ScvO的臨床意義醫(yī)學(xué)知識(shí)講解培訓(xùn)課件

1、ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO的臨床意義醫(yī)學(xué)知識(shí)講解內(nèi) 容 氧供與氧耗SvO2與ScvO2ScvO2的臨床應(yīng)用2ScvO的臨床意義醫(yī)學(xué)知識(shí)講解內(nèi) 容 氧供與氧耗2ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧供與氧耗3ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧供與氧耗3ScvO的臨床意義醫(yī)學(xué)知識(shí)講解15vol%=15ml/dl5vol%=5ml/dl4ScvO的臨床意義醫(yī)學(xué)知識(shí)講解15vol%=15ml/dl5vol%=5ml/dl4Scv5ScvO的臨床意義醫(yī)學(xué)知識(shí)講解5ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧供DO2與氧耗VO2DO2=CaO2CO =(1.34SaO2Hb+0.0031PaO2)CO =1.34

2、SaO2HbCOVO2=(CaO2-CvO2)CO = (SaO2- SvO2) 1.34 HbCOSvO2=SaO2-VO2/(1.34HbCO) 呼吸血紅蛋白循環(huán)(Fick方程)6ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧供DO2與氧耗VO2DO2=CaO2CO呼吸血紅蛋白循環(huán)氧攝取EO2EO2=VO2/DO2EO2=(SaO2 - SvO2)/SaO2當(dāng)SaO2=100%時(shí) ： EO2=1-SvO2全身 EO2=1 - 75% = 25%各組織EO2不同，其相應(yīng)之靜脈氧飽和度不同SvO2 = 1 - EO27ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧攝取EO2EO2=VO2/DO27ScvO的臨床意義醫(yī)學(xué)知

3、氧供氧耗失衡SvO2降低或增加無(wú)氧代謝組織缺氧乳酸生成8ScvO的臨床意義醫(yī)學(xué)知識(shí)講解氧供氧耗失衡SvO2降低或增加無(wú)氧代謝8ScvO的臨床意義醫(yī)影響SvO2的因素75%-+DO2應(yīng)激發(fā)熱寒戰(zhàn)躁動(dòng)疼痛呼吸做功VO2CO(心衰、低容量）Hb（貧血、出血）SaO2（缺氧、呼衰）DO2CO（液體復(fù)蘇、正性肌力）Hb（輸血）SaO2（氧療）VO2低體溫鎮(zhèn)靜鎮(zhèn)痛麻醉機(jī)械通氣氧攝?。ǚ至?、細(xì)胞死亡）9ScvO的臨床意義醫(yī)學(xué)知識(shí)講解影響SvO2的因素75%-+DO2VO2CODO2COVO2SvO2 的界值Pinsky MR, Mancebo J, Applied physiology in intensi

4、ve care. 10ScvO的臨床意義醫(yī)學(xué)知識(shí)講解SvO2 的界值Pinsky MR, Mancebo J, ScvO2與SvO211ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO211ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO212ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO212ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO2SvO2由肺動(dòng)脈導(dǎo)管測(cè)得反映全身的氧耗量正常值：75%ScvO2由中心靜脈（上腔靜脈）導(dǎo)管測(cè)得反映腦及上半身的氧耗量正常值：72%13ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO2SvO213ScvO的臨床意義醫(yī)學(xué)知識(shí)講測(cè)定方法連續(xù)監(jiān)測(cè)光纖導(dǎo)管或光

5、纖中心靜脈導(dǎo)管間斷測(cè)定中心靜脈血?dú)?4ScvO的臨床意義醫(yī)學(xué)知識(shí)講解測(cè)定方法連續(xù)監(jiān)測(cè)14ScvO的臨床意義醫(yī)學(xué)知識(shí)講解15ScvO的臨床意義醫(yī)學(xué)知識(shí)講解15ScvO的臨床意義醫(yī)學(xué)知識(shí)講解正常各組織器官的靜脈氧飽和度Pinsky MR, Mancebo J, Applied physiology in intensive care. 16ScvO的臨床意義醫(yī)學(xué)知識(shí)講解正常各組織器官的靜脈氧飽和度Pinsky MR, Mance休克時(shí)？17ScvO的臨床意義醫(yī)學(xué)知識(shí)講解休克時(shí)？17ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO2的相關(guān)性Charalambos Ladakis Pavlos Myr

6、ianthefs Andreas Karabinis et al.Central Venous and Mixed Venous Oxygen Saturation in Critically ill patients,Respairation,2001;68 279-285Linear correlation of paired ScvO2 and SvO2 measurements for 296 paired samples ScvO2 increases by 0.87% for every unit increase in SvO218ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO

7、2的相關(guān)性Charalambos LadaScvO2與SvO2的相關(guān)性Dueck MH et al. Anesthesiology 2005; 103:249 5719ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與SvO2的相關(guān)性Dueck MH et al. Moina and Podbregar Critical Care2010,14:R42 th20ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Moina and Podbregar Critical Moina and Podbregar Critical Care2010,14:R4221ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Moina and Podbreg

8、ar Critical Moina and Podbregar Critical Care2010,14:R4222ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Moina and Podbregar Critical Moina and Podbregar Critical Care2010,14:R4223ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Moina and Podbregar Critical SvO2與ScvO2的一致性絕對(duì)值相差518%24ScvO的臨床意義醫(yī)學(xué)知識(shí)講解SvO2與ScvO2的一致性絕對(duì)值相差518%24ScvOScvO2的臨床應(yīng)用25ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2的臨床應(yīng)用25

9、ScvO的臨床意義醫(yī)學(xué)知識(shí)講解休克中的應(yīng)用VO2DO2ScvO2/SvO2乳酸休克的本質(zhì)是組織缺氧和氧代謝障礙，最終結(jié)果是MODS。液體復(fù)蘇、及早糾正氧供與氧耗的失衡、降低組織缺氧程度至關(guān)重要。26ScvO的臨床意義醫(yī)學(xué)知識(shí)講解休克中的應(yīng)用VO2DO2ScvO2/SvO2休克的本質(zhì)是組織急診患者的復(fù)蘇多數(shù)（31例/36例）存在休克的危重患者經(jīng)初期復(fù)蘇至正常生命體征后乳酸繼續(xù)升高(2mmol/L)，ScvO2仍低于正常(65%)，提示存在無(wú)氧酵解和氧債。這些患者進(jìn)一步治療后乳酸下降（4.63.8 to 2.62.5, p0.05)，ScvO2升高（5218 to 6513%, p0.05)Scv

10、O2能作為初期復(fù)蘇后指導(dǎo)休克治療的指標(biāo)Rady MY, Rivers EP, Novak RM: Resuscitation of the critically ill in the ED:responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med1996, 14:218-225.27ScvO的臨床意義醫(yī)學(xué)知識(shí)講解急診患者的復(fù)蘇多數(shù)（31例/36例）存在休克的危重患者經(jīng)初期重癥感染與感染性休克中的應(yīng)用13681377 N E

11、ngl J Med, Vol. 345, No. 19 November 8, 2001早期目標(biāo)指導(dǎo)治療（EGDT）28ScvO的臨床意義醫(yī)學(xué)知識(shí)講解重癥感染與感染性休克中的應(yīng)用13681377 N En29ScvO的臨床意義醫(yī)學(xué)知識(shí)講解29ScvO的臨床意義醫(yī)學(xué)知識(shí)講解研究結(jié)果死亡率30ScvO的臨床意義醫(yī)學(xué)知識(shí)講解研究結(jié)果死亡率30ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Rivers E, Nguyen B, Havstad S, et a1Early goal directed therapy in the treatment of severe sepsis and septic shock.

12、N Eng J Med,2001,345:13681377.進(jìn)行ScvO2監(jiān)測(cè)，達(dá)到EGDT目標(biāo)，可使患者病死率下降16%（46.5% vs 30.5%）。低ScvO2的預(yù)后差31ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Rivers E, Nguyen B, Havstad S,2012 “拯救膿毒癥運(yùn)動(dòng)”指南早期復(fù)蘇目標(biāo)MAP 65mmHgCVP 812mmHg , 機(jī)械通氣1215mmHg尿量0.5ml/kg/h ScvO2 70% or SvO2 65%32ScvO的臨床意義醫(yī)學(xué)知識(shí)講解2012 “拯救膿毒癥運(yùn)動(dòng)”指南早期復(fù)蘇目標(biāo)MAP 感染性休克高ScvO2的預(yù)后33ScvO的臨床意義醫(yī)學(xué)知識(shí)講

13、解感染性休克高ScvO2的預(yù)后33ScvO的臨床意義醫(yī)學(xué)知識(shí)講34ScvO的臨床意義醫(yī)學(xué)知識(shí)講解34ScvO的臨床意義醫(yī)學(xué)知識(shí)講解單因素分析結(jié)果35ScvO的臨床意義醫(yī)學(xué)知識(shí)講解單因素分析結(jié)果35ScvO的臨床意義醫(yī)學(xué)知識(shí)講解存活組與死亡組的ScvO236ScvO的臨床意義醫(yī)學(xué)知識(shí)講解存活組與死亡組的ScvO236ScvO的臨床意義醫(yī)學(xué)知識(shí)講解該研究共納入4家醫(yī)院急診科膿毒癥患者619名，按EDGT復(fù)蘇方案治療，據(jù)ScvO2水平分為三組：低ScvO2組(70%)、正常ScvO2組(7189%)、高組(90100%)。比較住院死亡率并進(jìn)行多因素分析37ScvO的臨床意義醫(yī)學(xué)知識(shí)講解該研究共納入4

14、家醫(yī)院急診科膿毒癥患者619名，按EDGT復(fù)蘇23%25%31%初始ScvO2與死亡率(81/351)(56/223)(14/45)38ScvO的臨床意義醫(yī)學(xué)知識(shí)講解23%25%31%初始ScvO2與死亡率(81/351)(525/6296/46531/9239ScvO的臨床意義醫(yī)學(xué)知識(shí)講解25/6296/46531/9239ScvO的臨床意義醫(yī)學(xué)知ScvO2在ACS 中的應(yīng)用該研究納入患者43名，為收住CCU的急性冠脈綜合征（ACS）并急性肺水腫或心源性休克患者，測(cè)定入室時(shí)、24h、48h的中心靜脈和外周動(dòng)脈血?dú)?，主要終點(diǎn)為致死性事件，次要終點(diǎn)為住院全因死亡率Acta Cardiol Sin

15、 2008;24:1263340ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2在ACS 中的應(yīng)用該研究納入患者43名，為收住CC結(jié)果：存活組與死亡組ScvO2的差異有顯著性Acta Cardiol Sin 2008;24:1263341ScvO的臨床意義醫(yī)學(xué)知識(shí)講解結(jié)果：存活組與死亡組ScvO2的差異有顯著性Acta Car所有患者ScvO2、SaO2的變化存活患者ScvO2的變化Acta Cardiol Sin 2008;24:1263342ScvO的臨床意義醫(yī)學(xué)知識(shí)講解所有患者ScvO2、SaO2的變化存活患者ScvO2的變化A創(chuàng)傷患者的評(píng)估Low central venous saturati

16、on predicts poor outcome in patients with brain injury after major trauma: a prospective observational studyAlessandro Di Filippo*1, Chiara Gonnelli1, Lucia Perretta1,Rosario pina1, Marco Chiostri2, Gian Franco Gensini2 and Adriano Peris1Scandinavian Journal of Trauma, Resuscitation and Emergency Me

17、dicine2009, 17:2343ScvO的臨床意義醫(yī)學(xué)知識(shí)講解創(chuàng)傷患者的評(píng)估Low central venous satuScandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23ScvO265%的患者住院時(shí)間延長(zhǎng)，死亡率明顯增加44ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Scandinavian Journal of Trauma急診插管對(duì)重癥患者ScvO2的影響15minHernandez et al. Critical Care2009, 13:R63 45ScvO的臨床意義醫(yī)學(xué)知識(shí)講解急診插

18、管對(duì)重癥患者ScvO2的影響15minHernandeHernandez et al. Critical Care2009, 13:R63 46ScvO的臨床意義醫(yī)學(xué)知識(shí)講解Hernandez et al. Critical Care插管改善ScvO2的機(jī)制插管前預(yù)充純氧，溶解氧增加，氧供提高插管時(shí)鎮(zhèn)靜與肌松使氧攝取減少而降低氧耗初始機(jī)械通氣減輕了過(guò)度通氣，使pH升高而使氧離曲線右移，利于氧釋放47ScvO的臨床意義醫(yī)學(xué)知識(shí)講解插管改善ScvO2的機(jī)制插管前預(yù)充純氧，溶解氧增加，氧供提高圍術(shù)期ScvO2的應(yīng)用48ScvO的臨床意義醫(yī)學(xué)知識(shí)講解圍術(shù)期ScvO2的應(yīng)用48ScvO的臨床意義醫(yī)學(xué)知識(shí)

19、講解患者資料49ScvO的臨床意義醫(yī)學(xué)知識(shí)講解患者資料49ScvO的臨床意義醫(yī)學(xué)知識(shí)講解單因素分析After multivariate analysis, mean ScvO2 value (OR 1.23 95%CI 1.01 to 1.50, p = 0.037), hospital LOS (OR 0.75 95% CI 0.59 to 0.94, p = 0.012), and SAPS II (OR 0.90 95% CI 0.82 to 0.99, p = 0.029) were independently associated with postoperative complic

20、ations.多因素分析50ScvO的臨床意義醫(yī)學(xué)知識(shí)講解單因素分析After multivariate analys低ScvO2與術(shù)后并發(fā)癥相關(guān)P=0.004The optimal value of mean ScvO2 for discriminating between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%)51ScvO的臨床意義醫(yī)學(xué)知識(shí)講解低ScvO2與術(shù)后并發(fā)癥相關(guān)P=0.004The optimScvO2與乳酸在感染性休克中應(yīng)用比較Jone

21、s的研究顯示：在感染性休克的早期目標(biāo)性治療中，乳酸清除率達(dá)標(biāo)與ScvO2達(dá)標(biāo)，兩組的住院死亡率無(wú)差別【25% （1730%）vs 17%（1124%）】。Jones AE et al. JAMA. 2010 February 24; 303(8): 73974652ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與乳酸在感染性休克中應(yīng)用比較Jones的研究顯示：ScvO2與容量反應(yīng)性大循環(huán)指標(biāo)：血壓、心率、尿量、CVPCO、CIPPVSVVScvO2?53ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2與容量反應(yīng)性大循環(huán)指標(biāo)：血壓、心率、尿量、CVP?ScvO2 As a Marker to Define F

22、luid ResponsivenessMethods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes afte

23、r volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NRMethods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary art

24、ery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR Giraud R, et a

25、l. J Trauma.2011;70: 80280754ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2 As a Marker to Define FlScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 80280755ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2 As a Marker to Define FlScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 80280

26、756ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2 As a Marker to Define FlScvO2 As a Marker to Define Fluid ResponsivenessResults: ScvO2 and SvO2 variations after VE (SvO2) were significantly correlated with CI changes (CI) after VE (r 0.67 and r= 0.49,p0.001, respectively). AScvO2 threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 5798%) and 81% specificity (95%CI; 5496%) Giraud R, et al. J Trauma.2011;70: 80280757ScvO的臨床意義醫(yī)學(xué)知識(shí)講解ScvO2