168
168
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168
DOI：
10.1097/01.ccm.0000550923.88428.dc
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发表时间：
2019
影响因子：
8.8
通讯作者：
K. Burchard
中科院分区：
文献类型：
--
作者：
P. Atchinson;M. Roginski;K. Burchard
方法：一名36岁女性患者，以A群链球菌性死死性下肢筋膜炎为临床表现，在截肢术后3天出现低血压和生理填塞，大量液体复苏40升以上。在截肢和抗生素治疗后，患者的血流动力学得到改善，但在第三天出现了快速进行性休克，并出现了短暂的液体反应。最初，脓毒症引起的弥散性休克首先出现在鉴别诊断上，但是心包填塞是由重症监护医生通过急诊超声心动图诊断出来的。行心包穿刺，液体与渗出液一致，没有感染扩大或先前创伤提示其他原因。最终，填塞是由于她在全身性炎症的情况下进行了大容量复苏。结果：本病例报告与重症监护界有关，因为它提醒我们在大量液体复苏的情况下心脏填塞的可能性，这在目前的文献中没有很好的代表。心包填塞是一种严重危及生命的疾病，传统上描述的心包填塞的证据——贝克三联征、异脉征和Kussmaul征——是心包填塞生理学的不可靠指标。诊断依赖于临床怀疑和超声心动图结果。具有基本超声心动图技能的重症监护临床医生可以在床边很容易地识别心包积液的存在，迅速缩小广泛的鉴别范围，加快确定的救命治疗。
Methods: A 36-year-old female presenting with Group A Streptococcus necrotizing fasciitis of the lower extremity developed hypotension and tamponade physiology three days after amputation of the lower extremity and massive fluid resuscitation with over 40 liters of crystalloid. She had initial hemodynamic improvement after amputation and antibiotics, however on day three developed rapidly progressive shock which was transiently fluid responsive. Initially, distributive shock due to sepsis was first on the differential, however tamponade was diagnosed with point of care echocardiography performed by the critical care physician. Pericardiocentesis was performed and fluid was consistent with a transudative effusion, without extension of infection or prior trauma to suggest alternate cause. Ultimately, tamponade was attributed to her large volume resuscitation in the setting of systemic inflammation.Results: This case report is relevant to the critical care community because it alerts us to the possibility of cardiac tamponade in the setting of massive fluid resuscitation, which is not well represented in current literature. Cardiac tamponade is an acutely life threatening condition, and traditionally described evidence of tamponade-Beck’s triad, pulsus paradoxus and Kussmaul’s sign-are unreliable indicators of tamponade physiology. Diagnosis relies on clinical suspicion and echocardiographic findings. Critical care clinicians with basic echocardiographic skills can readily identify the presence of a pericardial effusion at bedside, rapidly narrowing a broad differential and hastening definitive, life saving therapy.