picco技术在ards诊断和治疗中的应用.pptxVIP

PiCCO技术在ARDS诊断和治疗中的应用会计学辅助检查血常规： WBC 3.6×109/L GRA 25% PLT 35×109/L血气： pH 7.429 PO2 86.4mmHg (FiO2 50%) Lac 6.5mmol/L生化： ALB 15g/L CR 330umol/L心电图： 窦性心律, ST-T异常急性呼吸衰竭的病因?主要诊断：右腹股沟疝 绞窄性肠梗阻 回肠部分切除术后弥漫性腹膜炎 感染性休克 急性肾衰急性呼吸衰竭 (病因?) ARDS 心源性肺水肿N Engl J Med 2005;353:2788-96ARDS 诊断标准急性起病PaO2/FiO2 200mm Hg (不管PEEP水平)正位X 线胸片显示双肺均有斑片状阴影PAWP≤18 mm Hg, 或无LAP增高的临床证据Am J Respir Crit Care Med, 1994,149:818-824缺乏反映其病理生理特征的血管通透性指标ARDS与心源性肺水肿的鉴别诊断对于有基础心脏病史，合并感染、休克时鉴别诊断非常困难ARDS vs cardiogenic pul edema支持ARDS的依据 急性起病 感染、休克病史 胸片 氧合(200mm Hg)支持心源性肺水肿的依据 既往有冠心病史 急性起病 术中心率40~170次/分 大量输液 胸片 CVP 16 mmHg/PAWP 22 mmHg 氧合 CVP/PAWP增高排除 ARDS/一定就是左心衰?高水平PEEP或气道平台压针对休克的早期大量液体复苏感染对心肌的抑制腹内压的增高肺血管阻力的增加(如COPD, ARDS)测量不当该患者可能因素？High PAWP in pats with ARDS 120 pats with or at high risk of ARDSThe mean maximum PAWP reading among patients was 22.5 mmHg and mean median was 16.6 mmHgPatients who met standard criteria for ARDS were more likely to develop a high PAWP. （30％ 18mm Hg，CI 5.3 L/min/m2) Intensive Care Med, 2002,28(8):1073-7PAWP＞18mmHg is common in ARDS1001 patients, 513 assigned to PAC, 488 to CVC 29％ pats ：PAWP 18mm Hg 97% pats with PAWP 18mm Hg had a normal or elevated CIN Engl J Med 2006,354:2213-24Objective Criteria for ARDSPAWP18 mmHg不应作为ARDS的诊断标准肺毛细血管通透性明显增加ARDS区别于心源性肺水肿的特征性改变应在诊断标准中体现，使诊断标准更具特征性Schuster DP. The search for “objective” criteria for ARDS. Intensive Care Med, 2007, 33:400-402.Ware LB,. Matthay MA. Acute Pulmonary Edema. N Engl J Med, 2005;353:2788-96.Objective Criteria for ARDSARDS高通透性肺水肿 vs 急性左心衰竭高静水压性肺水肿试图依据病史、临床特征、X线胸片的特征血管外白蛋白的漏出量Alb in BAL/Plasma无创性核医学技术热稀释技术计算肺内血容量(PBV)与血管外肺水(EVLW)肺血管通透性指数(PVPI) ,可用来反映肺毛细血管通透性 Objective Criteria for ARDS2002年Schuster以双肺水肿、病程24h的危重患者为研究对象99mTc-Alb示踪肺血管通透性的改变临床诊断为ARDS(21例)和急性左心衰竭(7例)肺部同位素放射强度并无显著差别高静水压性肺水肿也有少量白蛋白漏出肺泡II型上皮细胞对肺泡中液体的主动清除核示踪技术的敏感性不足Schuster DP, Stark T, Stephenson J, et al. Detecting lung injury in patients with pulmonary edema. Intensive Care Med, 2002, 28: 1246-1253. PiCCO的临床应用肺水指标： Extravascular Lung