[Fluid resuscitation strategy in septic shock following urinary infection with severe pulmonary capillary leakage].
Ключевые слова
абстрактный
OBJECTIVE
To characterize septic shock following urinary infection with severe pulmonary capillary leakage, and to evaluate the fluid therapy on treatment of hypovolemic shock and the role of transpulmonary thermodilution technique with pulse induced continuous cardiac output (PiCCO) monitoring.
METHODS
A retrospective study was conducted. Eight patients surviving septic shock following urinary infection with severe pulmonary capillary leakage were enrolled, and all of them underwent PiCCO monitoring in the intensive care unit (ICU) when the diagnosis was established. The monitoring started at admission, and ended when shock was corrected or transferred from ICU. The clinical data including general end diastolic volume index (GEDVI), extravascular lung water index (EVLWI), input and output volume of fluid, net fluid balance, oxygenation index (PaO2/FiO2), the level of arterial blood lactic acid, and chest X ray were collected and analyzed retrospectively the characteristics of septic shock following urinary infection, and the role of PiCCO monitoring in fluid resuscitation.
RESULTS
Septic shock following urinary infection occurred in a median of 4.5 days in 8 patients after renal and ureteric calculi lithotripsy, accompanied with severe pulmonary vessel effusion and hypoxemia in different degrees. The mean value of EVLWI was (22±7) ml/kg, and the PaO2/FiO2 (164±82) mm Hg at the time of admission to ICU. Conservative fluid resuscitation strategy was adopted in management of septic shock with severe pulmonary capillary leakage, the mean fluid input in 8 patients was (2412±1121) ml/d, and the net fluid balance -553 ml/d, and the central venous pressure (CVP) and GEDVI were maintained at levels of (9±3) mm Hg and (749±236) ml/m(2) respectively. Diuretics were administered to 6 patients and the mean dosage of fursemide was (264±133) mg. Norepinephrine and dobutamine infusion were given to 7 patients to maintain blood pressure at normal range for (4±1) days. Seven patients were mechanically ventilated, and the mean length of ventilation was (8±6) days. All of the 8 patients survived from septic shock after fluid resuscitation therapy, with the mean level of EVLWI decreased gradually to (11±3) ml/kg, and the lung effusion was absorbed significantly as shown in chest X ray. The mean length of ICU stay was (17±11) days. Pearson correlate analysis showed EVLWI was significantly correlated with PaO(2)/FiO(2) and the levels of artery blood serum lactate, with r -0.91 and 0.70 respectively (both P<0.05).
CONCLUSIONS
Successful management of septic shock following urinary infection with severe pulmonary vascular leakage is based on accurate assessment of blood volume status, especially the degree of EVLWI, emphasis on prevention of EVLWI increase, and adoption of conservative fluid resuscitation strategies according to hemodynamic monitoring parameters. PiCCO monitoring is a useful tool in assessment of the blood volume status and management of fluid resuscitation in patients with urinary lithotripsy-associated septic shock complicated with severe pulmonary edema.
