李 翠,王光權(quán),嚴(yán) 思,陳公海,顏光寰

PICCO在肺水腫危重患者中的應(yīng)用

李 翠,王光權(quán),嚴(yán) 思,陳公海,顏光寰

目的 觀察脈搏輪廓溫度稀釋連續(xù)心排血量監(jiān)測技術(shù)(PICCO)在肺水腫危重患者中的應(yīng)用及效果。方法 采用前瞻性臨床觀察研究方法,將54例肺水腫危重患者隨機(jī)分為觀察組和對照組,每組27例。觀察組采用PICCO對患者血流動(dòng)力學(xué)變化進(jìn)行監(jiān)測,并進(jìn)行早期積極的液體容量管理；對照組行中心靜脈導(dǎo)管留置,根據(jù)中心靜脈壓(CVP)指導(dǎo)液體容量管理。比較兩組治療第1、2、3 d的血流動(dòng)力學(xué)參數(shù)變化、機(jī)械通氣時(shí)間、住ICU時(shí)間、APACHEⅡ評(píng)分及28 d病死率等。結(jié)果 治療第2、3 d,觀察組心率(HR)、CVP及心排量指數(shù)(CI)與第1 d相比顯著改善,且HR及CI指標(biāo)明顯優(yōu)于同一時(shí)間對照組(P<0.05)；治療第2、3 d,觀察組全心舒張末期容積指數(shù)(GEDVI)、胸腔內(nèi)血容量指數(shù)(ITBVI)及血管外肺水含量指數(shù)(EVLWI)與第1 d相比均顯著改善(P<0.05)；觀察組機(jī)械通氣時(shí)間及住ICU時(shí)間明顯短于對照組,APACHEⅡ評(píng)分明顯高于對照組(P<0.05)；觀察組28 d內(nèi)無死亡病例,對照組死亡3例,觀察組28 d病死率低于對照組,但差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 PICCO監(jiān)測指導(dǎo)肺水腫危重患者早期液體管理,能有效縮短機(jī)械通氣時(shí)間及ICU住院時(shí)間,有助于肺水腫危重患者救治。

PICCO;肺水腫；危重患者

脈搏輪廓溫度稀釋連續(xù)心排血量監(jiān)測技術(shù)(pulse indicator continuous cardiac output,PICCO)是一種全新的脈搏輪廓連續(xù)心排血量與經(jīng)肺溫度稀釋心排血量聯(lián)合應(yīng)用技術(shù),不僅可以監(jiān)測常規(guī)血流動(dòng)力學(xué)參數(shù),還可有效指導(dǎo)臨床危重患者的治療[1-2]。PICCO采用熱稀釋方法測量單次的心輸出量,并通過分析動(dòng)脈壓力波形曲線下面積獲得連續(xù)的心臟指數(shù)及各種容量參數(shù),對危重患者的監(jiān)測和治療提供了重要的臨床資料。我科于2010～2014年將PICCO用于指導(dǎo)肺水腫危重患者的治療,取得滿意的效果,現(xiàn)報(bào)道如下。

1 資料與方法

1.1 病例資料 選取2010年1月～2014年1月我科收治的54例肺水腫危重患者為研究對象,研究得到醫(yī)院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn)同意。按患者入院順序編號(hào),采用隨機(jī)數(shù)字法分為觀察組和對照組。觀察組男性17例,女性10例,年齡36～72(53.6±5.7)歲,其中心源性肺水腫15例,神經(jīng)性肺水腫5例,感染性肺水腫4例,高原肺水腫1例,吸入性肺水腫2例；對照組男性18例,女性9例,年齡37～74(53.8±5.6)歲,其中心源性肺水腫16,神經(jīng)性肺水腫4例,感染性肺水腫5例,高原肺水腫1例,吸入性肺水腫1例。兩組在性別、年齡、基礎(chǔ)病因等方面未見明顯差異(P>0.05),具有可比性。所有患者及監(jiān)護(hù)人均簽署知情同意書。

1.2 方法 所有患者入院后均給予常規(guī)監(jiān)測生命體征及積極對癥治療。觀察組患者選擇右側(cè)鎖骨下靜脈或頸內(nèi)靜脈置入導(dǎo)管,導(dǎo)管主腔接溫度傳感器和換能器連接PICCO監(jiān)測儀(PC8500,德國Pulsion公司生產(chǎn)),患者股動(dòng)脈置入PICCO容量監(jiān)測導(dǎo)管,接壓力傳感器連接到監(jiān)測儀,連續(xù)監(jiān)測動(dòng)脈血壓和中心靜脈壓。每次測量時(shí),經(jīng)中心靜脈連接的溫度探頭處快速注入10～15 ml生理鹽水(溫度<8 ℃),計(jì)算機(jī)通過溫度傳感器熱敏電阻測量的溫度變化,畫出熱稀釋曲線,并自動(dòng)分析曲線波形,連續(xù)測量3次取平均值；當(dāng)患者出現(xiàn)循環(huán)動(dòng)力學(xué)變化時(shí),隨時(shí)進(jìn)行測量。對照組患者常規(guī)行頸內(nèi)靜脈置管,監(jiān)測CVP的變化。

1.3 觀察指標(biāo) 應(yīng)用德國Pulsion公司生產(chǎn)PICCO監(jiān)護(hù)儀測定容量指標(biāo),記錄觀察組患者心率(HR)、中心靜脈壓(CVP)、心排量指數(shù)(CI)、全心舒張末期容積指數(shù)(GEDVI)、胸腔內(nèi)血容量指數(shù)(ITBVI)及血管外肺水含量指數(shù)(EVLWI)變化。對照組患者常規(guī)記錄HR、CVP及CI變化情況。

2 結(jié)果

2.1 兩組治療后血流動(dòng)力學(xué)參數(shù)變化比較 治療第2、3 d后,觀察組HR、CVP及CI與第1d相比顯著改善(P<0.05),且觀察組HR及CI明顯優(yōu)于同時(shí)間對照組(P<0.05)。治療第2、3 d,觀察組患者GEDVI、ITBVI及EVLWI與第1 d相比均顯著改善(P<0.05)。見表1。

2.2 兩組機(jī)械通氣時(shí)間、住ICU時(shí)間、APACHEⅡ評(píng)分及病死率比較 觀察組機(jī)械通氣時(shí)間、住ICU時(shí)間及治療第3 d結(jié)束后APACHEⅡ評(píng)分明顯優(yōu)于對照組(P<0.05)；觀察組28 d內(nèi)無死亡病例,對照組死亡3例,觀察組病死率低于對照組,但組間差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表2。

3 討論

長期以來臨床多通過肺動(dòng)脈嵌頓壓(PAWP)及中心靜脈壓(CVP)來指導(dǎo)危重患者的容量管理。近年來,大量臨床研究發(fā)現(xiàn),PAWP及CVP與心臟前負(fù)荷的相關(guān)性受血容量、右房壓、心臟射血功能、胸內(nèi)壓等多因素影響,不能第一時(shí)間準(zhǔn)確反映患者體內(nèi)液體變化,在指導(dǎo)危重患者液體管理中具有一定的局限性[3-4]。不適當(dāng)?shù)娜萘抗芾聿呗钥赡軙?huì)導(dǎo)致患者血管外肺水增加,加重患者肺水腫程度,延長呼吸機(jī)使用時(shí)間,甚至增加患者的死亡風(fēng)險(xiǎn)。肺水腫是危重患者急性呼吸衰竭的重要原因,是急性心肌梗死或慢性心力衰竭患者主要的并發(fā)癥之一,常導(dǎo)致患者出現(xiàn)嚴(yán)重缺氧,危重者多需要機(jī)械通氣治療[5]。臨床常規(guī)監(jiān)測方法很難量化肺水腫的范圍和嚴(yán)重程度。PICCO創(chuàng)傷性小、操作簡單,能準(zhǔn)確、連續(xù)監(jiān)測心排量、外周血管阻力、血管外肺水含量等指標(biāo)的變化,給危重患者的臨床監(jiān)測和指導(dǎo)治療帶來新的希望[6]。

表1 兩組治療不同時(shí)間血流動(dòng)力學(xué)參數(shù)變化比較(n=27)

注：與同組治療第1 d相比,①P<0.05；與同時(shí)間對照組相比,②P<0.05

表2 兩組機(jī)械通氣時(shí)間、住ICU時(shí)間、APACHEⅡ評(píng)分及病死率比較(n=27)

注：與對照組相比,①P<0.05

本研究對27例肺水腫危重患者采用PICCO監(jiān)測血流動(dòng)力學(xué)變化,指導(dǎo)早期液體容量管理,并與常規(guī)CVP指導(dǎo)液體容量管理進(jìn)行對比研究。結(jié)果顯示,觀察組治療第2、3 d后,患者HR、CVP及CI與第1 d相比均顯著改善,且HR及CI明顯優(yōu)于同時(shí)間對照組,說明PICCO指導(dǎo)的液體容量管理能顯著改善肺水腫危重患者的心功能指標(biāo)。Bein等[7]的研究也發(fā)現(xiàn),PICCO技術(shù)可通過評(píng)價(jià)心臟前負(fù)荷指導(dǎo)容量管理和血管活性藥的使用,不僅能在保證臟器正常灌注的前提下,避免容量負(fù)荷過重造成肺水腫,還可提高機(jī)體對正性肌力及血管收縮藥物治療的療效。PICCO監(jiān)測的容量指標(biāo)ITBVI 、GEDVI比傳統(tǒng)壓力指標(biāo)能更好地反映患者的容量反應(yīng)性[8]。EVLWI不僅可提高肺損傷患者診斷的準(zhǔn)確率,還可作為評(píng)價(jià)肺水腫嚴(yán)重程度及患者預(yù)后的重要參考指標(biāo)[9-10]。Mallat等[11]的研究發(fā)現(xiàn),EVLW與肺水腫嚴(yán)重程度明顯相關(guān),EVLW水平越高,患者預(yù)后越差。Wiedemann等[12]研究也發(fā)現(xiàn),EVLW是判斷肺水腫患者預(yù)后的獨(dú)立危險(xiǎn)因素。本研究觀察組治療后第2、3 d,患者EVLW水平與第1 d相比明顯降低,提示患者病情得到有效改善。 觀察組機(jī)械通氣時(shí)間、住ICU時(shí)間及APACHEⅡ評(píng)分均顯著優(yōu)于對照組,說明PICCO作為肺水腫危重患者液體容量管理的有效監(jiān)測手段,療效確切,能較早幫助患者改善病情,早期脫離呼吸機(jī),從而降低相關(guān)并發(fā)癥的發(fā)生率,提高治療療效。

綜上所述,PICCO作為一種微創(chuàng)的血流動(dòng)力學(xué)監(jiān)測技術(shù),能有效指導(dǎo)肺水腫危重患者的早期液體管理,縮短機(jī)械通氣時(shí)間及ICU住院時(shí)間,提高治療療效,值得臨床推廣應(yīng)用。

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Application of PICCO to critical patients with pulmonary edema

Li Cui,Wang Guangquan,Yan Si,Chen Gonghai,Yan Guanghuan

ICU,the People's Hospital of Qionghai City,Hainan,571400,China

Objective To discuss the application of pulse indicator continuous cardiac output(PICCO)to critical patients with pulmonary edema and the effect.Methods 54 critical patients with pulmonary edema were randomly divided into 2 groups:observation group and control group,27 in each;PICCO was applied to monitor the hemodynamic changes of the patients in observation group and early positive volume management of fluid was performed,while detained central venous catheter was applied to patients in control group and volume management of fluid was carried out based on central venous pressure(CVP);a comparative study was made between the 2 groups on the changes of hemodynamic index,mechanical ventilation time,the time length of staying in ICU,the scores of APACHEⅡ and the case fatality rate in 28 days.Results The heart rate(HR),CVP and cardiac output index(CI)of the patients in observation group on the 2nd and 3rd day of the treatment were much more improved than those on the 1st day and much superior to those of the patients in control group of the same time(P<0.05);the GEDVI,ITBVI and EVLWI of the patients in observation group on the 2nd and 3rd day of the treatment were more improved than those on the 1st day(P<0.05);the mechanical ventilation time and the time length of staying in ICU of the patients in observation group were much shorter than those of the patients in control group while their scores of APACHEⅡ were higher than those of the patients in control group(P<0.05);the case fatality rate in observation group in 28 days was lower than that in control group(no death occurred in observation group while 3 patients died in control group)but the difference was of no obvious statistical significance(P>0.05).Conclusions The application of PICCO in monitoring the early volume management of fluid in critical patients with pulmonary edema can effectively shorten the mechanical ventilation time and the time length of staying in ICU,which is quite helpful in the treatment of the patients.

pulse indicator continuous cardiac output(PICCO)；pulmonary edema；critical patient

571400 海南 瓊海,海南省瓊海市人民醫(yī)院重癥醫(yī)學(xué)科

R 473.5

A

1004-0188(2014)09-0972-03

10.3969/j.issn.1004-0188.2014.09.017

2014-06-19)