老年重症肺炎并发感染性休克患者血管外肺水与液体管理

目的探讨脉搏指示连续心排血量(PiCCO)技术监测血管外肺水指数(ELWI)对老年重症肺炎并发感染性休克患者液体管理的指导意义。 方法2011年8月至2014年7月杭州市老年病医院ICU选取46例老年重症肺炎机械通气患者，其中以ELWI为目标进行容量管理22例(ELWI组)，以中心静脉压(CVP)结合胸部影像学为参照进行容量管理24例(CVP组)，观察两组患者24 h，48 h，72 h的APACHEⅡ评分、氧合指数、血乳酸、中心静脉血氧饱和度(ScVO₂)、液体出入量、机械通气时间、ICU住院时间及28 d病死率的变化。两组患者APACHEⅡ评分、氧合指数、血乳酸、ScVO₂、液体出入量、机械通气时间、ICU住院时间的比较均采用独立样本t检验，28d病死率的比较采用χ²检验。 结果与CVP组比较，ELWI组在24 h，48 h的APACHEⅡ评分及24 h的氧合指数、ScVO₂、血乳酸均未发生明显变化，差异均无统计学意义(t＝12.43、5.63、11.32、13.65、10.64、8.63，均P>0.05)；而72 h的APACHEⅡ评分明显下降，48 h，72 h的氧合指数、ScVO₂明显升高，72 h的血乳酸明显降低，差异均有统计学意义(t＝26.45、5.12、45.23、4.16、15.43、16.22，均P<0.05)。与CVP组比较，ELWI组24 h，48 h液体总入量及净入量均明显减少，差异均有统计学意义(t＝18.42、25.64、3.32、11.82，均P<0.05)；而72 h的液体总入量及净入量均未发生明显变化，差异均无统计学意义(t＝6.13、26.52，均P>0.05)。与CVP组比较，ELWI组机械通气时间及ICU住院时间均明显减少，差异均有统计学意义(t＝18.55、22.12，均P<0.05)；28 d病死率未发生明显变化，差异无统计学意义(χ²＝0.55，P>0.05)。 结论老年重症肺炎并发感染性休克患者进行PiCCO技术监测，根据ELWI指导液体复苏，能显著降低液体总入量，明显改善患者氧合指数，减少呼吸机使用时间，缩短ICU住院时间，降低病死率。

Fluid management of extravascular lung water in elderly patients with severe pneumonia and spetic shock

ObjectiveTo evaluate the clinical value of pulse-indicated continuous cardiac output (PiCCO) in elderly patients with severe pneumonia and spetic shock. MethodsTreat 46 elderly patients with severe pneumonia and respiratory failure with Extravascular Lung Water Index (ELWI) or conventional central venous pressure (CVP) and radiographic exam to monitor fluid management. Comparison between two groups include 24 h, 48 h and 72-h Acute Physiology and Chronic Health Evaluation(APACHE) Ⅱ score, oxygenation index, blood lactate and mixed venous oxygen saturation (ScVO₂). Fluid intake and output, duration of mechanical ventilation, ICU stay and 28-day mortality were also observed. ResultsSeventy-two h-APACHE Ⅱ score was significantly lower in PiCCO group than CVP group (t=26.45, P<0.05). 48 h, 72 h-oxygenation index and ScVO₂ in ELWI group were significantly higher than those in CVP group (t=4.16、15.43, P<0.05), while the 72 h-blood lactate was significantly lower in ELWI group than that in CVP group (t=16.22, P<0.05). The net liquid income were significantly reduced in ELWI group than that in CVP group (t=18.42、25.64、3.32、11.82, P<0.05). Compared with CVP group, duration of mechanical ventilation and ICU stay were significantly reduced in ELWI group (t=18.55、22.12, P<0.05). Compared with CVP group, 28-day mortality in PiCCO-monitoring patients decreased, but no significant difference was found (χ²=0.55, P>0.05). ConclusionExtravascular lung water for fluid management in elderly patients with severe pneumonia and respiratory failure can significantly reduce the total fluid intake, improve patient oxygenation index, reduce ventilating time, shorten ICU length of stay and reduce mortality.