无创心排血量监测联合重症超声在急性呼吸窘迫综合征患者中的临床应用

目的探讨无创心排血量监测（NICOM）联合重症超声在急性呼吸窘迫综合征（ARDS）患者液体管理中的应用效果。 方法选取深圳大学总医院2018年7月至2020年2月收治的126例ARDS患者，将其分为研究组（63例）和对照组（63例）。对照组采用传统的血流动力学监测方法指导液体管理治疗；研究组在对照组的基础上，采用NICOM联合重症超声评估指导液体管理治疗。比较两组患者的一般资料、呋塞米、液体入量、液体出量以及治疗7 d后肺损伤评分、氧合指数、动脉血二氧化碳分压、动脉血pH值、中心静脉血氧饱和度、B线计数、血肌酐、血尿素氮、血红蛋白、碳酸氢盐、血糖水平及预后情况。 结果研究组患者应用呋塞米（47.0 ±3.5）mg / d vs.（21.6 ± 2.3）mg / d，t = 48.035，P < 0.001]、液体出量（3 332 ± 106）mL / d vs.（2 862 ± 100）mL / d，t = 25.485，P < 0.001]、氧合指数（327.3 ± 3.5）mmHg vs.（203.4 ± 2.6）mmHg，t = 225.002，P < 0.001]、中心静脉血氧饱和度（77 ± 22）% vs.（67 ± 19）%，t = 2.847，P = 0.005]、血红蛋白（91.0 ±1.8）g / L vs.（87.0 ± 1.8）g / L，t = 12.369，P < 0.001]、28 d内脱离呼吸机时间（15.1 ± 0.5）d vs.（11.5 ± 0.6）d，t = 36.634，P < 0.001]均显著高于对照组，而液体入量（3 162 ± 90）mL / d vs.（3 837 ±120）mL / d，t = 35.693，P < 0.001]、肺损伤评分（2.79 ± 0.30）分vs.（4.70 ± 0.20）分，t = 41.912，P < 0.001]、B线计数（9 ± 4）个vs.（12 ± 4）个，t = 4.458，P < 0.001]、血糖（7.9 ± 0.3）mmol / L vs.（8.0 ± 0.4）mmol / L，t = 2.758，P = 0.007]及ICU住院时间（17.5 ± 1.8）d vs.（21.7 ± 2.3）d，t = 11.435，P < 0.001]均显著低于对照组。对照组及研究组患者28 d病死率27.0%（17 / 63） vs. 17.5%（11 / 63）]和28 d内器官功能障碍发生率41.3%（26 / 63） vs. 44.4%（28 / 63）]比较，差异均无统计学意义（ χ² = 1.653、0.130，P = 0.199、0.719）。 结论通过NICOM联合重症超声对ARDS患者的容量进行管理，可以改善ARDS患者肺部氧合情况，减少液体入量，明显缩短住ICU时间及机械通气时间，并不增加器官功能障碍，值得临床推广。

Clinical application of noninvasive cardiac output monitoring combined with severe ultrasound in patients with acute respiratory distress syndrome

ObjectiveTo investigate the effect of noninvasive cardiac output monitoring (NICOM) combined with severe ultrasound in fluid management of patients with acute respiratory distress syndrome (ARDS). MethodsFrom July 2018 to February 2020, 126 patients with ARDS admitted to Shenzhen University General Hospital were divided into a study group (n = 63) and a control group (n = 63). Traditional hemodynamic monitoring methods were used to guide fluid management in the control group, while in the study group, the NICOM combined with severe ultrasound evaluation were used on the basis of the control group. The general data, furosemide use, fluid intake, fluid output and prognosis were compared between these two groups, as well as the lung injury score, oxygenation index, arterial blood carbon dioxide partial pressure, arterial blood pH value, central venous oxygen saturation, B line count, blood creatinine, blood urea nitrogen, hemoglobin, bicarbonate and blood glucose after 7 days of treatment. ResultsThe furosemide use (47.0 ± 3.5) mg / d vs. (21.6 ± 2.3) mg / d, t = 48.035, P < 0.001], fluid output (3 332 ± 106) mL / d vs. (2 862 ± 100) mL / d, t = 25.485, P < 0.001], oxygenation index (327.3 ± 3.5) mmHg vs. (203.4 ± 2.6) mmHg, t = 225.002, P < 0.001], central venous oxygen saturation (77 ± 22)% vs. (67 ± 19)%, t = 2.847, P = 0.005], hemoglobin (91.0 ± 1.8) g / L vs. (87.0 ± 1.8) g / L, t = 12.369, P < 0.001], ventilator weaning within 28 d (15.1 ± 0.5) d vs. (11.5 ± 0.6) d, t = 36.634, P < 0.001] in the study group were significantly higher than those in the control group. The fluid intake (3 162 ± 90) mL / d vs. (3 837 ± 120) mL / d, t = 35.693, P < 0.001], lung injury score (2.79 ± 0.30) vs. (4.70 ± 0.20), t = 41.912, P < 0.001], B line count (9 ± 4) vs. (12 ± 4), t = 4.458, P < 0.001], blood glucose (7.9 ± 0.3) mmol / L vs. (8.0 ± 0.4) mmol / L, t = 2.758, P = 0.007] and ICU stay (17.5 ± 1.8) d vs. (21.7 ± 2.3) d, t = 11.435, P < 0.001] in the study group were significantly lower than those in the control group. There were no significant differences in the 28-d mortality 27.0% (17 / 63) vs. 17.5% (11 / 63)] and incidence of organ dysfunction within 28 d 41.3% (26 / 63) vs. 44.4% (28 / 63)] between the control group and study group ( χ² = 1.653, 0.130; P = 0.199, 0.719). ConclusionThe fluid management of ARDS patients by NICOM combined with severe ultrasound can improve their pulmonary oxygenation, reduce fluid intake and significantly shorten the duration of ICU stay and mechanical ventilation without increasing organ dysfunction, which is worth promotion in clinic.