每日一题_2022.09.16

A 55-year-old man with a history of cirrhosis presents with hepatic encephalopathy. He is intubated on a mechanical ventilator. Physical examination is remarkable for tense ascites and 3+ lower extremity edema that developed over a one-week period. He exhibits significant hypotensive episodes requiring significant pressor support to maintain a mean arterial pressure above 70 mm Hg. Central venous pressure is 15 mm Hg, with urine output of 10 mL/hour. Bladder pressures have increased from 15 mm Hg to 25 mm Hg. Serum laboratory values one week after presentation are: sodium 126 mEq/L, potassium 5.2 mEq/L, chloride 93 mEq/L, carbon dioxide 13 mEq/L, blood urea nitrogen 25 mg/dL, creatinine 1.9 mg/dL. Urine laboratory values one week after presentation are: creatinine 68 mg/dL, sodium 11 mEq/L.

Which of the following is the most appropriate next step in this patient’s management?

A. Abdominal CT with contrast

B. Decompressive laparotomy

C. Foley catheter placement and assessment of post-void residual

D. IV bolus with isotonic crystalloid fluids

E. Large-volume paracentesis

答案解析：

诊断基于导致急性肾功能衰竭的腹内压升高。 膀胱测压显示腹内压增加超过 20 mm Hg 提示腹腔室综合征。 如果去除腹水不能解决急性肾损伤，可能需要紧急手术减压。 腹部 CT 会延迟处理，不建议在肾损伤情况下使用 IV 对比剂。 低尿钠并不表明存在梗阻后过程。 虽然低尿钠提示肾前性病因，但没有证据表明这是继发于血容量不足。 因此，没有容量复苏的指征。

正确答案：E