Compton Friederike, Hoffmann Clemens, Zidek Walter, Schmidt Sven, Schaefer Juergen-Heiner
Charité University Medicine Berlin, Campus Benjamin Franklin, Nephrology and Endocrinology, Berlin, Germany.
Hemodial Int. 2007 Apr;11(2):231-7. doi: 10.1111/j.1542-4758.2007.00174.x.
Estimation of removable excess body fluid is difficult in critically ill patients with renal failure. Volumetric hemodynamic parameters are increasingly being used to guide fluid therapy in the intensive care unit, but their suitability to monitor fluid removal with hemodialysis in critically ill patients is not known. Changes in the extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI) measured with transpulmonary thermodilution immediately before and after hemodialysis were analyzed from 39 hemodialysis sessions of 9 patients consecutively treated in the medical intensive care unit of a German University Hospital. Additional hemodynamic, ventilation, and oxygenation-related parameters were recorded at the same time. Online relative blood volume (RBV) monitoring was performed in 29 sessions. Comparisons of pre and postdialysis values showed a significant reduction of the EVLWI with fluid removal (p=0.009), with only a slight nonsignificant decrease in the ITBVI. The cardiac index (CI) also decreased significantly (p=0.010), whereas blood pressure remained stable. Oxygenation improved significantly (p=0.005), and the hematocrit increased significantly with dialysis (p=0.039). There was no correlation between hematocrit changes and RBV measurements. Significant correlations existed between ITBVI and CI changes (p<0.001), but not to EVLWI reduction. The removal of excess body fluid on hemodialysis is reflected by the EVLWI reduction, whereas the preservation of cardiac preload is shown by ITBVI stability. Volumetric hemodynamic parameters could be useful to guide fluid removal with hemodialysis in the intensive care unit.
对于患有肾衰竭的重症患者，估算可去除的多余体液十分困难。容积血流动力学参数越来越多地用于指导重症监护病房的液体治疗，但其在监测重症患者血液透析时液体去除情况的适用性尚不清楚。我们分析了德国一家大学医院内科重症监护病房连续治疗的9例患者的39次血液透析过程中，经肺热稀释法测量的血管外肺水指数（EVLWI）和胸腔内血容量指数（ITBVI）在血液透析前后的变化。同时记录了其他血流动力学、通气和氧合相关参数。29次透析过程中进行了在线相对血容量（RBV）监测。透析前后数值的比较显示，随着液体的去除，EVLWI显著降低（p = 0.009），而ITBVI仅有轻微的非显著性下降。心脏指数（CI）也显著降低（p = 0.010），而血压保持稳定。氧合显著改善（p = 0.005），透析后血细胞比容显著升高（p = 0.039）。血细胞比容变化与RBV测量值之间无相关性。ITBVI与CI变化之间存在显著相关性（p < 0.001），但与EVLWI降低无关。血液透析中多余体液的去除通过EVLWI降低得以体现，而心脏前负荷的维持则通过ITBVI的稳定表现出来。容积血流动力学参数可能有助于指导重症监护病房血液透析时的液体去除。
