Krivec B, Voga G, Zuran I, Skale R, Pareznik R, Podbregar M, Noc M
Department of Intensive Internal Medicine, General Hospital Celje, Slovenia.
Chest. 1997 Nov 5;112(5):1310-6. doi: 10.1378/chest.112.5.1310.
To evaluate the diagnostic value of transesophageal echocardiography (TEE) as an initial diagnostic tool in shocked patients. The second objective was to study therapeutic impact of intrapulmonary thrombolysis in patients with diagnosed massive pulmonary embolism.
Prospective observational study.
Medical ICU in 800-bed general hospital.
Twenty-four consecutive patients with unexplained shock and distended jugular veins.
In 18 patients, right ventricular dilatation with global or segmental hypokinesis was documented. In addition, central pulmonary thromboemboli (12 patients), reduced contrast flow in right pulmonary artery (one patient), and right ventricular free wall akinesis (one patient) were found. No additional echocardiographic findings were apparent in four patients. According to pulmonary scintigraphy or autopsy, sensitivity of TEE for diagnosis of massive pulmonary embolism (MPE) in patients with right ventricular dilatation was 92% and specificity was 100%. In patients without right ventricular dilatation, left ventricular dysfunction (four patients) or cardiac tamponade (two patients) was confirmed. Intrapulmonary thrombolysis was evaluated in 11 of 13 patients with MPE. Two patients died prior to attempted thrombolysis. Three patients received streptokinase and eight received urokinase. Twenty-four hours after beginning of treatment, total pulmonary resistance index significantly decreased for 59% and mean pulmonary artery pressure for 31%. Cardiac index increased for 74%. Nine of 11 patients receiving thrombolysis survived to hospital discharge.
Bedside TEE is a valuable tool for diagnosis of MPE. It enables immediate intrapulmonary thrombolysis, which seems to be an effective therapeutic alternative in our group of patients with obstructive shock.
评估经食管超声心动图（TEE）作为休克患者初始诊断工具的诊断价值。第二个目的是研究肺内溶栓对已确诊大面积肺栓塞患者的治疗效果。
前瞻性观察性研究。
一家拥有800张床位的综合医院的内科重症监护病房。
连续24例原因不明的休克且颈静脉扩张的患者。
18例患者记录到右心室扩张伴整体或节段性运动减弱。此外，发现中央型肺血栓栓塞（12例患者）、右肺动脉造影剂充盈减少（1例患者）和右心室游离壁运动消失（1例患者）。4例患者未发现其他超声心动图异常。根据肺闪烁显像或尸检结果，TEE对右心室扩张患者诊断大面积肺栓塞（MPE）的敏感性为92%，特异性为100%。在无右心室扩张的患者中，确诊为左心室功能障碍（4例患者）或心脏压塞（2例患者）。13例MPE患者中的11例接受了肺内溶栓治疗。2例患者在尝试溶栓前死亡。3例患者接受链激酶治疗，8例患者接受尿激酶治疗。治疗开始24小时后，总肺阻力指数显著下降59%，平均肺动脉压下降31%。心指数增加74%。接受溶栓治疗的11例患者中有9例存活至出院。
床旁TEE是诊断MPE的有价值工具。它能够立即进行肺内溶栓，这在我们这组梗阻性休克患者中似乎是一种有效的治疗选择。
