Arieff A I
Department of Medicine, University of California School of Medicine, San Francisco, USA.
Chest. 1999 May;115(5):1371-7. doi: 10.1378/chest.115.5.1371.
Pulmonary edema is a known postoperative complication, but the clinical manifestations and danger levels for fluid administration are not known. We studied (1) 13 postoperative patients (11 adult, 2 pediatric) who developed fatal pulmonary edema, and (2) one contemporaneous year of inpatient operations at two university teaching hospitals to determine the clinical manifestations, causes, epidemiology, and guidelines for fluid administration.
Retrospective analysis of 13 patients with fatal postoperative pulmonary edema and one contemporaneous year of major inpatient surgery.
Thirteen patients had net fluid retention of at least 67 mL/kg in the initial 24 postoperative hours and developed pulmonary edema. Ten were generally healthy while three had serious associated medical conditions.
There was no measurement, laboratory value, or clinical finding predictive of impending pulmonary edema. The most common clinical manifestation following the onset of pulmonary edema was cardiorespiratory arrest (n = 8). Patients had metabolic acidosis (pH = 7.15 +/- .33), hypoxia (PO2 = 45 +/- 18 mm Hg), and normal electrolytes. The diagnosis of pulmonary edema was established by chest radiograph and confirmed by autopsy and pulmonary artery pressure (21 +/- 4 mm Hg). The mean net fluid retention was 7.0 +/- 4.5 L (90 +/- 36 mL/kg/d) and exceeded 67 mL/kg/d in all patients. Autopsy revealed pulmonary edema with no other cause of death. Among 8,195 major operations, 7.6% developed pulmonary edema with a mortality of 11.9%. Extrapolation to the 8.2 million annual major surgeries in the United States yields a projection of 8,000 to 74,000 deaths.
Pulmonary edema can occur within the initial 36 postoperative hours when net fluid retention exceeds 67 mL/kg/d. There are no known predictive warning signs and cardiorespiratory arrest is the most frequent clinical presentation. The monitoring systems currently in use neither detect nor predict impending pulmonary edema, and as yet, there are no known panic values for excessive fluid administration or retention.
肺水肿是一种已知的术后并发症，但关于其临床表现及输液危险水平尚不清楚。我们研究了（1）13例发生致命性肺水肿的术后患者（11例成人，2例儿童），以及（2）两所大学教学医院一年同期住院手术情况，以确定其临床表现、病因、流行病学特征及输液指南。
对13例致命性术后肺水肿患者及一年同期大型住院手术进行回顾性分析。
13例患者术后最初24小时内净液体潴留至少67 mL/kg，并发生肺水肿。10例患者一般健康，3例伴有严重基础疾病。
没有可预测即将发生肺水肿的测量指标、实验室值或临床表现。肺水肿发生后的最常见临床表现是心肺骤停（n = 8）。患者存在代谢性酸中毒（pH = 7.15 ± 0.33）、低氧血症（PO2 = 45 ± 18 mmHg），电解质正常。通过胸部X线片确诊肺水肿，并经尸检及肺动脉压（21 ± 4 mmHg）证实。平均净液体潴留为7.0 ± 4.5 L（90 ± 36 mL/kg/d），所有患者均超过67 mL/kg/d。尸检显示肺水肿，无其他死因。在8195例大型手术中，7.6%发生了肺水肿，死亡率为11.9%。据美国每年820万例大型手术推算，死亡人数预计为8000至74000例。
当净液体潴留超过67 mL/kg/d时，肺水肿可在术后最初36小时内发生。尚无已知的预测预警信号，心肺骤停是最常见的临床表现。目前使用的监测系统既不能检测也不能预测即将发生的肺水肿，而且目前尚无关于过量输液或液体潴留的恐慌值。
