摘要
目的分析肾源性脓毒性休克合并严重肺毛细血管渗漏的疾病特点，探讨液体复苏对休克治疗的影响以及脉搏指示连续心排血量（PiCCO）监测的意义。方法采用回顾性分析方法，选择8例在重症监护病房（ICU）进行PiCCO监测并成功复苏的肾、输尿管碎石手术后并发肾源性脓毒性休克伴严重肺毛细血管渗漏患者，均以人院为起点，休克纠正或转出为终点，记录全心舒张期末容积指数（GEDVI）、血管外肺水指数（EVLWI）、液体出入量、液体净平衡、氧合指数（Pa0卯i0：）、动脉血乳酸水平和x线胸片等指标，分析其内在联系，探讨肾源性脓毒性休克疾病的特点和PiCCO监测在休克液体复苏治疗中的意义。结果8例患者手术后4．5d（中位数）出现脓毒性休克，均伴有不同程度的肺毛细血管渗漏和低氧血症。入ICU时EVLWI均值为（22±7）ml／kg，PaO2/FiO2为（164±82）mmHg（1mmHg=0．133kPa）；液体复苏均采用保守性策略，平均液体入量为（2412±1121）ml／d，液体净平衡一553mud；中心静脉压（CVP）和GEDVl分别维持在（9±3）mmHg和（749±236）ml／m2。其中6例使用呋塞米利尿，平均剂量（264±133）mg；7例需要血管活性药物维持血压，去甲肾上腺素／多巴胺平均使用天数为（4±1）d；7例需要机械通气，通气时间（8±6）d。8例患者治疗后脓毒性休克均纠正，EVLWI下降至（11±3）ml／kg，肺部渗出吸收好转，平均住ICU天数（17±11）d。相关分析显示：EVLWI与PaO2/FiO2和动脉血乳酸水平显著相关，相关系数（r）值分别为-0．91和0．70（均P〈0．05）。结论准确评估血容量状态尤其是血管外肺水程度，参照血流动力学指标采取保守性液体复苏策略以及强调控制血管外肺水是成功救治肾源性脓毒性休克的关键，PiCCO是判断患者容量状态、指导液体复苏和评价治疗效果的有用工具。
Objective To characterize septic shock following urinary infection with severe pulmonary capillary leakage, and to evaluate the fluid therapy on treatment of hypovolemic shock and the role of transpulmonary thermodilution technique with pulse induced continuous cardiac output （PiCCO） monitoring. Methods A retrospective study was conducted. Eight patients surviving septic shock following urinary infection with severe pulmonary capillary leakage were enrolled, and all of them underwent PiCCO monitoring in the intensive care unit （ICU） when the diagnosis was established. The monitoring started at admission, and ended when shock was corrected or transferred from ICU. The clinical data including general end diastolic volume index （ GEDVI ）, extravascular lung water index （EVLWI）, input and output volume of fluid, net fluid balance, oxygenation index （PaO2/FiO2）, the level of arterial blood lactic acid, and chest X ray were collected and analyzed retrospectively the characteristics of septic shock following urinary infection, and the role of PiCCO monitoring in fluid resuscitation. Results Septic shock following urinary infection occurred in a median of 4.5 days in 8 patients after renal and ureterie calculi lithotripsy, accompanied with severe pulmonary vessel effusion and hypoxemia in different degrees. The mean value of EVLWI was （ 22 ±7 ） ml/kg, and the PaO2/FiO2 （ 164 ± 82） mm Hg （1 mm Hg=0.133 kPa） at the time of admission to ICU. Conservative fluid resuscitation strategy was adopted in management of septic shock with severe pulmonary capillary leakage, the mean fluid input in 8 patients was （2412 ± 1121） ml/d, and the net fluid balance -553 ml/d, and the central venous pressure （CVP） and GEDVI were maintained at levels of （9 ± 3 ） mm Hg and （749± 236） ml/m2 respectively. Diuretics were administered to 6 patients and the mean dosage of fursemide was （264± 133）mg. Norepinephrine and dobutamine infusion were given to 7 patients to maintain blood pressure at normal range for （4 ±1 ） days. Seven patients were mechanically ventilated, and the mean length of ventilation was （8 ±6） days. All of the 8 patients survived from septic shock after fluid resuscitation therapy, with the mean level of EVLWI decreased gradually to （11± 3） ml/kg, and the lung effusion was absorbed significantly as shown in chest X ray. The mean length of ICU stay was （ 17 ±11 ） days. Pearson correlate analysis showed EVLWI was significantly correlated with PaO2/FiO2 and the levels of artery blood serum lactate, with r -0.91 and 0.70 respectively （both P〈0.05）. Conclusions Successful management of septic shock following urinary infection with severe pulmonary vascular leakage is based on accurate assessment of blood volume status, especially the degree ofEVLWI, emphasis on prevention of EVLWI increase, and adoption of conservative fluid resuscitation strategies according to hemodynamic monitoring parameters. PiCCO monitoring is a useful tool in assessment of the blood volume status and management of fluid resuscitation in patients with urinary lithotrlpsy-associated septic shock complicated with severe pulmonary edema.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2013年第1期14-18,共5页
Chinese Critical Care Medicine
基金
国家自然科学基金项目（81101451）
广东省自然科学基金项目（9151051501000076）
关键词
肾源性脓毒性休克
肺毛细血管渗漏
液体复苏
脉搏指示连续心排血量监测技术
Septic shock following urinary infection
Pulmonary capillary leakage
Fluid resuscitation
Pulse induced continuous cardiac output monitoring
