Shoemaker W C, Wo C C, Demetriades D, Belzberg H, Asensio J A, Cornwell E E, Murray J A, Berne T V, Adibi J, Patil R S
Department of Surgery, University of Southern California School of Medicine, Los Angeles 90033, USA.
New Horiz. 1996 Nov;4(4):395-412.
The aim of the present study was to explore methods, concepts, and techniques that provide recognition of circulatory deficiencies at the earliest possible time in the patient's illness. We used both the standard invasive pulmonary artery thermodilution catheter and noninvasive hemodynamic monitoring systems consisting of a new bioimpedance cardiac output device, pulse oximetry, transcutaneous oxygen (PtCO2) and carbon dioxide tensions as well as the transcutaneous oxygen tension/fraction of inspired oxygen ratio (PtCO2/FIO2). These three noninvasive systems were used to evaluate cardiac function, pulmonary function, and tissue perfusion, respectively. This approach to early noninvasive monitoring is based on recent evidence suggesting that poor tissue perfusion and oxygenation initiate circulatory dysfunction that leads to shock and organ failure. We studied 303 acute episodes of circulatory dysfunction and shock in 261 patients in a university-run county hospital; 75 were acute traumatic injuries and 109 acute nontrauma medical emergencies on admission to the emergency department, and 77 ICU patients with an acute illness or exacerbation of their current illness. The study was a prospective, descriptive study to identify early abnormal circulatory patterns reflecting the cardiac, pulmonary, and perfusion functions associated with death and with survival. We described noninvasively monitored patterns in individual illustrative cases, in common etiologic groups, and in physiologic categories representing various abnormal functional patterns. We found that hypotensive shock usually was preceded by episodes of high flow followed by low flow and inadequate tissue perfusion indicated by reduced PtCO2; this frequent pattern was modified by associated co-morbid conditions, especially hypovolemia, limited cardiac reserve capacity, age, hypertensive states, and increased body metabolism from infection, trauma, stress, exercise, temperature, and endocrine disorders. Reduced pulmonary function occurred in 18% of emergency patients; these were usually patients with thoracic trauma, severe hypovolemia, head injuries, chronic obstructive pulmonary disease, asthma, drug overdose, and central nervous system failure (massive stroke and coma). We concluded that noninvasive measurements identify early circulatory problems reliably and provide objective criteria for physiologic analysis as well as for definition of therapeutic goals and titration of therapy.
本研究的目的是探索能够在患者疾病的最早阶段识别循环系统缺陷的方法、概念和技术。我们使用了标准的有创肺动脉热稀释导管以及由新型生物阻抗心输出量装置、脉搏血氧饱和度测定、经皮氧分压（PtCO2）和二氧化碳分压以及经皮氧分压/吸入氧分数比值（PtCO2/FIO2）组成的无创血流动力学监测系统。这三种无创系统分别用于评估心脏功能、肺功能和组织灌注。这种早期无创监测方法基于最近的证据，即组织灌注和氧合不良会引发循环功能障碍，进而导致休克和器官衰竭。我们在一家大学附属县级医院对261例患者的303次急性循环功能障碍和休克发作进行了研究；其中75例为急性创伤性损伤，109例为急诊科入院时的急性非创伤性医疗急症，77例为患有急性疾病或现有疾病加重的重症监护病房患者。该研究是一项前瞻性描述性研究，旨在识别反映与死亡和生存相关的心脏、肺和灌注功能的早期异常循环模式。我们描述了在个别典型病例、常见病因组以及代表各种异常功能模式的生理类别中通过无创监测得到的模式。我们发现，低血压休克通常之前会出现高流量发作，随后是低流量以及PtCO2降低所表明的组织灌注不足；这种常见模式会因相关的合并症而改变，特别是低血容量、有限的心脏储备能力、年龄、高血压状态以及感染、创伤、应激、运动、体温和内分泌紊乱导致的身体代谢增加。18%的急诊患者出现肺功能降低；这些患者通常患有胸部创伤、严重低血容量、头部损伤、慢性阻塞性肺疾病、哮喘、药物过量以及中枢神经系统衰竭（大面积中风和昏迷）。我们得出结论，无创测量能够可靠地识别早期循环问题，并为生理分析以及治疗目标的定义和治疗滴定提供客观标准。
