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Sihlolisise ixabiso le-bedside ultrasound monitoring dynamic monitoring of inferior vena cava diameter (IVCD) kunye ne-sniffing collapse (inferior vena cava collapse index [IVCCI]) ekulawuleni ukuchithwa kwamanzi kwizigulane kwi-renal renal replacement therapy (CRRT).Ukungaphumeleli kwentliziyo kunye nokungaphumeleli kwentliziyo.Kukhethwe izigulana ezingama-90 ezinesifo sezintso kunye nentliziyo ebuhlungu ethe yafumana iCRRT kwiyunithi yokhathalelo olunzulu (ICU) ukusuka ngoJanuwari 2019 ukuya kuJuni 2021. Ngokweendlela ezahlukeneyo zokuvavanya umthamo wegazi, izigulana zahlulwa ngokungenamkhethe kwiqela le-ultrasound, iqela lamava. kunye neqela lolawulo.Siqhathanise i-serum creatinine, i-potassium, kunye ne-brain N-terminal natriuretic peptide (NT-proBNP) amanqanaba angaphambili, ixesha lokuphucula iimpawu zokungaphumeleli kwentliziyo, ixesha lokuya kwi-CRRT, ukusetyenziswa kwe-ventilator, ubude be-ICU yokuhlala, ukusetyenziswa kwe-vasopressor, kunye nokugula kweqela.iziganeko ezingafunwayo. Kwakungekho nantlukwano ebalulekileyo kumanqanaba e-serum creatinine, i-potassium, kunye ne-NT-proBNP ngokuthelekisa i-pairwise phakathi kwamaqela ngaphambi nangemva kwe-CRRT (P> 0.05). Kwakungekho nantlukwano ebalulekileyo kumanqanaba e-serum creatinine, i-potassium, kunye ne-NT-proBNP ngokuthelekisa i-pairwise phakathi kwamaqela ngaphambi nangemva kwe-CRRT (P> 0.05). Не было никаких существенных различий в уровнях креатинина в сыворотке, калия и NT-proBNP при попарных сравнениях между между между между пуппа, Т0ми группа, Тебе. Kwakungekho nantlukwano ebalulekileyo kumanqanaba e-serum creatinine, i-potassium, kunye ne-NT-proBNP ngokuthelekisana phakathi kwamaqela ngaphambi nangemva kwe-CRRT (P> 0.05). CRRT前后各组血清肌酐、血钾、NT-proBNP水平比较差异无统计学意义（P>0.05）. CRRT前后各组血清肌酐、血钾、NT-proBNP水平比较差异无统计学意义（P>0.05）. Не было существенной разницы в уровнях сывороточного креатинина, сывороточного калия и NT-proBNP между группами до и после ПЗПТ (P>0,0). Kwakungekho nantlukwano ephawulekayo kwi-serum creatinine, i-potassium ye-serum, kunye namanqanaba e-NT-proBNP phakathi kwamaqela angaphambili kunye ne-post-CRRT (P> 0.05).Ixesha lokuphucula iimpawu zokungaphumeleli kwentliziyo, ixesha le-CRRT, kunye ne-ICU yokuhlala yayiphantsi kwi-ultrasound kunye namaqela amava kuneqela lokulawula; iiyantlukwano zibalulekile ngokwezibalo (P <0.05). iiyantlukwano zibalulekile ngokwezibalo (P <0.05). различия были статистически значимыми (P < 0,05). iiyantlukwano zibalulekile ngokwezibalo (P <0.05).差异有统计学意义(P <0.05）).差异有统计学意义(P <0.05）). Разница была статистически значимой (P <0,05). Umahluko wawubalulekile ngokwezibalo (P <0.05). Ubude bokusebenzisa i-Ventilator buphantsi kwi-ultrasound kunye namaqela amava xa kuthelekiswa neqela lokulawula, kunye nokwahlukana okuphawulekayo phakathi kwe-ultrasound kunye namaqela okulawula (P <0.05). Ubude bokusebenzisa i-Ventilator buphantsi kwi-ultrasound kunye namaqela amava xa kuthelekiswa neqela lokulawula, kunye nokwahlukana okuphawulekayo phakathi kwe-ultrasound kunye namaqela okulawula (P <0.05). Продолжительность использования ИВЛ была ниже в группах УЗИ и опыта по сравнению с контрольной группой со статистипах . Ubude bexesha lokusetyenziswa kwe-ventilator laliphantsi kwi-ultrasound kunye namaqela amava xa kuthelekiswa neqela lokulawula, kunye nokwahlukana okuphawulekayo phakathi kwe-ultrasound kunye namaqela okulawula (P <0.05).超声组和体验组呼吸机使用时间低于对照组，超声组与对照组比较差异有统计孉。 P <0.05 Время использования ИВЛ в группе УЗИ и опытной группе было меньше, чем в контрольной группе, а разница между группой УЗИ и контрольной группой была статистически значимой (P < 0,05). Ixesha lokusetyenziswa kwe-ventilator kwiqela lase-US kunye neqela lovavanyo lalifutshane kuneqela lolawulo, kwaye umahluko phakathi kweqela lase-US kunye neqela lolawulo lalibalulekile ngokwezibalo (P <0.05).Ixesha lokusetyenziswa kwe-vasopressors kwiqela le-ultrasound kunye neqela lokulawula lalingaphantsi kweqela lokulinga; umahluko wawubalulekile ngokwezibalo (P <0.05). umahluko wawubalulekile ngokwezibalo (P <0.05). Разница была статистически значимой (P <0,05). Umahluko wawubalulekile ngokwezibalo (P <0.05).差异有统计学意义(P <0.05）).差异有统计学意义(P <0.05）). Разница была статистически значимой (P <0,05). Umahluko wawubalulekile ngokwezibalo (P <0.05).Iqela le-ultrasound lineziganeko eziphantsi zeziganeko ezimbi xa kuthelekiswa namaqela okulinga kunye nokulawula; umahluko wawubalulekile ngokwezibalo (P <0.05). umahluko wawubalulekile ngokwezibalo (P <0.05). Разница была статистически значимой (P <0,05). Umahluko wawubalulekile ngokwezibalo (P <0.05).差异有统计学意义(P <0.05）).差异有统计学意义(P <0.05）). Разница была статистически значимой (P <0,05). Umahluko wawubalulekile ngokwezibalo (P <0.05).I-Ultrasound monitoring monitoring ye-EFA kunye ne-nasal collapse inokuvavanya ngokuchanekileyo imeko yomthamo wegazi kwaye inike iingcebiso zokulungisa ukungabikho kwamanzi kwi-CRRT kunye nokunciphisa ngokukhawuleza iimpawu zokungaphumeleli kwentliziyo kwizigulane ezine-renal kunye ne-acute heart failure.
Ukungaphumeleli kwezintso okunxulunyaniswa nokungaphumeleli kwentliziyo ebukhali sisifo esibalulekileyo ekliniki esibonakala kukukhula ngokukhawuleza kwesifo, ukuhlala ixesha elide esibhedlele kunye nokufa okuphezulu, nto leyo esongela kakhulu ukhuseleko lwesigulane.Kwinkqubo yeklinikhi, isicwangciso esiphambili sonyango kukukhululeka kweempawu zokungaphumeleli kwentliziyo, kuquka i-cardiotonic, i-diuretic kunye ne-vasodilators.Nangona kunjalo, ngenxa yokungaphumeleli kwezintso, i-metabolites eqokelelweyo kunye nomthamo wegazi kwezi zi gulane awukwazi ukukhutshwa ngezintso.Uxinzelelo lwegazi kunye noxinzelelo luhlala luphendula kakubi kwi-diuretics eqhelekileyo kunye ne-vasodilators yodwa, ngelixa unyango oluqhubekayo lwe-renal replacement (CRRT) lunokulungisa umonakalo wezintso nge-cardiopulmonary blood clearance, ukususwa ngokuqhubekayo kwe-metabolites kunye nomthamo wegazi ogqithiseleyo emzimbeni, ngaloo ndlela ukunciphisa ukusilela kwangaphambili kunye ne-postoperative cardiovascular failure.umthambo ophucula ngempumelelo iimpawu kunye nemeko eqhelekileyo yezigulane ezinentliziyo engaphumeleliyo3.
Nangona kunjalo, ukusetyenziswa kweklinikhi ye-CRRT kaninzi kubangela iingxaki ezahlukeneyo, enye eyona nto iphambili i-arterial hypotension4,5.Uphononongo lubonise ukuba iqondo lokunciphisa umthamo wegazi yimbangela ebalulekileyo yotshintsho kwixinzelelo lwegazi ngexesha le-CRRT.Ukuphelelwa ngamanzi emzimbeni okugqithisileyo kunye nokukhawulezayo kudlula ukubuya kolwelo phakathi kwe-interstitial okukhokelela kwi-hypovolemia esebenzayo kunye ne-hypotension6.Ukuvavanya ngokufanelekileyo isimo somthamo wegazi lesigulane ngexesha le-CRRT kunye nokuyila irejimeni yokuphelelwa ngamanzi emzimbeni ngumngeni abajongene nawo oogqirha.
Kwiminyaka yakutshanje, ukubeka iliso kwe-ultrasound ye-inferior vena cava (SVC) ububanzi kunye nokuhluka kwayo (i-NSAID kunye ne-odor collapse, i-inferior vena cava collapse index [IVVC]) isetyenziswe ngenxa ye-intuitive, echanekileyo, engabonakaliyo, kunye nenzuzo yokuvelisa.Izifundo zangaphambili zicebise ukusebenzisa i-IVCD njengomlinganiselo wokuvavanya isimo somthamo wegazi kwizigulane7,8,9 kodwa kukho iingxelo ezimbalwa zokusetyenziswa kwe-CRRT kwizigulane ezinokuhluleka kwezintso eziyinkimbinkimbi ngenxa yokungaphumeleli kwentliziyo.Ke, sijonge ukuphanda isicelo seklinikhi sokujongwa okuguquguqukayo kwebhedi ye-NSAIDs kunye nee-NSAID ukulungisa ukuphelelwa ngamanzi emzimbeni ngexesha le-CRRT kwizigulana ezinokusilela kwezintso ezintsonkothileyo ngenxa yokungaphumeleli kwentliziyo.
Olu phononongo lwamkele uyilo olulindelekileyo olulawulwa ngokungenamkhethe kwaye lwamkelwa yiKomiti yeeNqobo zoPhando lweBiomedical yeSibhedlele seSibini esiManyano neYunivesithi yaseNanchang.Uphononongo luqhutywe ngokuhambelana nezikhokelo kunye nemimiselo efanelekileyo.Zonke izigulane zaziswa ngeenzuzo ezinokubakho kunye nobungozi.Zonke izigulane zafumana imvume ebhaliweyo enolwazi.
Sikhethe abaguli abangama-90 abanokusilela kwezintso kudityaniswe nokungaphumeleli kwentliziyo ebukhali efuna i-CRRT eyamkelwa kwigumbi labagula kakhulu (ICU) yesibhedlele sethu ukusuka ngoJanuwari 2019 ukuya kuJuni ka-2021.Iminyaka engama-41 ubudala, abafazi abangama-28 kunye namadoda angama-62.
Sifake ezi zigulane zilandelayo: (1) ubudala ≥18 iminyaka kunye ≤80 iminyaka;(2) kuvunyelwene neCRRT;(3) ngokuhambelana ne "Izikhokelo zokuqala zokuxilongwa kunye nokunyangwa kwesifo senhliziyo esibuhlungu kunye neziphumo eziphuculweyo ezipheleleyo kwisifo sezintso (2019) "Iikhrayitheriya zokuxilonga ukuhluleka kwentliziyo.
Asibandakanyi izigulane kunye naziphi na ezi zilandelayo: (1) imbali yesifo esibi okanye isifo sengqondo;(2) imbali yesifo senhliziyo yokuzalwa, i-hypertrophic cardiomyopathy, okanye i-pulmonary hypertension;(3) ukungasebenzi kakuhle kwe-clotting ngexesha leenyanga ezi-3 zokugqibela.ukopha kwe-visceral okanye kwesisu okanye ukuchasana kwi-heparin anticoagulant therapy;(4) Ixesha le-CRRT ≤ iiyure ze-12;(5) I-Ultrasound ayikwazi ukubona i-vena cava engaphantsi, ebangela ukuba idatha engekho;(6) ukutshatyalaliswa kwe-cardiogenic okanye i-cardiac ejection fraction ≤ 50%.
Izigulane zahlulwa ngokungenamkhethe zibe ngamaqela amathathu (i-ultrasound, yovavanyo kunye nolawulo) kusetyenziswa i-random number table.Iqela ngalinye laliquka izigulane ezingama-30.Kwakungekho nantlukwano ephawulekayo phakathi kwamaqela amathathu ngokwesini, ubudala, imeko ye-physiological acute, kunye nesikali sesifo esingapheliyo II, kunye neempawu zabathathi-nxaxheba zithelekiseka phakathi kwamaqela kwisiseko (iThebhile 1).
Ukuqala i-CRRT, oogqirha babeka isigulane emqolo kwaye baveze isifuba kunye nesisu sabo.Ummandla osuka kwi-IVCD ukuya kwinkqubo ye-xiphoid emva koko walinganiswa usebenzisa i-3.5 MHz convex array probe ye-Mindray M7 ephathwayo yombala we-Doppler ultrasound isixhobo.Imijikelezo yokuphefumula emininzi yabhalwa kusetyenziswa i-M-mode ultrasound kumgama we-2.0 cm ukusuka entliziyweni elungileyo ecaleni kwe-inferior vena cava.Ubuninzi bokugqibela obuphefumlelweyo (IVCDmax) kunye nenani elincinci lokuphela kokuphelelwa yisikhathi (IVCDmin) lilinganiswe ngaxeshanye.I-IVCD ichazwa njenge-IVCDmax kunye ne-IVCCI ibalwa ngokusebenzisa le fomula ilandelayo: (IVCDmax-IVCDmin)/IVCDmax×100%.Zonke iimviwo zenziwa liqela leengcali ze-ultrasound, ezibandakanya oogqirha abaneziqinisekiso ze-ultrasound.Bonke oogqirha bafumana uqeqesho olufanayo lokulawula umgangatho ukuqinisekisa ukuqokelelwa ngokucokisekileyo kwedatha ye-ultrasound. Ngokusekelwe kwi-IVCD elinganiswe ngugqirha oyintloko we-ultrasound njengexabiso lenyani eliqhelekileyo, uhlalutyo lwangaphambili lubonise impazamo ehambelana nemilinganiselo ye-IVCD ngamagqirha ahlukeneyo <0.05 kunye nephutha elihlobene nemilinganiselo ye-IVCD ngugqirha ofanayo ngamaxesha ahlukeneyo. < 0.02. Ngokusekelwe kwi-IVCD elinganiswe ngugqirha oyintloko we-ultrasound njengexabiso lenyani eliqhelekileyo, uhlalutyo lwangaphambili lubonise impazamo ehambelana nemilinganiselo ye-IVCD ngamagqirha ahlukeneyo <0.05 kunye nephutha elihlobene nemilinganiselo ye-IVCD ngugqirha ofanayo ngamaxesha ahlukeneyo. < 0.02. На основании измеренного главным врачом УЗИ МЖК как условно истинного значения, предэкспериментальный анализ показал относительную погрешность измерения МЖК разными врачами < 0,05 и относительную погрешность измерения МЖК одним и тем же врачом в разные периоды времени < 0,02. Ngokusekelwe kwi-MFA elinganiswe ngugqirha we-ultrasound yentloko njengexabiso lokwenyani ngokwemeko, uhlalutyo lwangaphambili lovavanyo lubonise impazamo ehambelana nokulinganisa i-MFA ngoogqirha abahlukeneyo <0.05 kunye nephutha elihlobene nokulinganisa i-MFA ngugqirha ofanayo ngamaxesha ahlukeneyo <0.02 .以 超声超声 医师 测量 的 的 真值 真值 真值 真值 真值 不同 不同 不同 不同 测量 相对 相对以 超声超声 医师 的测量 IVCD 为 常规 常规 表明 医师 医师 医师 医师 测量 误差 误差 误差 误差 不同 时间 时间 段 测量 测量 测量 测量 测量 测量 <0.02. Принимая за условную истинную величину МЖК, измеренную главным врачом УЗИ, предэкспериментальный анализ показал, что относительная погрешность измерения МЖК разными врачами составляет <0,05, а относительная погрешность измерения МЖК одним и тем же врачом в разные периоды времени был <0,02. Ukuthatha njengexabiso lokwenyani lemeko ye-MFA elinganiswe ngugqirha we-ultrasound yentloko, uhlalutyo lwangaphambili lovavanyo lubonise ukuba impazamo ehambelanayo yokulinganisa i-MFA ngoogqirha abahlukeneyo ngu <0.05, kunye nephutha elihlobene nokulinganisa i-MFA ngugqirha ofanayo amaxesha ahlukeneyo exesha yayingu <0.02.Ixesha lokulinganisa kwindlela nganye ye-ultrasonic imalunga ne-10 ukuya kwimizuzu eyi-15.Isalathisi ngasinye silinganiswe ngamaxesha e-3 kwaye ixabiso eliphakathi libalwe.Oogqirha balungisa ukuchithwa kwamanzi ngokwe-IVCD kunye ne-IVCCI ngokuphindaphinda inkqubo engentla rhoqo kwiiyure ze-4 de i-CRRT iyeke.
Isimo somthamo wegazi savandlakanywa ngokwemigaqo esebenzayo ye-British Society ye-Echocardiography10: IVCD ≤ 2.1 cm kunye ne-IVCCI> 50%, ichazwa njengexabiso eliphantsi; Isimo somthamo wegazi savandlakanywa ngokwemigaqo esebenzayo ye-British Society ye-Echocardiography10: IVCD ≤ 2.1 cm kunye ne-IVCCI> 50%, ichazwa njengexabiso eliphantsi; Статус объема крови оценивался в соответствии с практическими рекомендациями Британского общества эхокардиографии10: IVCD ≤50, VC7, 5, 10 Isimo somthamo wegazi sihlolwe ngokweengcebiso zokwenza i-British Society ye-Echocardiography10: IVCD ≤ 2.1 cm kunye ne-ICCCI> 50%, echazwe njengexabiso eliphantsi;根据英国超声心动图学会的实用指南评估血容量状态10：IVCD ≤ 2.1 cm 且IVCCI > 50%，恶灵灵獻着 Ngokwesikhokelo esisebenzayo sovavanyo lwe-United Kingdom ye-ultrasonography yoluntu lwe-volume volume10: IVCD ≤ 2.1 cm 且IVCCI> 50%, ichazwa njengexabiso eliphantsi; Usetyenziso olunxulumeneyo noluhlu lwe-IVCD ≤ 2.1 Uvavanyo lomthamo wegazi ngokweengcebiso ezisebenzayo zeBritish Society of Echocardiography10: IVCD ≤ 2.1 cm kunye ne-ICCCI> 50%, echazwe njengemeko ye-hypovolemic; I-IVCD ≤ 2.1 cm kunye ne-IVCCI <50% okanye i-IVCD> 2.1 cm kunye ne-IVCCI> 50%, echazwe njengemeko yomthamo olinganayo; I-IVCD ≤ 2.1 cm kunye ne-IVCCI <50% okanye i-IVCD> 2.1 cm kunye ne-IVCCI> 50%, echazwe njengemeko yomthamo olinganayo; IVCD ≤ 2,1 см при IVCCI < 50% или IVCD > 2,1 см при IVCCI > 50%, что определяется как состояние сбалансированного объема; I-IVCD ≤ 2.1 cm kunye ne-IVCCI <50% okanye i-IVCD> 2.1 cm kunye ne-IVCCI> 50%, echazwa njengemeko yokulinganisa umthamo; IVCD ≤ 2.1 cm 且IVCCI < 50% 或IVCD > 2.1 cm 且IVCCI > 50%，定义为平衡容积状态； I-IVCD ≤ 2.1 cm 且IVCCI <50% okanye IVCD> 2.1 cm 且IVCCI> 50%, ichazwa njengemeko yomthamo olinganayo; IVCD ≤ 2,1 см и IVCCI <50% okanye IVCD> 2,1 см и IVCCI> 50%, определяемые как состояние равновесного объема; I-IVCD ≤ 2.1 cm kunye ne-IVCCI <50% okanye i-IVCD> 2.1 cm kunye ne-IVCCI> 50%, echazwe njengelizwe lokulinganisa umthamo; kunye ne-IVCD> 2.1 cm kunye ne-IVCCI <50%, echazwe njengomgangatho ophezulu womthamo. kunye ne-IVCD> 2.1 cm kunye ne-IVCCI <50%, echazwe njengomgangatho ophezulu womthamo. kunye ne-IVCD > 2,1 см с IVCCI < 50%, что определяется как состояние большого объема. kunye ne-IVCD> 2.1 cm kunye ne-IVCCI <50%, echazwa njengomgangatho ophezulu womthamo.和IVCD > 2.1 cm 且IVCCI < 50%，定义為高容量状态。和IVCD > 2.1 cm 且IVCCI <50%, ichazwa njengombuso womthamo ophezulu. kunye ne-IVCD > 2,1 см и IVCCI < 50%, что определяется как состояние большого объема. kunye ne-IVCD> 2.1 cm kunye ne-IVCCI <50%, echazwa njengemeko yomthamo omkhulu.I-diuresis yemihla ngemihla yabantu abaphilileyo yi-1500-2000 ml.Ukuze kube lula ukubala, i-diuresis eqhelekileyo yemihla ngemihla ichazwa njenge-1800 ml, kunye ne-diuresis ephakathi kwe-300 ml nganye iiyure ze-4.Iimvavanyo zangaphambili zangaphambili zibonise ukuba ukuba umthamo we-dehydration udlula umthamo oqhelekileyo womchamo ngama-4 ngamaxesha kwiiyure ze-4 kwisimo somthamo ophezulu, ukuphindaphinda kweengxaki kwandisa kakhulu;ukuba idlula umthamo oqhelekileyo womchamo ngamaxesha angama-2, ixesha lokuphucula iimpawu zentliziyo kunye nokuphindaphinda kweengxaki ziye zanda kakhulu.Kwiimeko zokulinganisela umthamo, ukuphindaphinda kweengxaki kwanda kakhulu xa umthamo wokuphelelwa ngamanzi emzimbeni udlula amaxesha angama-2 umthamo oqhelekileyo womchamo ngexesha leeyure ze-4, kwaye ixesha lokuphucula iimpawu zentliziyo landa kakhulu xa umthamo wokuphelelwa ngamanzi emzimbeni wawufana ne umthamo oqhelekileyo womchamo..Umthamo ojoliswe kuwo wokuphelelwa ngamanzi emzimbeni ngexesha leeyure ze-4 ubekwe kwinqanaba le-1000 ml kwizigulane ezine-hypervolemia kunye ne-500 ml kwizigulane ezinomthamo wegazi elilinganayo.Ngenxa yokuba ukuphelelwa ngamanzi emzimbeni okuqhubekayo kwimeko ye-hypovolemic kunokukhokelela kwi-hypotension, kwaye i-hydration iyancipha iimpawu zokungaphumeleli kwentliziyo, oogqirha bahlengahlengisa i-4-hour dehydration target kwi-0 mL yezigulane ze-hypovolemic (i-CRRT i-4-yure ye-dehydration = i-4-yure ye-dehydration target + 4- ngeyure. ukwamkela - i-4-yure diuresis).
Oogqirha balungiswa ngenxa yokuphelelwa ngamanzi emzimbeni besebenzisa isikali esiqhelekileyo se-empirical esekelwe kwizinga lentliziyo, uxinzelelo lwe-arterial, uxinzelelo lwe-venous central, kunye ne-pulmonary rales emva kwe-CRRT (Itheyibhile 2).
Uvavanyo lwenziwa rhoqo kwiiyure ze-4 ukususela ekuqaleni kwe-CRRT de isigulane sincediswe ukukhupha kwisixhobo.Ugqirha ulungelelanise i-4 iyure yokuchithwa kwamanzi ekujoliswe kuyo kwi-1000 ml, i-500 ml kunye ne-0 ml kwaye ifumene i-8-11, i-4-7 kunye ne-0-3 (i-NRRT kwiiyure ze-4 = i-4 iiyure ezijoliswe kuyo) Umthamo + i-4 iyure yokuthatha - i-4- umchamo weyure imveliso).
Ukususela ekuqalisweni kwe-CRRT ukuya ekuyekisweni kweyeza, i-target dehydration yayihlala ihleli kwi-100 ml / h kwaye akukho mthamo wavavanywa ngexesha lokunyanga (i-CRRT dehydration kwiiyure ze-4 = i-target dehydration kwiiyure ze-4 + ukungena kwiiyure ze-4).h) h – diuresis 4 h).
Ukongeza kule milinganiselo ingentla yovavanyo ejoliswe ekulungiseni ukuphelelwa ngamanzi emzimbeni, onke amaqela amathathu ezigulane afumene unyango olulinganayo, kubandakanywa unyango lwesifo esisisiseko, i-anti-infective regimen, ulawulo lwendlela yomoya, isicwangciso somatshini wokungenisa umoya, ukugcinwa komthamo we-fluid kunye nebhalansi ye-electrolyte (4.0 mmol) ) /l < potassium <5.3 mmol / l), unyango lweziyobisi, i-colloidal liquid supplementation efana ne-albumin (ukugcina amanqanaba e-albumin> 3.5 g / l), kunye nenkxaso yesondlo.
Onke amaqela amathathu ezigulane aphathwa ngesicoci segazi esifanayo (inkqubo yePrismaFlex) kunye nenkqubo ye-CRRT efanayo (i-CVVHD irejimeni).Zonke izigulane zafumana i-heparin ye-extracorporeal ye-anticoagulation yendawo kunye ne-protamine neutralization.Oogqirha bahlengahlengisa iidosi ze-heparin kunye neprotamine ngokusekelwe kwiiparamitha ezine zokuvala igazi (ixesha elisebenzayo le-thromboplastin ligcinwa ngaphakathi kwe-1-1.5 amaxesha aqhelekileyo).Kwi-CPT, ukuhamba kwegazi kwagcinwa kwi-150-200 ml / min kwaye ukuhamba kwe-dialysate kwagcinwa kwi-2000 ml / h (i-dialysate formulation: i-saline 2000 ml; umthamo we-injection oyinyumba 1000; 50% isisombululo se-glucose 10 ml; 10% saline, 20 ml; magnesium sulfate, 2.5 ml; 10% potassium chloride, 7.5 ml; sodium bicarbonate, 45 ml; peripheral calcium chloride, 10 ml ngeyure).
Xa isigulana sihlakulela i-hypotension, yeka ukuphuma kwamanzi ngokukhawuleza kwaye ulawule i-intravenous fluids kunye ne-vasopressors (kuquka i-norepinephrine kunye ne-dopamine) njengoko kuyimfuneko ukugcina uxinzelelo lwe-arterial yesigulane ngaphezu kwe-65 mmHg.
I-Serum creatinine, i-potassium, kunye ne-N-terminal pro-brain natriuretic peptide (NT-proBNP) amanqanaba alinganiswa iiyure ze-24 ngaphambi nangemva kwe-CRRT.Ixesha lokuphucula ukungaphumeleli kwentliziyo, ixesha lokuya kwi-CRRT, ixesha lokusetyenziswa kwe-ventilator, ixesha lokuhlala kwiyunithi yokunyamekela kakhulu, ixesha lokusetyenziswa kwe-vasopressor, kunye nemilinganiselo yesiganeko esibi (kubandakanywa ne-hypotension, arrhythmias, kunye ne-delirium kodwa kungekhona isigqi esibi) zaqokelelwa ngexesha lokulaliswa esibhedlele.) idatha.ICandelo labagula kakhulu.Ukuphindaphinda kweziganeko ezimbi kubalwa ngokusekelwe ekubeni iziganeko ezimbi zenzeke kwizigulane ezibhalisiweyo.
Ukuphuculwa kweempawu: Ngokutsho kweNew York Classification of Heart Function, ukuqina kwesifuba kunye ne-dyspnea kuphuculwe kwibanga le-1, kwaye i-frequency ye-expectoration ye-pink foamy sputum yehla nge-20% xa kuthelekiswa novavanyo lwangaphambili (ngaphandle kwezigulane ezine-endotracheal intubation), iimpawu. zijongwe ziphuculwe.
Ukujongwa okuphuculweyo: i-20% yokunciphisa izinga lentliziyo, izinga lokuphefumula, uxinzelelo lwe-venous central, okanye i-arterial pressure.
Oogqirha benza iimvavanyo zeyure, kwaye xa izigulane zihlangabezana nazo zonke ezi zintathu zingentla, ukungaphumeleli kwentliziyo yabo kuthathwa njengokuphucula.
Uhlalutyo lwamanani lwenziwa kusetyenziswa isoftware ye-SPSS 22.0 (IBM Corp., Armonk, NY, USA).Idatha eqhubekayo ichazwa njengentsingiselo ± ukutenxa okusemgangathweni.Idatha yoluhlu ichazwa njengamaza kunye neepesenti.Umahluko phakathi kwamaqela amabini wavavanywa kusetyenziswa uvavanyo lwe-t yoMfundi kwizinto eziguquguqukayo eziqhubekayo okanye uvavanyo lwe-chi-square kwiintlobo ezahlukeneyo zecategorical. Ukubaluleka kwamanani kubekwe kwi-P <0.05. Ukubaluleka kwamanani kubekwe kwi-P <0.05. Статистическая значимость была установлена ​​​​на уровне P <0,05. Ukubaluleka kwamanani kubekwe kwi-P <0.05.统计学显着性设定为P <0.05.统计学显着性设定为P <0.05. Статистическая значимость была установлена ​​​​на уровне P <0,05. Ukubaluleka kwamanani kubekwe kwi-P <0.05.
I-Serum creatinine, i-potassium, kunye ne-NT-proBNP amanqanaba kumaqela amathathu anciphile kwiiyure ze-24 ze-CRRT. Ukwahluka phakathi kwamaqela kwakubaluleke kakhulu (P <0.05), nangona kwakungekho nantlukwano ephawulekayo ebonwayo ngokuthelekisana phakathi kwamaqela amathathu (P> 0.05) (Itheyibhile 3). Ukwahluka phakathi kwamaqela kwakubaluleke kakhulu (P <0.05), nangona kwakungekho nantlukwano ephawulekayo ebonwayo ngokuthelekisana phakathi kwamaqela amathathu (P> 0.05) (Itheyibhile 3). Различия внутри групп были статистически значимыми (P < 0.05), хотя при попарном сравнении между тремя групппами не наблуппами не наблуппами не наблуппами не наблуппами не наблю30, 50. Ukwahluka phakathi kwamaqela kwakubaluleke kakhulu (P <0.05), nangona kwakungekho nantlukwano ephawulekayo phakathi kwamaqela amathathu xa kuthelekiswa ne-pairwise (P> 0.05) (Itheyibhile 3).组内差异具有统计学意义（P <0.05），但三组之间的成对比较无显着差异（0）））））组内差异具有统计学意义（P <0.05），但三组之间的成对比较无显着差异（0））））） Различия внутри групп были статистически значимыми (P <0,05), но попарные сравнения между тремя группами субественно не 0,05 (3,5)> Ukwahluka phakathi kwamaqela kwakubaluleke kakhulu (P <0.05), kodwa ukuthelekiswa kweebini phakathi kwamaqela amathathu kwakungafani kakhulu (P> 0.05) (Itheyibhile 3).Ukubona kakuhle utshintsho lwevolumu, siphinde sacwangcisa utshintsho kwi-NT-proBNP, IVCD, kunye ne-IVCCI (Amanani 1 kunye ne-2).
I-Dynamics yamaxabiso aphakathi kwe-IVKD kunye ne-IVKKI ye-CPT yokuqala kwiqela le-ultrasound yezigulana ezingama-30 emva kokungeniswa kwi-ICU.
Ixesha lokuphucula ukuhluleka kwentliziyo, ixesha le-CRRT, kunye ne-ICU yokuhlala yayiphantsi kakhulu kwi-ultrasound kunye neqela lamava kuneqela lokulawula. Ukwahluka kwakubaluleke kakhulu (P <0.05), ngelixa kwakungekho nantlukwano ebalulekileyo kwizikhombisi ezingentla phakathi kwe-ultrasound kunye namaqela amava (P> 0.05) (umzobo 3). Ukwahluka kwakubaluleke kakhulu (P <0.05), ngelixa kwakungekho nantlukwano ebalulekileyo kwizikhombisi ezingentla phakathi kwe-ultrasound kunye namaqela amava (P> 0.05) (umzobo 3). Различия были статистически значимыми (Р < 0,05), тогда как достоверных различий по вышеуказаным показателям между групИпами 0.30 Ukwahluka kwakubaluleke kakhulu (P <0.05), ngelixa kwakungekho nantlukwano ebalulekileyo kwiiparamitha ezingentla phakathi kwe-ultrasound kunye namaqela amava (P> 0.05) (umzobo 3).差异有统计学意义（P <0.05)差异有统计学意义（P <0.05），而超声组与体验组在上述指标上差异无统计学意 3P （0.） Разница была статистически значимой (Р < 0,05), но достоверной разницы между группой УЗИ и группой опыта по вышеуказанны, по вышеуказаным (3) (3) Umahluko wawubaluleke kakhulu (P <0.05), kodwa kwakungekho nantlukwano ephawulekayo phakathi kweqela le-ultrasound kunye neqela lokulinga ngokwemiqathango yale parameters ingentla (P> 0.05) (Umfanekiso 3).
Ubude bexesha lokusetyenziswa kwe-ALV zombini kwiqela le-ultrasound kunye neqela lokulinga laliphantsi kuneqela lokulawula. Ukwahlukana phakathi kwe-ultrasound kunye namaqela okulawula kwakubaluleke kakhulu (P <0.05), kanti akukho ntlukwano ephawulekayo phakathi kwamava kunye namaqela okulawula, okanye phakathi kwamava kunye namaqela e-ultrasound (P> 0.05). Ukwahlukana phakathi kwe-ultrasound kunye namaqela okulawula kwakubaluleke kakhulu (P <0.05), kanti akukho ntlukwano ephawulekayo phakathi kwamava kunye namaqela okulawula, okanye phakathi kwamava kunye namaqela e-ultrasound (P> 0.05). Разница между ультразвуковой и контрольной группами была статистически значимой (P < 0,05), тогда как между опытной и контрольной группами, а также между опытной и ультразвуковой группами не наблюдалось существенной разницы (P > 0,05). Ukwahlukana phakathi kwe-ultrasound kunye namaqela okulawula kwakubaluleke kakhulu (P <0.05), ngelixa kwakungekho mmahluko omkhulu phakathi kwamaqela onyango kunye nokulawula kunye naphakathi kwonyango kunye namaqela e-ultrasound (P> 0.05).超声组 与 对照组 差异 有 统计学 统计学 统计学 统计学 统计学 统计学 意义 对照组 与 与 对照组 或 与 超声组 之间 差异 无 无 无 意义超声组 与 对照组 差异 有 有 有 意义 意义 而 而 而 对照组 对照组 经验组 与 超声组 之间 之间 无 无 无 Разница между группой УЗИ и контрольной группой была статистически значимой (P < 0,05), но не было существенной разницы между группой опыта и группой контроля или между группой опыта и группой УЗИ (P> 0,05). Umahluko phakathi kweqela le-ultrasound kunye neqela lokulawula lalibaluleke kakhulu (P <0.05), kodwa kwakungekho mmahluko omkhulu phakathi kweqela lokufunda kunye neqela lokulawula okanye phakathi kweqela lokufunda kunye neqela le-ultrasound (P> 0.05).
Ixesha lokusetyenziswa kwe-vasopressor e-US kunye namaqela okulawula lalifutshane kuneqela lonyango kwaye umehluko wawubaluleke kakhulu (P <0.05), ngelixa kwakungekho mmahluko omkhulu phakathi kwe-US kunye namaqela okulawula (P> 0.05).) (Uluhlu 4).
Iziganeko ezimbi zenzeke kwizigulane ezi-5 kwezingama-30 kwiqela le-ultrasound (i-5 ene-hypotension, i-1 ene-arrhythmia), kwi-16 yezigulane ezingama-29 kwiqela lamava (i-16 ene-hypotension, i-4 ene-arrhythmia kunye ne-1 ene-delirium), kunye neqela lokulawula. : kwiqela kwakukho iimeko ze-16 kwi-29 (iimeko ezi-7 ze-hypotension, iimeko ze-8 ze-arrhythmia, iimeko ze-6 ze-delirium). Iziganeko zeziganeko ezimbi kwiqela le-ultrasound zaziphantsi kakhulu kunokuba kumava kunye namaqela okulawula, kwaye umehluko wawubaluleke kakhulu (P <0.05). Iziganeko zeziganeko ezimbi kwiqela le-ultrasound zaziphantsi kakhulu kunokuba kumava kunye namaqela okulawula, kwaye umehluko wawubaluleke kakhulu (P <0.05). Частота нежелательных явлений в группе УЗИ была значительно ниже, чем в опытной и контрольной группах, и разница значина, и разница значение (0). Iziganeko zeziganeko ezimbi kwiqela le-ultrasound zaziphantsi kakhulu kunamaqela okulinga kunye nokulawula, kwaye umehluko wawubaluleke kakhulu (P <0.05).超声组不良事件发生率明显低于体验组和对照组，差异有统计学意义（P<0.05）. P <0.05 УЗИ была значительно ниже, чем в группе опыта и контрольной группе, ибительные, бесплатно. Iziganeko zeziganeko ezimbi kwiqela le-ultrasound zaziphantsi kakhulu kunamaqela okulinga kunye nokulawula, kwaye umehluko wawubaluleke kakhulu (P <0.05). Ngokwahlukileyo, umahluko phakathi kwamava kunye namaqela olawulo ayengabalulekanga ngokwezibalo (P> 0.05) (Itheyibhile 5). Ngokwahlukileyo, umahluko phakathi kwamava kunye namaqela olawulo ayengabalulekanga ngokwezibalo (P> 0.05) (Itheyibhile 5). Напротив, разница между опытной и контрольной группами не была статистически значимой (P > 0,05) (табл. 5). Ngokuchasene noko, umahluko phakathi kwamaqela okulinga kunye nokulawula awuzange ubaluleke kakhulu (P> 0.05) (Itheyibhile 5).相反，经验组和对照组之间的差异无统计学意义（P > 0.05）（表5）。相反，经验组和对照组之间的差异无统计学意义（P > 0.05）（表5）。 Напротив, разница между опытной группой и контрольной не была статистически значимой (P > 0,05) (таблица 5). Ngokuchasene noko, umehluko phakathi kweqela lokulinga kunye neqela lokulawula lalingabalulekanga ngokwezibalo (P> 0.05) (Itheyibhile 5).
Ukungaphumeleli kwezintso ngokudibanisa nokungaphumeleli kwentliziyo enzima kubandakanya iinkqubo eziyinkimbinkimbi ze-pathophysiological.I-Metabolites kunye nolwelo olugqithisileyo emzimbeni alukwazi ukukhutshwa ngezintso ezonakalisiweyo.Ukuqokelelwa kwe-metabolites kunye nolwelo lomzimba kunokunyusa umthwalo wentliziyo kwaye kukhokelela ekungaphumeleli kwentliziyo ebukhali11.
Ukusebenzisana phakathi kokungaphumeleli kwezintso kunye nokungaphumeleli kwentliziyo kugqithisekile, ukwenza isangqa esibi ekugqibeleni sikhokelela ekuwohlokeni okubukhali kwintliziyo kunye nokusebenza kwezintso, okusongela kakhulu ukhuseleko lwesigulane12.Izintso zisusa ulwelo olugqithisileyo kunye ne-metabolites emzimbeni ukuphucula imeko yesigulane13.Nangona kunjalo, eyona ndlela ilungileyo yokufumana isiqabu ngokukhawuleza nangokukhuselekileyo kwiimpawu zokungaphumeleli kwentliziyo kuhlala kungacacanga.Ngoko ke, kubaluleke kakhulu ukuvavanya ngokuchanekileyo isimo somthamo wegazi lesigulane ukwenzela ukuba kube lula ukulungiswa kokuchithwa kwamanzi kwi-CRRT.
Okwangoku, iindlela eziphambili zokuvavanya umthamo wegazi ziquka ukusetyenziswa kwe-catheters ye-pulmonary artery, ukuhlolwa kwe-pulse (ebonisa ukuphuma kwentliziyo eqhubekayo), i-echocardiography ye-transesophageal, kunye ne-bioimpedance14,15,16,17.Ezi ndlela zineenzuzo, kodwa kunye nemida emininzi.Iikliniki ezininzi zisakhetha ukusebenzisa iindlela eziqhelekileyo zokuvavanya umthamo wegazi lesigulane, njengokuvavanya ubunzima obomileyo besigulane, ukuvavanya ubukho bemiphunga ye-pulmonary okanye i-edema kwiindawo ezisezantsi kunye nobuso, kunye nokuvavanya utshintsho kwiimpawu ezibalulekileyo.Nangona ezi ndlela zilula kwaye zilula ukuzisebenzisa, ukuthembeka kwazo kuphantsi kwaye azikwazi ukuhlangabezana neemfuno zovavanyo lweklinikhi olukhawulezayo, olushukumisayo, oluchanekileyo kunye nolungabonakaliyo.
Olu pho nonongo lusebenzise iindlela ze-ultrasound kunye ne-empirical ukulinganisa umthamo wegazi kwizigulane kwi-ultrasound kunye namaqela amava, kwaye uthelekise iziphumo kunye neqela lokulawula.Sifumene ukuba i-serum creatinine, i-potassium, kunye ne-NT-proBNP amanqanaba ehla kumaqela amathathu ngexesha le-24 yeeyure ze-CRRT, kwaye akukho mmahluko omkhulu phakathi kwamaqela amathathu, ebonisa ukuba iindlela ezahlukeneyo zokuvavanya umthamo wegazi azizange zichaphazele ukusebenza kwe-serum.Ukukhutshwa kwe-creatinine kunye ne-potassium ngexesha lonyango lokuqala.Akukho mpembelelo ibalulekileyo kumanqanaba e-NT-proBNP yabonwa.
Siphinde safumanisa ukuba ixesha lokuphucula ukuhluleka kwentliziyo, ixesha le-CRRT, kunye nokuhlala kwe-ICU kwakufutshane kakhulu kwi-ultrasound kunye namaqela okulinga kuneqela lokulawula.Xa kuthelekiswa neqela lokulawula, ixesha lokusebenzisa i-ventilator kwiqela le-ultrasound lancitshiswa kakhulu, kwaye umehluko wawubaluleke kakhulu.Ezi ziphumo zibonisa ukuba i-ultrasound kunye neqela lonyango liye lafumana ukuphuculwa ngokukhawuleza kweempawu ze-HF, ixesha elifutshane le-CRRT, kunye nokuhlala kwe-ICU xa kuthelekiswa neqela lokulawula ngaphandle kovavanyo lomthamo wamanzi.
Uphononongo lwethu lucebisa ukuba uvavanyo lwangexesha lomthamo we-ambulatory fluid ngexesha le-CRRT lunexabiso elikhulu leklinikhi ekulawuleni ukuphelelwa ngamanzi emzimbeni kwizigulane ezinokungaphumeleli kwezintso kunye nokungaphumeleli kwentliziyo.
Xa kuthelekiswa nokusetyenziswa kwe-vasopressors kunye neziganeko zeziganeko ezimbi (umzekelo, i-hypotension, i-arrhythmia, i-delirium), sifumene ukuba ixesha lokusetyenziswa kwe-vasopressor lalifutshane kakhulu e-US kunye namaqela olawulo kuneqela lonyango, kunye nesiganeko esibi. iziganeko kwiqela le-US laliphantsi kakhulu (i-hypotension, i-arrhythmia, i-delirium) iphantsi kakhulu kunamaqela okulinga kunye nokulawula.
Siye saqwalasela izizathu ezininzi zezi ziphumo.Okokuqala, iindlela zobungqina zinexabiso elithile ekuvavanyeni izigulane eziphezulu, ezifana nokuphuculwa ngokukhawuleza kweempawu zokungaphumeleli kwentliziyo, ixesha le-CRRT, kunye nokuhlala kwe-ICU, ngelixa ukuchaneka kwabo kuthandabuza kwizigulane ezinqongopheleyo.ube nokunyuka kwe-reflex kwizinga lentliziyo kunye noxinzelelo lwegazi, olunokuthi lubonakalise njenge-pseudo-hypervolemic state ngokubhekiselele kwimvelaphi ye-CRRT, ekhokelela ekuphelelweni kwamanzi ngokukhawuleza, okwandisa ukuphindaphinda kwe-hypotension kunye nobude bokusetyenziswa kwe-vasopressor.Okwesibini, izigulane ezikwiqela lolawulo zikhupha amanzi ngokuthe ngcembe kwaye ngokulinganayo.Nangona ukusetyenziswa kwe-vasopressors kufutshane, iimpawu zokungaphumeleli kwentliziyo zixazululwa ngokukhawuleza, ixesha le-CRRT linyuka kakhulu, ukuhlala kwe-ICU ixesha elide, kwaye iziganeko ezimbi ezifana ne-arrhythmia kunye ne-delirium zanda.Okwesithathu, izigulana kula maqela mathathu zahlala kwi-ventilator ixesha elide kuneempawu zokungaphumeleli kwentliziyo ziphuculwe, ngenxa yokuphuculwa kwamanqanaba eoksijini kwizigulana emva kwe-ventilator.Ukongezelela, nangona umthamo wegazi lomguli wawusaxinene, iimpawu zokungaphumeleli kwentliziyo ziphuculwe kakhulu.Ukuba i-ventilator iyekile, iimpawu zokungaphumeleli kwentliziyo zingabuya.Ngoko ke, ixesha lokungena komoya kufuneka linyuswe ukuze kuqinisekiswe ukuba iimpawu zesigulane sokungaphumeleli kwentliziyo aziphindi.
Ngokwahlukileyo, iimpawu zokungaphumeleli kwentliziyo ziphuculwe ngokukhawuleza kwiqela le-ultrasound, kunye nexesha elifutshane kakhulu le-CRRT, ukuhlala kwe-ICU, kunye nokusetyenziswa kwe-ventilator.Okubaluleke ngakumbi, iziganeko ze-CRRT ezihambelana ne-hypotension, ubude bokusetyenziswa kwe-vasopressor, kunye neziganeko ezimbi zancitshiswa kakhulu.
Umda oyintloko wophononongo lwethu kukuba yayisisifundo esinye seziko kunye nobungakanani besampulu encinci.Ke ngoko, uphononongo olulindelekileyo lwamaziko amaninzi kunye nobungakanani besampulu enkulu iyafuneka ukuze kuqinisekiswe iziphumo zethu kunye nokubonelela oogqirha ngesiseko esingcono.
Ukuqukumbela, ngenxa yokuqhubela phambili ngokukhawuleza kokungaphumeleli kwezintso ngokudibanisa nokungaphumeleli kwentliziyo, ukuqikelelwa komthamo wegazi kufuneka kube yinto enembile kwaye ichanekile.Ukuhlolwa kwe-Ultrasound eguquguqukayo ye-NSAID kunye ne-NSAID inokubonelela ngeengcebiso ezichanekileyo zokulungiswa kwe-CRRT ye-dehydration kwizigulane ezinokuhluleka kwezintso eziyinkimbinkimbi ngenxa yokungaphumeleli kwentliziyo.Inokunciphisa ngokukhawuleza iimpawu zokungaphumeleli kwentliziyo, ukunciphisa iziganeko zemiphumo emibi kunye neendleko zonyango kwiyunithi yokunyamekela, kunye nokuphucula umgangatho wobomi bezigulane.Ke, i-ultrasonic esweni eguquguqukayo ye-LPVC kunye ne-NPVC ineenzuzo ezilungileyo kwezentlalo nezoqoqosho.
Iisethi zedatha ezisetyenzisiweyo kunye/okanye ezihlalutyiweyo kuphononongo lwangoku ziyafumaneka xa ziceliwe kubabhali abachaphazelekayo.
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