Martin Greg S, Ely E Wesley, Carroll Frank E, Bernard Gordon R
Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Room 2D-004, Atlanta, GA 30335, USA.
Chest. 2002 Dec;122(6):2087-95. doi: 10.1378/chest.122.6.2087.
Fluid balance concerns occur daily in critically ill patients, complicated by difficulties assessing intravascular volume. Chest radiographs (CXRs) quantify pulmonary edema in acute lung injury (ALI) and total blood volume in normal subjects. We hypothesized that CXRs would reflect temporal changes in fluid balance in critically ill patients.
Standardized scoring of 133 supine, portable, anteroposterior CXRs. Outcomes included subjective and objective measures of intravascular volume and pulmonary edema.
Academic university medical center and affiliated Veterans Affairs hospital.
Thirty-seven patients with ALI receiving mechanical ventilation blindly randomized to treatment with diuretics and colloids or dual placebo for 5 days.
Treated patients experienced a 3.3-L diuresis and 10-kg weight loss during the 5-day period. A significant correlation was observed in all patients between changes in vascular pedicle width (VPW) and net intake/output (r = 0.50, p = 0.01) or weight (r = 0.51, p = 0.01). The correlation between VPW and fluid balance was greatest for weight changes in the treatment group alone (r = 0.71, p = 0.005). Pulmonary artery occlusion pressure correlated highly with changes in VPW (r = 0.70, p < 0.001). After day 1, CXRs revealed significant between-group differences in VPW without changes in cardiothoracic ratio or subjective measures of edema. The proportion of patients with VPW < 70 mm did not differ at baseline but was significantly more in the treatment group on all subsequent days (p < 0.05).
We conclude that temporal fluid balance changes are reflected on commonly utilized portable CXRs. Objective radiographic measures of intravascular volume may be more appropriate indicators of fluid balance than subjective measures, with VPW appearing most sensitive. If systematically quantitated, serial CXRs provide a substantial supplement to other clinically available data for the purpose of fluid management in critically ill patients.
重症患者每天都会出现液体平衡问题，评估血管内容量存在困难使情况更为复杂。胸部X光片（CXR）可对急性肺损伤（ALI）患者的肺水肿及正常受试者的总血容量进行量化。我们假设胸部X光片能反映重症患者液体平衡的时间变化。
对133张仰卧位、便携式前后位胸部X光片进行标准化评分。结果包括血管内容量和肺水肿的主观及客观测量指标。
大学附属医院及附属退伍军人事务医院。
37例接受机械通气的ALI患者，被随机分为两组，一组接受利尿剂和胶体治疗，另一组接受双重安慰剂治疗，为期5天。
治疗组患者在5天内尿量增加3.3升，体重减轻10千克。所有患者的血管蒂宽度（VPW）变化与净入量/出量（r = 0.50，p = 0.01）或体重（r = 0.51，p = 0.01）之间存在显著相关性。仅治疗组的体重变化与VPW和液体平衡之间的相关性最强（r = 0.71，p = 0.005）。肺动脉闭塞压与VPW变化高度相关（r = 0.70，p < 0.001）。第1天后，胸部X光片显示两组间VPW存在显著差异，而心胸比或水肿主观测量指标无变化。VPW < 70 mm的患者比例在基线时无差异，但在随后所有天数中治疗组显著更多（p < 0.05）。
我们得出结论，常用的便携式胸部X光片可反映液体平衡的时间变化。血管内容量的客观影像学测量指标可能比主观测量指标更适合作为液体平衡的指标，其中VPW最为敏感。如果进行系统量化，系列胸部X光片可为重症患者液体管理提供大量补充临床可用数据。
