每日一题_2022.5.8

A 30-year-old man was severely burned in a house fire and explosioncaused by a gas leak. He sustained third-degree burns over 70% of his body and remains in the ICU seven days later in respiratory failure and shock. He has no other injuries. Overnight, his urine output decreases to 10 mL/hr and he has increasing vasopressor requirements to maintain a mean arterial pressure above 65 mm Hg. On examination, his temperature is 39°C (102.2°F), heart rate 96 beats/min, blood pressure 130/75 mm Hg (mean arterial pressure 70 mm Hg), and oxygen saturation 100% on 40% fraction of inspired oxygen. Pulse pressure variation is 6%, and central venous pressure is 13 mm Hg. He remains intubated and sedated on fentanyl and low-dose propofol, has equal breath sounds bilaterally, and a firm and distended abdomen with edematous arms and legs. On pressure-control ventilation, his tidal volume is 300 mL, down from 500 mL earlier in the day. His urine is dark in color, with a recent creatinine kinase level down-trending from 2,500 to 1,000 U/L. His evening laboratory results show evidence of acute kidney injury, with a creatinine level of 2.05 mg/dL.

Which of the following is the most appropriate next step in management?

A. Administer 1 liter normal saline bolus. 

B. Check bladder pressure.

C. Check urine electrolytes.

D. Administer IV furosemide, 40 mg.

答案解析：

该患者在严重烧伤的情况下由于广泛的容量复苏而患有腹腔间隔室综合征(ACS)。应紧急检查膀胱压力，正式诊断这种情况，加快进一步处理。在重症患者中，ACS通常被低估，因为器官衰竭通常是多因素的，并归因于基础疾病过程。当发现腹压大于20 mmHg伴相关器官衰竭时，符合ACS诊断标准。器官衰竭可表现为腔静脉受压引起的低血压和静脉回流减少，随后心输出量下降。接受机械通气的患者由于腹部膨胀，气道峰压通常较高。然而，该患者接受了压力控制通气，其中气道压力受到调节，因此ACS表现为该通气模式下潮气量减少。肾衰竭是另一种常见结果，被认为继发于肾静脉压迫导致的肾灌注减少和心输出量减少。处理方法是腹腔减压。提供更多IV液体可能会恶化腔室压力。在脉压变化较低的情况下，他不太可能对更多的液体推注做出反应。横纹肌溶解可能导致急性肾小管坏死，但考虑到造影剂推注的时间范围和相对较低的肌酸激酶水平，可能性较小。

正确答案：B