARDSARDS高通透性肺水肿高通透性肺水肿 vs vs 急性左心衰竭高静水压性肺水肿急性左心衰竭高静水压性肺水肿试图依据病史、临床特征、试图依据病史、临床特征、X X线胸片的特征线胸片的特征血管外白蛋白的漏出量血管外白蛋白的漏出量 Alb in BAL/PlasmaAlb in BAL/Plasma 无创性核医学技术无创性核医学技术热稀释技术热稀释技术 计算肺内血容量计算肺内血容量(PBV)(PBV)
7、与血管外肺水与血管外肺水(EVLW)(EVLW)肺血管通透性指数肺血管通透性指数(PVPI),(PVPI),可用来反映肺毛细血管通透性可用来反映肺毛细血管通透性 Objective Criteria for ARDS20022002年年SchusterSchuster以双肺水肿、病程以双肺水肿、病程24h24h的危重患者的危重患者为研究对象为研究对象99mTc-Alb99mTc-Alb示踪肺血管通透性的改变示踪肺血管通透性的改变临床诊断为临床诊断为ARDS(21ARDS(21例例)和急性左心衰竭和急性左心衰竭(7(7例例)肺部同位素放射强度并无显著差别肺部同位素放射强度并无显著差别 高静水压性
8、肺水肿也有少量白蛋白漏出高静水压性肺水肿也有少量白蛋白漏出 肺泡肺泡II II型上皮细胞对肺泡中液体的主动清除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核示踪技术的敏感性不足Objective Criteria for ARDSSchuster DP,Stark T,Stephenson 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：肺水指标：Extravascular Lung Water:EVL
9、W Pulmonary Vascular Permeability Index:PVPI(EVLW/PBV)Objective Criteria for ARDSARDS与心源性肺水肿的鉴别诊断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:Design:Retrospective review of cases Retrospective review of cases Patients:Patients:48 critically ill pats ventilated fo
10、r ARF 48 critically ill pats ventilated for ARF bilateral infiltrates on chest radiograph bilateral infiltrates on chest radiograph PaOPaO2 2/FiO/FiO2 2 300 mm Hg 300 mm Hg EVLWI 12 ml/kg EVLWI 12 ml/kgIntervention:Intervention:Pulmonary permeabilityPulmonary permeability：PVPI and EVLWi/GEDVi PVPI a
11、nd EVLWi/GEDVi Cause of pulmonary edema Cause of pulmonary edema：determined by 3 expertsdetermined by 3 expertsEVLWi/GEDVi 3.01021.2102 1.41020.4102*Objective Criteria for ARDSPVPI can be helpful for distinguishing hydrostatic pulmonary edema and ARDSCut-off value=3 Se=85%Sp=100%ROC-PVPI:0.920.04Obj
12、ective Criteria for ARDS肺水指标可协助鉴别肺内/外原因ARDSl l10 pats,4 with 10 pats,4 with direct and 6 with direct and 6 with indirect(sepsis indirect(sepsis induced)induced)l lGEDV,ITBV and GEDV,ITBV and EVLW were EVLW were measured measured l l PI(permeability PI(permeability index)index)(EVLW/ITBV EVLW/ITBV)Cr
13、itical Care 2006,10(Suppl 1):P326 DirectDirectIndirectIndirectP P valuevalueITBVIITBVI984 331.7984 331.71279 1279 312.1312.10.00010.0001EVLWEVLWI I13.2 4.713.2 4.716.8 6.516.8 6.50.0140.014PIPI0.59 0.270.59 0.270.44 0.220.44 0.220.0060.006EVLWI 20 ml/kg:肺水肿PVPI 3.8%:ARDSEVLWI/GEDI 0.31:ARDS indirect
14、EKG:sepsis induced 心肌损害 PiCCO：(Dopa 5ug/kg.min(Dopa 5ug/kg.min，Dobu 10ug/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 3.8Objective Criteria for ARDS下一步治疗下一步治疗 A、去甲肾上腺素 B、加肾上腺素 C、IABP D、CRRT E、补液PiCCOPiCCO：(Doba 5ug/kg/min(Doba 5ug/kg/min，Dobu 10ug/k
15、g/min)Dobu 10ug/kg/min)CO CO 4.1 L/min 4.1 L/min CI CI 2.44 L/min/m2.44 L/min/m2 2CVP CVP 16mmHg16mmHgPAWPPAWP22mmHg22mmHgSVV SVV 30%30%GEDI GEDI 641 ml/m641 ml/m2 2 EVLWI EVLWI 20 ml/kg 20 ml/kg PVPI PVPI 3.8%3.8%Management of ARDSn nProspective,nonrandomized,Prospective,nonrandomized,nonblindednon
16、blinded interventional interventional study.study.n nCardiac catheterization and echocardiography Cardiac catheterization and echocardiography laboratories.laboratories.n nNormal healthy volunteersNormal healthy volunteersn nGroups:Groups:Group 1:Pulmonary catheterization and radionuclide Group 1:Pu
17、lmonary catheterization and radionuclide cineangiographycineangiography n=12 n=12 Group 2:volumetric echocardiography n=32Group 2:volumetric echocardiography n=32n nVolume load:Volume load:3 L 3 L salinsalin iv over 3 hrs iv over 3 hrsCrit Care Med.2004;32:691699.Crit Care Med 2004;32:691699CVP/PAWP
18、CVP/PAWP对容量试验的反应对容量试验的反应n择期心脏手术患者n=20n监测GEDVI:PiCCOCEDVIPAC:PACLV preload assessment:TEEnHemodynamic measurements:before(T0)and 20 min(T1)and 40 min(T2)after a volume loadnVolume load:HES10 ml/kg over 20min British Journal of Anaesthesia.2005,94(6):748755.British Journal of Anaesthesia 94(6):74855(2
19、005)容量状态评估SVVSVV、PPV:predicting fluid responsivenessPPV:predicting fluid responsiveness40 patients undergoing elective OPCABGChest 2005,128:848854nSVV、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):296-327Crit Care Med 2008,36(1):296-327ARDS：通透性增加 容量控制 N Engl
20、J Med 2006,354:2564-75N 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：主要处理：大量血浆、白蛋白输注，循环稳定下间断利尿大量血浆、白蛋白输注，循环稳定下间断利尿 (前前3 3日液体平衡：日液体平衡：2000ml2000ml，50ml,50ml,800ml)800ml)泰能、替考拉宁、替硝唑联合大扶康抗感染泰能、替考拉宁、替硝唑联合大扶康抗感染 呼吸机呼吸机(BiPAP(BiPAP模式，模式，PEEP 1015cmHPEEP 1015cmH2 2O,O,MAP 20cm
21、H MAP 20cmH2 2O,VO,VT T 420ml 420ml左右左右),),间断行间断行SISI 6-07 6-07 PiCCOPiCCO：(多巴胺多巴胺4 4ug/kg/minug/kg/min，血压，血压120/80mmHg120/80mmHg)CO 6.56 L/min CI 3.62 L/min/m CO 6.56 L/min CI 3.62 L/min/m2 2 SVV 10%GEDI 1310 ml/m SVV 10%GEDI 1310 ml/m2 2 EVLWI 12 ml/kg PVPI 2.0EVLWI 12 ml/kg PVPI 2.0Management of
22、ARDS6-07 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？拔管失败可能的原因？Management of ARDS再插管前一天胸片再插管前一天胸片 再插管后胸片再插管后胸片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 成功脱机成功脱机Management of ARDSPiCCO for ARDS肺水及血管通透性相关指标有助于肺水肿类型的肺水及血管通透性相关指标有助于肺水肿类型的鉴别及鉴别及ARDSARDS诊断诊断容量指标可更好的指导容量指标可更好的指导ARDSARDS患者前负荷的评价患者前负荷的评价血管外肺水指标可指导血管外肺水指标可指导ARDSARDS患者容量管理和脱患者容量管理和脱机判断机判断