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Tonometry

Tonometry in ARDS management

V. Sramek, M.D.
Charles University Hospital, Medical Dpt 1, ICU
304 60 Plzen
Czech Republic

Article also available in PDF: 20 KB

 

A 68 year old male patient was admitted to the ICU with septic shock and respiratory failure secondary to bilateral community acquired pneumonia (CAP). On admission signs of acute renal failure were also present (creatinine 302 umol*l-1). The patient was intubated and mechanical ventilation was initiated concomitantly with hemodynamic resuscitation. After 12 hours of resuscitation, guided by PA catheter, hyperdynamic septic shock did not resolve (norepinephrine 0.08 umol*kg-1*min-1 and dobutamine 7.3 umol*kg-1*min-1) and gas exchange continued to deteriorate. A subsequent X-ray compatible with the diagnosis of ARDS along with an oxygenation index of (PaO2/FiO2 = 73 mmHg). Monitoring of the patient was extended to include the transpulmonary double indicator technique (COLD System, Pulsion, Germany) and gastric tonometry (Tonocap, Datex-Ohmeda, Helsinki, Finland). Continuous venovenous hemofiltration (CVVH) was intiated. After 12 hours of zero balance CVVH the patient was weaned from norepinephrine with a CI of 3.0 l*min-1*m-2 and PAOP of 19 mmHg on an unchanged dose of dobutamine. At this point in time severely pathological values of EVLWI and pCO2gap were measured (14.3 ml*kg-1*m-2 and 4.7 kPa, respectively). A negative fluid regime (i.e. 200–300 ml/hour) was started by means of CVVH. The patient remained stable (CI range 2.8-4 l*min-1*m-2, PAOP 17-23 mmHg) throughout the following period of 36 hours (total fluid balance – 2400ml) with decreasing both EVLWI and pCO2gap values

Conclusion:

Gastric tonometry proved to be a good guide in monitoring safety of a negative fluid balance treatment of a severe ARDS patient. Under the course of an aggressive negative fluid regime no signs of impending gut stress developed. On the contrary a progressively decreasing pCO2gap levels suggested an improval in gut perfusion. We conclude that gastric tonometry is a useful tool in ARDS management in order to find a balance between dry lungs and volume resuscitated gut.

 

 


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