Yan Weiyuan, Wang Lijie
Department of Pediatric Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China.
Department of Pediatric Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China. Email:
Zhonghua Er Ke Za Zhi. 2014 Sep;52(9):693-8.
To evaluate the clinical value of the pulse indicator continuous cardiac output (PiCCO) system in patients with severe acute pancreatitis (SAP) complicated with acute respiratory distress syndrome (ARDS).
Two cases of SAP with ARDS were monitored using PiCCO during comprehensive management in the Pediatric Intensive Care Unit (PICU) of Shengjing Hospital, China Medical University. To guide fluid management, the cardiac index (CI) was measured to assess cardiac function, the global end-diastolic volume index (GEDVI) was used to evaluate cardiac preload, and the extravascular lung water index (EVLWI) was used to evaluate the pulmonary edema.
Case 1 was diagnosed with type L2 acute lymphoblastic leukemia (intermediate risk) and received the sixth maintenance phases of chemotherapy this time. After a 1-week dosage of chemotherapeutic drugs (pegaspargase and mitoxantrone), he suffered SAP combined with ARDS. Except comprehensive treatment (life supporting, antibiotic, etc.) and applying continuous veno-venous hemodiafiltration (CVVHDF) to remove inflammatory mediators. PiCCO monitor was utilized to guide fluid management. During the early stage of PiCCO monitoring, the patient showed no significant manifestations of pulmonary edema in the bedside chest X-ray (bedside ultrasound showed left pleural effusion), and had an oxygenation index 223 mmHg (1 mmHg = 0.133 kPa), GEDVI 450 ml/m², and ELVWI 7 ml/kg. We increased cardiac output to increase tissue perfusion and dehydration speed of CVVHDF was set at 70 ml/h. Two hours later, GEDVI significantly increased to 600 ml/m² and ELVWI significantly increased to 10 ml/kg, the oxygenation index declined to 155 mmHg, the bedside chest X-ray showed a significant decrease of permeability (right lung) and PEEP was adjusted to 5 cmH₂O (1 cmH₂O = 0.098 kPa), indicating circulating overload. ARDS subsequently occurred, upon which the fluid infusion was halted, the dehydration rate of CVVHDF raised (adjusted to 100-200 ml/h). On day 3 in the PICU, EVLWI dropped to 6 ml/kg, GEDVI dropped to 370 ml/m², and the oxygenation index increased to 180 mmHg. On day 8, the patient was successfully weaned from the ventilator. However, on day 9, the patient reverted to mechanical ventilation due to secondary infection. On day 30, the patient was discharged for voluntarily giving up treatment. Late follow-up results showed that the patient was dead one day after giving up treatment. Case 2 was admitted due to SAP induced by overeating one day before admission. On day 2, the patient showed dyspnea and oxygen saturation decreased to 80%. We applied mechanical ventilation, CVVHDF to remove inflammatory mediators and PiCCO to guide fluid management. According to the initial data of PiCCO, EVLWI was 9 ml/kg, GEDVI was 519 ml/m², the oxygenation index was 298 mmHg, the bedside chest X-ray showed decreased permeability and PEEP was adjusted to 5 cmH₂O, suggesting the existence of ARDS. During treatment, the dehydration speed of CVVHDF was set at 50 ml/h to maintain the balance of fluid input and output. Two hours after PiCCO monitoring, the oxygenation index decreased to 140 mmHg, GEDVI 481 ml/m², EVLWI 9 ml/kg, thus the dehydration speed of CVVHDF was increased (up to 100 ml/h). On day 4 in the PICU, EVLWI was 9 ml/kg, GEDVI was 430 ml/m², oxygenation index was 394 mmHg, and the bedside chest X-ray showed that permeability was higher. On day 5, the patient was transferred from PiCCO. On day 30, the patient recovered and was discharged.
PiCCO monitoring can provide real-time surveillance of cardiac function, cardiac preload and afterload, and extravascular lung water in pediatric patients with SAP combined with ARDS. These results are clinically significant for the rescue of critically ill patients with ARDS or shock.
评估脉搏指示连续心输出量（PiCCO）系统在重症急性胰腺炎（SAP）合并急性呼吸窘迫综合征（ARDS）患者中的临床价值。
在中国医科大学附属盛京医院儿科重症监护病房（PICU）对2例合并ARDS的SAP患者在综合治疗期间使用PiCCO进行监测。为指导液体管理，测量心脏指数（CI）以评估心功能，使用全心舒张末期容积指数（GEDVI）评估心脏前负荷，使用血管外肺水指数（EVLWI）评估肺水肿情况。
病例1诊断为L2型急性淋巴细胞白血病（中危），此次接受第6阶段维持化疗。在使用1周化疗药物（培门冬酶和米托蒽醌）后，发生SAP合并ARDS。除综合治疗（生命支持、抗生素等）及应用连续性静脉-静脉血液透析滤过（CVVHDF）清除炎症介质外，利用PiCCO监测指导液体管理。在PiCCO监测早期，患者床边胸部X线无明显肺水肿表现（床边超声显示左侧胸腔积液），氧合指数223 mmHg（1 mmHg = 0.133 kPa），GEDVI 450 ml/m²，ELVWI 7 ml/kg。增加心输出量以增加组织灌注，CVVHDF脱水速度设定为70 ml/h。2小时后，GEDVI显著增至600 ml/m²，ELVWI显著增至10 ml/kg，氧合指数降至155 mmHg，床边胸部X线显示通透性显著降低（右肺），PEEP调整为5 cmH₂O（1 cmH₂O = 0.098 kPa），提示循环超负荷。随后发生ARDS，停止液体输注，CVVHDF脱水速度提高（调整至100 - 200 ml/h）。在PICU第3天，EVLWI降至6 ml/kg，GEDVI降至370 ml/m²，氧合指数增至180 mmHg。第8天，患者成功脱机。然而，第9天因继发感染再次机械通气。第30天，患者因自动放弃治疗出院。后期随访结果显示患者放弃治疗1天后死亡。病例2因入院前1天暴饮暴食诱发SAP入院。第2天，患者出现呼吸困难，氧饱和度降至80%。应用机械通气、CVVHDF清除炎症介质及PiCCO指导液体管理。根据PiCCO初始数据，EVLWI为9 ml/kg，GEDVI为519 ml/m²，氧合指数为298 mmHg，床边胸部X线显示通透性降低，PEEP调整为5 cmH₂O，提示存在ARDS。治疗期间，CVVHDF脱水速度设定为50 ml/h以维持液体出入平衡。PiCCO监测2小时后，氧合指数降至140 mmHg，GEDVI 481 ml/m²，EVLWI 9 ml/kg，因此CVVHDF脱水速度增加（至100 ml/h）。在PICU第4天，EVLWI为9 ml/kg，GEDVI为430 ml/m²，氧合指数为394 mmHg，床边胸部X线显示通透性较高。第5天，患者转出PiCCO监测。第30天，患者康复出院。
PiCCO监测可为合并ARDS的儿科SAP患者的心功能、心脏前负荷和后负荷以及血管外肺水提供实时监测。这些结果对ARDS或休克危重症患者的抢救具有临床意义。
