ARDS患者液体管理策略重点分析.pptVIP

Rivers E. N Engl J Med. 2001 Nov 8;345(19):1368-77. PiCCO监测提供容量负荷、心脏后负荷、心肌收缩力、肺水含量等信息 因此，低血容量休克时若以大量晶体液进行复苏，可以引起血浆蛋白稀释以及胶体渗透压下降，同时出现组织水肿 因此，成功治疗肺水肿取决于能否正确回答下列问题 Thus, the success of our therapy often depends on the correct answers to the following questions: (1) 肺组织水分是多少 (1) How much water is in the lungs, (2) 为何会有肺水肿 (2) Why is it there, (3) 如何使肺组织水分回到正常水平 (3) What can we do to return lung water to the normal limits Lung is a fairly dry place Make them dry Increase EVLW by only 200-300ml – ALI In ALI mortality approaches 100% if EVLW 14.3 ml/kg PBW on day 1 Make them dry Evidence strongly suggests for most patients with ALI/ARDS who are not in shock using: 1. Diuretics 2. Fluid restriction 3. Albumin and furosemide in selected patients with hypoproteinemia and ALI 2. Want to know precisely what is happening to lung water with resuscitative and therapeutic interventions * ICU医生面对的患者多合并不同系统的疾患，治疗结果往往不取决于医生治疗的强项，而是短项 不合理治疗导致功亏一篑 The new paradigm for alveolar salt transport. Sodium (Na+) is absorbed from the apical surface of both ATI and ATII cells via ENaC, both highly selective channels (HSC) and nonselective channels (NSC channels), and via cyclic nucleotide-gated channels (CNGC; seen only in ATI cells). Electroneutrality is conserved with chloride (Cl?) movement through the cystic fibrosis transmembrane conductance regulator (CFTR) or through chloride channels (CLC) in ATI and ATII cells and/or paracellularly through tight junctions. In ATII cells, β-adrenergic agonists activate both ENaC and CFTR; in contrast, ENaC is activated in ATI and ATII cells by dopamine, but CFTR is not. Purines inhibit ENaC in ATII cells, but their effect on ENaC in ATII cells is yet to be determined. Na+ is transported from the basal surface of both cell types into the interstitial space by Na+-K+-ATPase. Potassium (K+) may be transported from alveolar epithelial cells via K+ channels located on the apical surface of ATI cells or through potential-dependent basolateral K+ channe