Burns Justin M, Sing Ronald F, Mostafa Gamal, Huynh Toan T, Jacobs David G, Miles William S, Thomason Michael H
F. H. Sammy Ross Jr. Trauma Center, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA.
J Trauma. 2005 Jul;59(1):36-40; discussion 40-2. doi: 10.1097/01.ta.0000171460.56972.42.
The goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients.
A retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated.
Twenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified.
TEE altered resuscitation management in almost two thirds of patients. Many patients with "acceptable" pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.
复苏的目标是纠正氧输送与细胞需求之间的不匹配。肺动脉导管（PAC）常用于评估复苏的充分性，并根据心室充盈压指导治疗。经食管超声心动图（TEE）已成为评估急性血流动力学复苏充分性的一种潜在工具。本研究的目的是评估TEE在评估创伤患者持续容量复苏期间的前负荷中的作用。
对2002年1月至2004年在一级创伤中心因失血性休克复苏期间接受TEE检查的急性受伤患者进行回顾性研究。TEE的指征是在没有持续手术出血的情况下持续存在血流动力学不稳定。变量包括血流动力学和PAC参数、TEE检查前的复苏容量以及血管升压药的需求。评估TEE检查结果对治疗决策的影响。
25例患者接受了TEE检查，18例（72%）留置了PAC，平均肺动脉闭塞压为19.3mmHg（范围12 - 29mmHg），平均心脏指数为2.9L/min/m²（范围1.6 - 4.6L/min/m²）。12例患者（48%）在进行TEE检查时因低血压正在接受正性肌力药物和/或血管升压药治疗。TEE检查前6小时内的复苏容量平均包括6.5L晶体液和12.2单位血液制品（浓缩红细胞、新鲜冰冻血浆和血小板）。TEE显示13例患者（52%）左心室血容量不足，16例患者（64%）的治疗方案发生改变，包括增加容量（n = 13）、加用一种正性肌力药物（n = 4）以及在1例心室过度扩张的患者中加用一种血管扩张剂（n = 1）。异常TEE组和正常TEE组的比较显示，只有心脏指数有显著差异（异常组为2.6L/min/m²，正常组为3.9L/min/m²；p = 0.005）。在1例患者中发现严重二尖瓣反流导致瓣膜置换。未发现临床上相关的心包积液。
TEE改变了近三分之二患者的复苏管理。许多肺动脉闭塞压参数“可接受”的患者实际上可能左心室充盈不足。此外，TEE具有直接评估心脏瓣膜功能、心肌壁收缩力和心包积液的优势。
