Fliud Management By PICCO In Patients With ARDS After Esophagectomy

Objective: The acute respiratory distress syndrome(ARDS)is the major cause of acute respiratory failure in the critically ill patient.Currently,it is believed that ARDS result from the extensive and excessive inflammatory reaction in the lung due to serious strikes such as serious infection,trauma, shock,massive blood transfusion,high-dose infusion.Excessive inflammatory injury the alveolar epithelial and endothelial barriers of the lung and increse pulmonary capillary permeability,which brings about protein rich fliud accumulated in alveolar and interstitial and than causes pulmonary edema further.Increase in pumonary vascular endothelial permeability(PPI)incresae is an important pathophysiological feature of ARDS,which would lead to increase in extravascular lung water(EVLW)and that increased the severity of pumonary edema,which is closely related to the prognosis of ARDS.Unfortunately there is still a controversy that how to keep a fliud balance in this patient population.Recent data indicated that consistent positive fluid gain was associated with a worse outcome in patients with ARDS or after major surgery and a negative fluid balane was correlation with the mortality decrease of septic shock patients.Recommendated fluid management goal is the lowest possible pulmonary wedge pressure consistent with an adequate cardiac output.However,recent clinical studies confirmed that it was not accurate to reflect cardic volume by pressure(CVP and PAWP).May be Intrathoracic Blood Volume(ITBV)/Global End Diastolic Volume(GEDV)was a better indicater of circulation blood volume in critical ill patient.Pulse indicator cardiac output (PICCO) would provide two important haemodynamics information-EVLW and cardic preload(ITBV/GEDV).In this study,PICCO was used to guide ARDS capacity management in order to ensure adequate capacity on the basis of minimizing extravasclar lung water and achieve an early negative fluid balance for improvement of patients'prognosis.Methods:Twenty-four patients with ARDS after esophagectomy were randomly divided into 2 groups(n=12each):①C VP monitoring-treated group,in which the traditional liberty fliud management strategy was given according to the CVP,urine output,heart rate and mean arterial pressure;②PICCO monitoring-treated group,in which a restrictive fliud management was given according to the PICCO monitoring of hemodynamic data in conbination with urine output,heart rate,mean arterial pressure.Then the amount of liqud into and out volume,fliud balance,extravascular lung water index(EVLWI)changes and oxygenation index(PaO2/FiO2)were record during study days 1 to 7,ventilator days,length of stay and the 28-days mortality were record too.Statistical analysis was performed using SPSS 13.0 software package. Data were expressed as mean±SD;Compared two-sample using Student's t-tests.The means of each group were analysed with ANOVA;Compared two-sample rate use chi-square test;The relationship bettween EVLWI with GEDVI,ITBVI,PVPI,LIS,PaO2/FiO2 ratio,CI,SVRI and CVP were analyzed by linea correlation analysis.A statistical significant was P-value<0.05.Results:1 No statistical difference developed to the overall 28-day mortality beteen the two groups(18.0%VS18.0%,P>0.05).The mean cumulative fluid input during 1 to 7 day was 27851.8±4578.6ml in PICCO group and 33247±4524.2 ml in cvp group,respectively(P<0.05).The net balance of the two groups of liquid was 4584.0±3615.0ml in the PICCO group,and 8402.0±4248.0ml in the cvp group(P<0.05)during the first seven days;The time by which a nagative fliuld balance(>500mL)was achieved was earlier in the PICCO group than in the cvp group(4.17±1.64d VS 6.75±2.63d,P=0.009);The oxygenation index of Day 5 was better in the PICCO group than in cvp group(248±21 VS 200±22, P<0.05).The PICCO group reduce the number of ventilator days (6.1±1.6d VS 8.0±2.4d,P<0.05) and ICU length of stay(8.4±2.5d VS 10.5±2.2d,P<0.05). The shock and acute kidney falure incidenc was not increased in the PICCO group than in the cvp group.There was a positive correlation between ventilator days and the achievement of negative fluid balance of the time(r=0.61,P<0.01);The mean CVP was high in CVP group compared with PICCO group(13±0.7mmHg VS 9±0.5mmHg,P<0.05).2 Correlation with extravascular lung water index(EVLWI)There was a positive correlation between EVLWI and ITBVI(r=0.512, P<0.01);EVLWI was well correlated with the GEDVI(r=0.573,P<0.05);The change in EVLWI has positive correlation with the change in fliud balance (r=0.439,P<0.05);EVLWI was also well correlated with the pumonary vascular endothelial permeability index(PVPI)(r=0.767,P<0.01)and lung injury score(LIS)(r=0.613,P<0.01);EVLWI was negative correlation with oxygenation index(r=0.48,P<0.01).There was a signifacant correlation between the highest EVLWI and the lowest PaO2/FiO2 ratio(r=0.65,P<0.01);There was no correlation between EVLWI with CI, SVRI,and CVP(P>0.05); There was also no correlation between CVP and GEDVI or ITBVI,either.3 Lab IndexThere was no statistical difference in pH value,acid-base status,serum urea nitrogen levels and serum creatinine levels between the PICCO group and the CVP group at each time point.But the ALB level was improved significantly in PICCO group compared with CVP group.The ALB level was 24.74±2.51g/l in PICCO group and 21.68±3.06g/l in CVP group at day 5,P<0.05.Conclusions:Conservative-strategy with PICCO seystem moniter hemodynamic of patients with ARDS after esophagectomy has better outcome compared to liberal-strategy with CVP.Though there was no reduction in overall mortality, PICCO group can reduce the volume overload, reduce the incidence of acute pulmonary edema, improved the oxygenation index and decreased the number of ventilator days and ICU length of stay,without increse the extrapulmonary organ damage.