胸腔积液对经肺热稀释法血管外肺水监测准确性的影响

目的 探讨胸腔积液对经肺热稀释技术监测血管外肺水(EVLW)准确性的影响.方法 6只北京长条猪通过静脉注射油酸制备急性肺损伤(ALI)模型,然后先后分别向肺泡内及胸膜腔内灌注一定量的生理盐水,在两种不同灌注方式的前后均采用经肺热稀释法测定EVLW,观察肺泡灌注前后EVLW变化与所灌注生理盐水量之间的相关性,同时观察胸腔内灌注生理盐水前后EVLW含量的变化.结果 基础状态下正常肺组织EVLW含量(276.6±10.8)mL,ALI模型成功后EVLW含量(378.9±12.2) mL,与基础状态比较差异有统计学意义(P＜0.001);肺泡灌注前后EVLW的变化与实际肺泡灌注生理盐水量之间具有良好的相关性(r=0.973,P＜0.001);胸腔内灌注前后测定的EVLW含量无变化(P＞0.05).结论 经肺热稀释技术对血管外肺水的监测具有良好的准确性,胸腔积液对血管外肺水监测准确性无影响.     

肺移植围术期容量监测和血管外肺水监测的临床研究

目的:应用脉搏指示连续心排血量(PiCCO)技术监测肺移植患者围术期的容量指标和血管外肺水,评估其临床应用价值。方法:肺移植术的终末期肺病患者20例,15例单肺移植,5例序贯式双肺移植。麻醉诱导:咪唑安定2～4mg、依托咪酯0.2～0.4mg/kg、芬太尼4～5μg/kg,维库溴铵0.1～0.15mg/kg;插入双腔支气管导管,纤支镜定位后,取颈内和锁骨下静脉穿刺分别置入中心静脉导管和Swan-Ganz漂浮导管,取左侧股动脉穿刺置入PiCCO导管。分别监测麻醉后双肺通气(T0)、单肺通气(T1)、肺动脉夹闭(T2)、肺动脉开放(T3)、术毕(T4)、术后8h(T5)、术后24h(T6)各时点血流动力学和血管外肺水。结果:与麻醉后双肺通气比较,心排指数在单肺通气和肺动脉夹闭时明显降低(P<0.05),肺动脉开放和术毕、术后时明显升高(P<0.05);血管外肺水、肺血管通透性在肺动脉开放时和术毕、术后明显升高(P<0.05);且肺动脉开放后ITBI与SVI正相关(r=0.69,P<0.01),PAWP与SVI不相关(r=0.23,P>0.05;),ELWI与PVPI正相关(r=0.82,P<0.01)。结论:Pi...     

血管外肺水指数对脓毒性休克患者的预后价值研究

脓毒性休克是临床常见的急危重症,是引起多器官功能障碍综合征( MODS)的重要诱因.其中肺脏是最多受累的器官,可改变肺脏通透性,导致间质水肿,严重影响气体交换及氧合过程,使全身各组织器官处于缺氧状态,加重病情.     

三七总皂苷对急性肺损伤犬血管外肺水及呼吸力学的影响

目的 探讨三七总皂苷(PNS)对急性肺损伤(ALI)犬血管外肺水(EVLW)与呼吸力学参数的影响.方法 18只犬被随机均分为正常对照组、模型组,PNS治疗组.均给予犬气管插管建立人工气道并实施机械通气支持[潮气量(VT)10 ml/kg,呼气末正压(PEEP)0,吸人氧浓度(FiO2)1.00].静脉注射油酸建立ALI犬模型.成模后PNS组静脉给予PNS 10 mg/kg(溶于葡萄糖注射液中,2.5 ml/min),正常对照组和模型组给予等量葡萄糖注射液.连续监测各组犬的呼吸力学参数及动脉血气.成模后4 h处死动物,采用重力法测定EVLW,计算血管外肺水指数(EVLWI).结果 PNS能显著降低ALI犬的EVLWI[(14.10±1.45)ml/kg比(17.97±0.85)ml/kg,P<0.05],但仍显著高于正常对照组[(8.82±0.54)ml/kg,P<0.01].制模成功后,氧合指数(PaO2/FiO2)及静态肺顺应性(Cst total)显著下降;静脉注射PNS 2 h后PaO2/FiO2和Cst total较模型组显著升高(P<0.05或P<0.01);而气道阻力(Raw)、动脉血二氧化碳分压(PaCO2)则无明显变化,3组间比较差异亦无统计学意义(P均>0.05).结论 PNS对ALI犬具有一定的保护作用,使EVLW降低、肺顺应性增高,有助于改善低氧血症.     

PICCO指导下的血管外肺水指数监测在重症急性胰腺炎合并急性呼吸窘迫综合征中的应用

目的 探讨脉波指示连续心排血量指导下的血管外肺水指数监测在重症急性胰腺炎合并急性呼吸窘迫综合征中的应用.方法 将70例重症急性胰腺炎合并急性呼吸窘迫综合征患者按照随机数字表法分为研究组与对照组,每组35例.对照组给予常规肺水管理,研究组给予脉波指示连续心排血量指导下的血管外肺水指数监测.比较两组有创通气、无创通气及总通...     

肺超声定量联合血管外肺水指数在成人ARDS早期诊断中的应用研究

目的 分析肺超声定量联合血管外肺水指数（EVLWI）用于成人急性呼吸窘迫综合征（ARDS）早期诊断的临床价值。方法 前瞻性选择高度怀疑ARDS患者共78例为研究对象,经确诊ARDS患者58例（观察组）,非ARDS患者20例（对照组）。比较两组肺超声显示彗星尾征（即B线）数量和半定量评分、EVLWI,以及观察组患者治疗前后上述指标的变化。结果 观察组治疗后B线数量、半定量评分和EVLWI值均明显低于治疗前,差异均有统计学意义（t分别=8.12、10.20、5.86,P均<0.05）。观察组B线数量、半定量评分和EVLWI值均明显高于对照组,差异有统计学意义（t分别=9.62、15.43、7.50,P均<0.05）。半定量评分和EVLWI值有较好的正相关性（r=0.45,P<0.05）。受试者工作特征曲线（ROC）显示,半定量评分联合EVLWI值诊断ARDS的曲线下面积为0.86,灵敏度为85.61%,特异度为74.34%,半定量评分临界值为12.34分,EVLWI临界值为2.76。结论 肺超声联合脉搏指示连续心排血量监测（PiCCO）测量EVLWI在成人ARDS早期诊断...     

血管外肺水指标在脓毒症合并急性肺损伤/急性呼吸窘迫综合征患者中的作用

目的 应用PiCCO技术监测并比较脓毒症合并急性肺损伤(ALI)或急性呼吸窘迫综合征(ARDS)患者的血流动力学改变,以探讨血管外肺水与各肺损伤指标及肺内炎症因子水平的相关性.方法 选取40例2009年至2010年广州市第一人民医院ICU住院脓毒症患者进行观察,其中未合并ALI/ARDS的患者作为对照组.应用PiCCO技术连续7d监测血管外肺水等血流动力学指标,并记录血气分析结果、呼吸机参数、胸片,检测血清及肺泡灌洗液中炎症因子白介素-1( IL-1)及肿瘤坏死因子-α(TNF-α)的水平.结果 在40例脓毒症患者中,15例(37.5％)合并ARDS,14例(35％)合并ALI.与对照组相比,ALI及ARDS患者表现为显著增高的血管外肺水指数(EVLWI)及肺泡灌洗液中IL-1、TNF-α水平.同时,血管外肺水指数与氧合指数、肺损伤指数及IL-1、TNF-α水平呈显著相关性(r=-0.524,r=0.147,r=0.572,r=0.655;P＜0.05),且高ELVW水平组患者ICU病死率及住院病死率均显著高于低ELVW水平组.结论 在脓毒症介导的ALI及ARDS患者中,血管外肺水指标与肺内炎症因子水平及肺损伤严重程度具有相关性.因此,EVLW的检测可能对于判断脓毒症患者肺损伤程度及预后具有一定意义.     

血管外肺水监测对脓毒症急性肾损伤的应用研究

目的探讨血管外肺水监测(PICCO)在脓毒症合并急性肾损伤肾脏替代治疗(RRT)中的应用价值。方法选取2012年3月-2014年12月我院收治的脓毒症合并急性肾损伤患者41例,在PICCO监测下,予每天6~8hRRT,根据血管外肺水指数(EVLWI)值分成观察组(EVLWI7mL/kg)21例和对照组(EVLWI≤7mL/kg)20例。观察初始液体复苏治疗后,两组患者氧合指数(PO_2/FiO_2)、动脉氧分压(PO_2)、经皮脉氧饱和度(SPO_2)、血乳酸值的变化。结果观察组液体复苏24h的PO_2/FiO_2明显低于治疗前及对照组(P0.05);观察组在液体复苏48h后PO_2/FiO_2开始恢复,但仍低于对照组(P0.05);两组患者液体复苏72h的PO_2/FiO_2恢复正常。观察组液体复苏24h的PO_2低于观察组(P0.05)。两组患者液体复苏24h的SPO_2均呈一过性下降,48h恢复正常,两组患者SPO_2液体复苏治疗前后及相互比较均无统计学差异(P0.05)。观察组与对照组液体复苏24h的血乳酸明显低于治疗前(P0.01),两组间比较差异无统计学意义(P0.05)。结论血管外肺水监测有助于脓毒症合并急性肾损伤患者氧合情况的观察与护理。     

ALI/ARDS早期血管外肺水影响因素研究进展

血管外肺水(extravascular lung water,EVLW)增加是急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)的重要病理生理改变之一。研究ALI/ARDS早期EVLW变化及其影响因素,对于了解ALI/ARDS早期病理特征及指导临床治疗有重要意义。本文介绍ALI/ARDS早期EVLW的变化情况及主要影响因素,如上皮钠通道、呼吸末正压通气、糖皮质激素、心输出量、肺动脉压、一氧化氮等的相关研究进展。     

经肺热稀释法评估重度急性敌敌畏中毒猪呼吸功能变化

目的 有机磷农药中毒早期即可出现急性呼吸衰竭,能反映呼吸功能早期变化的指标不多.为此,制作重度急性敌敌畏中毒猪模型,利用PiCCO监测仪,评估敌敌畏中毒早期呼吸功能变化.方法 20只雌性家猪随机(随机数字法)分成敌敌畏组(7只)、阿托品组(7只),对照组(6只).敌敌畏组胃管注入80％乳油敌敌畏(100 mg/kg),复制重度敌敌畏中毒猪模型,阿托品组注入敌敌畏半小时后静脉推注阿托品至阿托品化并维持,对照组除不使用敌敌畏和阿托品以外,其他均相同.所有动物均在0、0.5、1、2、4、6 h 6个时点采集动、静脉血进行血气分析以及胆碱酯酶水平,记录EVLWI和PVPI值,6h后活杀动物,取肺组织行肺湿质量/干质量比及组织学观察.结果 从0.5h时点开始,敌敌畏组SaO2、PO2/FiO2出现明显下降,第1小时时点下降幅度最为明显,而PaCO2经历了先下降(1h前)而后上升的过程;阿托品组SaO2、PaCO2、PO2/FiO2先下降,但从第1小时时点开始逐渐回升.敌敌畏组EVLWI和PVPI变化过程相似,表现为逐渐升高;经过阿托品治疗后,二者上升趋势从第1小时时点开始明显减缓;对照组上述指标与基础时点比较无明显变化.相关关系分析,敌敌畏组和阿托品组,EVLWI与PO2/FiO2呈负相关关系;与PVPI变化呈正相关关系.与对照组比较,敌敌畏组肺湿质量/干质量明显增加,而阿托品组轻度增加.与此同时,敌敌畏组肺组织病理和超微病理变化显著,而阿托品组变化较轻.结论 重度急性敌敌畏中毒猪呼吸功能变化显著,EVLWI是早期评估中毒猪呼吸功能变化的有效指标.     

Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution

Objective: Transpulmonary double-indicator dilution is a useful monitoring technique for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). In this study, we compared a simpler approach using single arterial thermodilution derived measurements of ITBV and EVLW with the double-indicator dilution technique.¶Design: Prospective observational clinical study.¶Setting: Surgical intensive care units of two university hospitals.¶Patients and methods: Global end-diastolic volume (GEDV) derived from single thermodilution was used for calculation of ITBV. Structural regression analysis of the first two thermo-dye dilution measurements in a derivation population of 57 critically ill patients (38 male, 19 female, 18–79 years, 56 ± 15 years) revealed ITBV = (1.25 · GEDV)–28.4 (ml). This equation was then applied to all first measurements in a validation population of 209 critically ill patients (139 male, 70 female, 10–88 years, mean 53 ± 19 years), and single-thermodilution ITBV (ITBV_ST) and EVLW (EVLW_ST) was calculated and compared to thermo-dye dilution derived values (ITBV_TD, EVLW_TD). For inter-individual comparison, absolute values for ITBV and EVLW were normalised as indexed by body surface area (ITBVI) and body weight (EVLWI), respectively.¶Measurements and results: Linear regression analysis yielded a correlation of ITBVI_ST = (1.05 · ITBVI_TD)–58.0 (ml/m²), r = 0.97, P < 0.0001. Bias between ITBVI_TD and ITBVI_ST was 7.6 (ml/m²) with a standard deviation of 57.4 (ml/m²). Single-thermodilution EVLWI (EVLWI_ST) was calculated using ITBVI_ST and revealed the correlation EVLWI_ST = (0.83 · EVLWI_TD) + 1.6 (ml/kg), r = 0.96, P < 0.0001. Bias between EVLWI_TD and EVLWI_ST was –0.2 (ml/kg) with a standard deviation of 1.4 (ml/kg). In detail, EVLWI_ST systematically overestimated EVLWI_TD at low-normal values for EVLWI and underestimated EVLWI at higher values (above 12 ml/kg).¶Conclusion: Determinations of ITBV and EVLW by single thermodilution agreed closely with the corresponding values from the double-indicator technique. Since transpulmonary single thermodilution is simple to apply, less invasive and cheaper, all these features make it a promising technique for the bedside. Nevertheless, further validation studies are needed in the future.     

Room-temperature vs iced saline indicator injection for transpulmonary thermodilution

Purpose

Ice-cold injectate is assumed to provide best accuracy for transpulmonary thermodilution (TPTD)-derived cardiac index (CI), global end-diastolic volume index (GEDVI), and extravascular lung-water index (EVLWI). Room-temperature injectate might facilitate TPTD. Therefore, this study compares TPTD-results derived from iced injectate with room-temperature injectate TPTDs (TPTD_Room).

Materials and methods

Forty-five adult intensive care unit patients with PiCCO monitoring (Pulsion Medical Systems, Munich, Germany) were included in this observational study. Four hundred one sets of TPTDs were recorded. Each set consisted of four 15 mL TPTDs (twice with 21°C and subsequently twice with 4°C saline). Means of 2 TPTD_Room were compared with means of 2 cold TPTDs (primary end point).

Results

Mean CI (4.70 ± 1.60 vs 4.54 ± 1.52 L/min per square meter; P < .001), GEDVI (985 ± 294 vs 954 ± 269 mL/m²; P < .001), and EVLWI (14.4 ± 7.8 vs 13.8 ± 7.3 mL/kg; P < .001) were significantly higher for TPTD_Room compared with TPTD-results derived from iced injectate. Mean bias and percentage error were 0.15 ± 0.52 L/min per square meter and 21.9% for CI, 30 ± 145 mL/m² and 29.3% for GEDVI, and 0.59 ± 2.1 mL/kg and 29.3% for EVLWI.Percentage error values were higher in case of femoral compared with jugular indicator injection for CI (25% vs 20%), GEDVI (35% vs 25%), and EVLWI (41% vs 23%).

Conclusions

Room-temperature injectate TPTDs results in slight but significant overestimation of CI, GEDVI, and EVLWI. Percentage error values for GEDVI_Room and EVLWI_Room are acceptable only in case of “jugular” indicator injection.     

Influence of extravascular lung water on transpulmonary thermodilution-derived cardiac output measurement

Objective The transpulmonary thermo-dye dilution technique enables assessment of cardiac index (CI) intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI). Since the extent of lung edema may influence the reliability of CI measurement by transpulmonary thermodilution due to loss of indicator, we analyzed the impact of EVLWI on transpulmonary thermodilution-derived CI in critically ill patients. Design Retrospective, clinical study. Setting Surgical intensive care unit in a university hospital Patients and methods With ethics approval we analyzed data from 57 patients (38 men, 19 women; age range 18–79 years) who, for clinical indication, underwent hemodynamic monitoring by transpulmonary thermo-dye dilution and pulmonary artery thermodilution (572 measurements). All patients were mechanically ventilated and had received a femoral artery thermo-fiberoptic and pulmonary artery catheter which were connected to a computer system (Cold-Z021, Pulsion Medical Systems, Munich, Germany). For each measurement, 15–17 ml indocyanine green(4–6 °C) was injected central venously. Injections were made manually and independently from the respiratory cycle. Linear regression was used for statistical analysis. Interventions and main results The difference between transpulmonary and pulmonary artery thermodilution CI was not correlated with EVLWIfor all measurements (n = 572, r = 0.01, p = 0.76) and when using only the first simultaneous measurement (n = 57, r = 0.08, p = 0.56). Furthermore, EVLWI was not correlated with transpulmonary thermodilution CI (n = 572, r = 0.07, p = 0.08). Coefficient of variation for transpulmonary thermodilution CI was 7.7 ± 4.3%. Conclusion Measurement of cardiac output by transpulmonary thermodilution is not influenced by EVLWI in critically ill patients and loss of indicator as the underlying reason is probably overestimated.     

Influence of cardiac output on thermal-dye extravascular lung water (EVLW) in cardiac patients

The influence of varying cardiac output (CO) on thermal-dye extravascular lung water (EVLW) was investigated in a total of 40 cardiac surgery patients before the onset of the operation. EVLW was measured by means of the double indicator dilution technique with indocyanine green as the non-diffusible inducator and a microprocessed lung water computer 15 min and 30 min after change of CO. CO was varied from -45% to +70% of the baseline value by nifedipine infusion (CO, n=20) or halothane application (CO, n=20), respectively. CO was measured from the femoral artery instream thermistor tipped lung water catheter and, simultaneously, from the pulmonary artery. In spite of a highly significant decrease (-45%) and increase (+70%) in CO no change in EVLW could be observed. CO estimation was comparable for both methods used. Regression analysis revealed no relationship between CO and EVLW as well as between EVLW and various hemodynamic parameters. We conclude that thermal-dye technique for estimation of EVLW may be accurate in spite of changing cardiac output over a wide range.     

PiCCO监测在神经源性肺水肿患者中的应用研究

目的 探讨脉搏指示连续心排血量(PiCCO)监测在神经源性肺水肿(NPE)患者中的应用,评估容量参数胸腔内血容量指数(ITBVI)、全心舒张期末容量指数(GEDVI)及压力参数中心静脉压(CVP)对NPE严重程度评估的准确性,评价血管外肺水指数(EVLWI)对NPE患者预后判断的意义.方法 采用前瞻性临床观察研究方法,对36例并发NPE的神经科危重患者,采用PiCCO监测平均动脉压(MAP)、心排血指数(CI)、CVP、ITBVI、GEDVI、EVLWI、肺血管通透性指数(PVPI)等指标,ITBVI、GEDVI、CVP与EVLWI之间进行相关性分析;根据患者结局分为死亡组与存活组,比较两组在治疗前及治疗3d的EVLWI变化.结果 EVLWI与ITBVI呈显著正相关(r=0.54,P＜0.001),与GEDVI呈显著正相关(r=0.62,P＜0.0001),而与CVP无显著相关性(r=0.12,P＞0.05);PVPI、EVLWI与氧合指数(PaO2/FiO2)均呈显著负相关(r=-0.55、P＜0.001,r=-0.48、P＜ 0.05).存活组与死亡组治疗前EVLWI(ml/kg)水平差异无统计学意义(8.6±2.6比9.4±1.8,P＞0.05);存活组治疗3d后EVLWI水平明显低于治疗前(6.92±1.64比8.64±2.62,P＜0.05),且明显低于死亡组治疗3d后(6.92±1.64比9.88±2.44,P＜0.05).结论 容量参数GEDVI、ITBVI比压力参数CVP评估NPE患者的EVLWI更为准确、可靠;NPE患者PVPI、EVLWI越高,PaO2/FiO2越低;动态观察NPE患者的EVLWI可评估预后.     

Extravascular lung water assessed by transpulmonary single thermodilution and postmortem gravimetry in sheep

Introduction  

Acute lung injury is associated with accumulation of extravascular lung water (EVLW). The aim of the present study was to compare two methods for quantification of EVLW: transpulmonary single thermodilution (EVLW_ST) and postmortem gravimetric (EVLW_G).