常记溪亭日暮,沉醉不知归路。
孙丹雄
急性呼吸窘迫综合症(acute respiratory distress syndrome),可能我们对他还很陌生:熟悉的陌生人!
双肺多发斑片状阴影,呼吸衰竭,不一定是肺部感染,还可能是肺外疾病继发的急性呼吸窘迫综合症(ARDS)。
肺外疾病,不需要继发感染,继发炎症反应,引起急性呼吸窘迫综合症(ARDS),就可以形成双肺多发斑片状阴影。
01
病人女,24岁,严重的上腹痛。
The first patient was a 24-year old woman who had severe epigastric pain.
血淀粉酶明显升高。
The serum amylase was 1650 Somogyi U/L.
出现低氧血症,第五天需要呼吸机治疗。
Hypoxia developed and she required ventilation by day 5.
什么情况?
By day 6, her ratio of PaO2:FiO2 was 72.8 mmHg,her Murray score was 4.0 (4), and she was transferred for ECMO.
体外膜肺氧合(ECMO),血液从颈内静脉引出,回到股静脉。
She was cannulated percutaneously for veno-venous ECMO, draining from the right internal jugular vein,and returning via the right femoral vein (Fig. 1.).
体外血流量59 ml/kg.min,这样让呼吸机参数减至休息状态(气道峰压20cmH20, PEEP10cmH20, 呼吸频率10, FiO2 30%)。
Extracorporeal flow was initially 59 mL/kg per minute, which allowed ventilation to be reduced to rest settings (peak pressure 20 cm H20, end expiratory pressure 10 cm H20, rate 10, and FiO2 30%).
治疗78小时后拔中心静脉导管(为什么不说3天后),24小时后拔气管导管。
Her lung function gradually improved,and she was decannulated after 78 hours and extubated 24 hours later.
三月后病人恢复正常的生活方式。
At 3 months she resumed a normal lifestyle.
02
青年人,妊娠25周。
突发右上腹部疼痛,为持续性钝痛。
2天后出现呼吸急促(32次/min),心率158次/min,意识不清。
查血糖明显升高,尿酮体++,甘油三酯36mmol/L,血淀粉酶、脂肪酶均明显升高。
初步诊断: 妊娠期糖尿病、糖尿病酮症酸中毒、高甘油三酯血症及重症急性胰腺炎。
紧急予以气管插管,呼吸机辅助通气,初始参数:FiO2(氧浓度) 60% ,呼气末正压(PEEP)0.8 kPa(什么鬼?),压力支持水平( PS)1.2 kPa(什么鬼?)。
床旁纤维支气管镜检查,气管壁有少量胃内容物,给予冲洗干净。
入院3小时后,产科协助臀位自然流产一死婴,胎盘自行娩出,呼吸困难加重。
呼吸机氧浓度改为纯氧,氧饱和度约60%。
床旁胸片示双肺多发斑片状阴影!
考虑重症急性胰腺炎继发重度ARDS。
甘油三酯36mmol/L,行血液灌流2次纠正高脂血症,并行连续肾脏替代疗法( CRRT) 治疗纠正酸中毒、减轻肺水肿。
加用去甲肾上腺素1.2μg /(kg·min) 静脉泵入维持血压。
呼吸衰竭无好转。
03 人工肺闪亮登场
行体外膜肺氧合( V-V ECMO) 辅助治疗。
血流量4.5L/min(75ml/秒),氧流量5L/min,氧浓度60% ,离心泵转速4500转/min,患者SpO2立即上升至96% 。
犇!
应用ECMO2天后,胆红素升高,以间接胆红素升高为主,考虑溶血所致,降低离心泵转速后好转。
ECMO第5天,膜肺暂停供氧,继续呼吸机治疗,SIMV模式,病情好转逐渐拔管。
治疗前!
治疗后
拔管后随访
效果very good!
李国福,贾 佳,王 睿,臧 彬,张成普.体外膜肺氧合辅助治疗妊娠期重症急性胰腺炎合并重度急性呼吸窘迫综合征1例报告.中国实用内科杂志,2012.
04
2012年,玛雅人预言the end of the word,结果科技改变生活!
05
这个患者,支气管镜都发现了误吸,也不提有没有使用抗生素!
急性呼吸窘迫综合症,关键是呼吸支持治疗,小潮气量!根本是病因治疗。
06
翻译欣赏
Extracorporeal life support for pancreatitis-induced acute respiratory distress syndrome.
急性胰腺炎所致急性呼吸窘迫综合征的体外生命支持。
Results: Overall, 5 of the 8 patients (63%) survived to discharge. Seven of the 8 patients underwent venovenous ECLS, and 1 underwent venoarterial ECLS. The overall mean length of ECLS was 9.7 ± 10.7 days. However, the mean ECLS run length in survivors was 4.3 ± 1.8 days and the longest ECLS run in a survivor was 7.25 days. Two of the 3 patients who died had very long run lengths (28.8 and 24.7 days, respectively), whereas 1 patient had a short run (2.4 days). Five of the 8 patients (63%), including all of the 3 who died, experienced a bleeding complication of some kind. Two patients required continuous venovenous hemofiltration, 1 of whom died and 1 of whom survived. Six patients underwent tracheostomy on ECLS, 1 patient already had undergone tracheostomy, and 1 patient did not undergo tracheostomy.
结果:8例患者中有5例(63%)存活出院。8例患者中7例接受静脉-静脉电切术(改:静脉-静脉体外生命支持),1例接受静脉-血管性ECL(改:静脉-动脉体外生命支持)。ECLS总平均长度(改:平均时间)为9.7±10.7天。然而,幸存者的平均ECLS运行时间为4.3±1.8天,幸存者中最长的ECLS运行时间为7.25天。死亡的3名患者中有2人的跑步时间(改:体外生命支持设备运行时间)很长(分别为28.8天和24.7天),而1名患者的跑步时间很短(2.4天)。8名患者中有5名(63%)出现了某种出血并发症,其中包括3名死亡患者。2例患者需要持续静脉-静脉血液滤过,1例死亡,1例存活。6例在ECLS上行气管造口术,1例已行气管造口术,1例未行气管造口术。
07
人工智能,能不能快点发展,学外语很累的!
08 好句子
Five of the 8 patients (63%), including all of the 3 who died, experienced a bleeding complication of some kind.
09
The patient completed six months of itraconazole 100 mg twice-daily with symptomatic and radiographic improvement.
伊曲康唑100mg bid,原来这么简单:itraconazole 100 mg twice-daily.
杨柳岸,晓风残月。
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