Compton Friederike, Vogel Marie, Zidek Walter, van der Giet Markus, Westhoff Timm
Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany.
Ther Apher Dial. 2015 Feb;19(1):23-9. doi: 10.1111/1744-9987.12193. Epub 2014 Sep 4.
Management of volume status is difficult in critically ill patients with renal failure. Volumetric hemodynamic indices are increasingly being used to guide fluid therapy in the intensive care unit (ICU), but are not established to monitor hemodialysis-induced fluid removal in critically ill patients. Using volumetric hemodynamic monitoring, changes in extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI) were measured immediately before and after hemodialysis sessions in 35 ICU patients. Additional hemodynamic and oxygenation related parameters were recorded at the same time, and online relative blood volume (RBV) monitoring was performed during hemodialysis. EVLWI decreased significantly with fluid removal (median 10.0 vs. 9.6 mL/kg, P = 0.001), whereas ITBVI remained stable (median 1012 vs. 1029 mL/m(2) , P = 0.402). Significant changes were also observed in stroke volume variation (median 12.0 vs. 13.0 %, P = 0.012), cardiac index (median 4.2 vs. 3.5 mL/min/m(2) , P = 0.003), mean arterial pressure (median 77 vs. 85.5 mmHg, P = 0.006), norepinephrine dose (median 0.092 vs. 0.114 μg/kg per min, P = 0.043), and hemoglobin values (median 9.5 vs. 10.4 gm/dL, P = 0.036). RBV decreased by 7.8% (median); there was no correlation with either the volumetric measurements or the other hemodynamic parameters recorded. EVLWI reduction with dialysis reflects the removal of excess body fluid, whereas preservation of cardiac preload is indicated by ITBVI stability. Volumetric hemodynamic measurements provide additional information concerning fluid status and are thus potentially useful to guide fluid removal on hemodialysis in critically ill patients.
对于患有肾衰竭的重症患者，容量状态的管理颇具难度。容积血流动力学指标越来越多地被用于指导重症监护病房（ICU）的液体治疗，但尚未被确立用于监测重症患者血液透析引起的液体清除情况。利用容积血流动力学监测，对35例ICU患者血液透析治疗前后即刻的血管外肺水指数（EVLWI）和胸腔内血容量指数（ITBVI）变化进行了测量。同时记录了其他血流动力学和氧合相关参数，并在血液透析期间进行了在线相对血容量（RBV）监测。随着液体清除，EVLWI显著下降（中位数10.0 vs. 9.6 mL/kg，P = 0.001），而ITBVI保持稳定（中位数1012 vs. 1029 mL/m²，P = 0.402）。每搏输出量变异（中位数12.0 vs. 13.0%，P = 0.012）、心脏指数（中位数4.2 vs. 3.5 mL/min/m²，P = 0.003）、平均动脉压（中位数77 vs. 85.5 mmHg，P = 0.006）、去甲肾上腺素剂量（中位数0.092 vs. 0.114 μg/kg per min，P = 0.043）和血红蛋白值（中位数9.5 vs. 10.4 gm/dL，P = 0.036）也出现了显著变化。RBV下降了7.8%（中位数）；与容积测量值或记录的其他血流动力学参数均无相关性。透析导致的EVLWI降低反映了体内多余液体的清除，而ITBVI稳定表明心脏前负荷得以维持。容积血流动力学测量提供了有关液体状态的额外信息，因此可能有助于指导重症患者血液透析时的液体清除。
