危重病患者的血流動(dòng)力學(xué)監(jiān)測與治療課件

1、危重病患者的血流動(dòng)力學(xué)監(jiān)測與治療危重病患者的血流動(dòng)力學(xué)監(jiān)測與治療危重病患者的血流動(dòng)力學(xué)監(jiān)測與治療危重病患者的血流動(dòng)力學(xué)監(jiān)測與治療危重病患者的血流動(dòng)力學(xué)監(jiān)測與血流動(dòng)力學(xué)監(jiān)測與治療COMAPSVR=xSVHRx后負(fù)荷前負(fù)荷心肌收縮力血流動(dòng)力學(xué)監(jiān)測與治療COMAPSVR=xSVHRx后負(fù)荷前負(fù)血流動(dòng)力學(xué)監(jiān)測血流動(dòng)力學(xué)監(jiān)測血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷Preload3組織灌注Tissue Perfusion2灌注壓MAP血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷3組織灌注2灌注壓危重病患者的容量缺乏危重病患者的容量缺乏為何需要擴(kuò)容治療?CVP (mmHg)CO (L/min)為何需要擴(kuò)容治療?CVP (m

2、mHg)CO (L/min)根據(jù)臨床表現(xiàn)判斷容量狀態(tài)低容量表現(xiàn)心動(dòng)過速低血壓(嚴(yán)重者)高乳酸(嚴(yán)重者)肢端溫度降低脫水表現(xiàn)皮膚充盈下降口渴口干腋窩干燥高血鈉高蛋白血癥高血紅蛋白高血球壓積體位性低血壓動(dòng)脈血壓或每搏輸出量的呼吸波動(dòng)下肢被動(dòng)抬高容量負(fù)荷試驗(yàn)結(jié)果陽性腎臟灌注減少濃縮尿(低尿鈉,高尿滲)BUN升高(與肌酐升高不成比例)持續(xù)性代謝性酸中毒動(dòng)態(tài)指標(biāo)靜態(tài)指標(biāo)容量狀態(tài)評價(jià)根據(jù)臨床表現(xiàn)判斷容量狀態(tài)低容量表現(xiàn)脫水表現(xiàn)體位性低血壓腎臟灌低血容量: 臨床表現(xiàn)體格檢查發(fā)現(xiàn)敏感性/特異性, %+LR (95%CI)-LR (95%CI)大量失血體位性脈搏加快 30 bpm97/9848.50.03仰臥位心

3、動(dòng)過速( 90 bpm)12/963.00.9仰臥位低血壓(SBP 30 bpm22/9811.00.8仰臥位心動(dòng)過速( 90 bpm)0/96仰臥位低血壓(SBP 30 bpm43/751.7 (0.7 4.0)0.8 (0.5 1.3)體位性低血壓29/811.5 (0.5 4.6)0.9 (0.6 1.3)粘膜干燥85/582.0 (1.0 4.0)0.3 (0.1 0.6)舌干59/732.1 (0.8 5.8)0.6 (0.3 1.0)舌體皺縮85/582.0 (1.0 4.0)0.3 (0.1 0.6)眼睛凹陷62/823.4 (1.0 12.2)0.5 (0.3 0.7)意識(shí)模糊

4、57/732.1 (0.8 5.7)0.6 (0.4 1.0)肢體無力43/822.3 (0.6 8.6)0.7 (0.5 1.0)言語不流利56/823.1 (1.2 14.9)0.7 (0.5 0.9)脫水: 臨床表現(xiàn)體格檢查發(fā)現(xiàn)敏感性/特異性, %+LR (9前負(fù)荷的維持: 指南建議復(fù)蘇目標(biāo) (1C)中心靜脈壓(CVP) 8 12 mmHg*平均動(dòng)脈壓 65 mmHg尿量 0.5 ml/kg/hr中心靜脈(上腔靜脈)血氧飽和度 70%，或混合靜脈血氧飽和度 65%Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campa

5、ign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.前負(fù)荷的維持: 指南建議復(fù)蘇目標(biāo) (1C)Dellinger中心靜脈壓: 影響因素基礎(chǔ)水平出血420 ml(310 470 ml)NE0.001 g/kg/minHR (bpm)167 (35)210 (44)*153 (56)*MAP (mmHg)144

6、(42)85 (46)*153 (36)*CVP (mmHg)5.5 (4.2)3.0 (4.2)2.0 (4.0)PAOP (mmHg)6.0 (5.1)4.5 (4.0)3.5 (5.1)CO (lpm)4.68 (3.30)1.98 (0.86)*3.08 (1.72)*,*SVR (dyne.sec/cm5)2367 (1475)3313 (1900)*3922 (2744)*,*PVR (dyne.sec.cm-5)213 (182)303 (245)*428 (310)PPV (%)12 (9)28 (11.5)*14.5 (6.2)*SPV (mmHg)12.5 (6.5)21

7、(8.2)*15.5 (4.5)*Nouira S, Elatrous S, Dimassi S, et al. Effects of norepinephrine on static and dynamic preload indicators in experimental hemorrhagic shock. Crit Care Med 2005; 33: 2339-2343中心靜脈壓: 影響因素基礎(chǔ)水平出血420 mlNEHR (b容量負(fù)荷試驗(yàn): 判斷標(biāo)準(zhǔn)每10分鐘測定CVPCVP 2 mmHg繼續(xù)快速補(bǔ)液CVP 2 5 mmHg暫?？焖傺a(bǔ)液, 等待10分鐘后再次評估CVP 5 mmH

8、g停止快速補(bǔ)液每10分鐘測定PAWPPAWP 3 mmHg繼續(xù)快速補(bǔ)液PAWP 3 7 mmHg暫?？焖傺a(bǔ)液, 等待10分鐘后再次評估PAWP 7 mmHg停止快速補(bǔ)液Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132容量負(fù)荷試驗(yàn): 判斷標(biāo)準(zhǔn)每10分鐘測定CVP每10分鐘測定P病例1: 現(xiàn)病史男性, 70歲, 2001年1月9日入院咳嗽, 咳痰12天, 發(fā)熱4天, 呼吸困難1天12天前咳嗽, 咳黃粘痰,

9、伴全身乏力4天前寒戰(zhàn)高熱, 體溫39.5CCXR：肺部感染, 右上肺膨脹不全頭孢呋肟治療無效1天前呼吸困難, 紫紺, 伴血壓下降(50/20 mmHg)病例1: 現(xiàn)病史男性, 70歲, 2001年1月9日入院病例1: 入院情況入ICU時(shí)BT 37.2CHR 130 bpmBP 84/40 mmHg (DA 10 g/kg/min)SpO2 78%雙肺散在濕羅音病例1: 入院情況入ICU時(shí)病例1: 入院診斷診斷重度社區(qū)獲得性肺炎急性呼吸功能衰竭感染性休克病例1: 入院診斷診斷病例1: 支持治療呼吸功能支持(SIMV + PSV)FiO2 100%, PEEP 10 cmH2OSpO2 92%循環(huán)

10、支持羥基淀粉500 ml擴(kuò)容無效DA 13 g/kg/min NE 1.2 g/kg/minBP 110/70 mmHg病例1: 支持治療呼吸功能支持(SIMV + PSV)病例1: 血流動(dòng)力學(xué)監(jiān)測放置肺動(dòng)脈漂浮導(dǎo)管HR130MAP71CVP9PAWP9CI1.96SVRI2524PVRI529NE1.0病例1: 血流動(dòng)力學(xué)監(jiān)測放置肺動(dòng)脈漂浮導(dǎo)管病例1: 血流動(dòng)力學(xué)監(jiān)測擴(kuò)容3000 ml后HR103MAP118CVP12PAWP18CI3.63SVRI2182PVRI331NE1.0病例1: 血流動(dòng)力學(xué)監(jiān)測擴(kuò)容3000 ml后白蛋白 vs. 晶體液: SAFE研究多中心, 隨機(jī), 雙盲, 對照

11、試驗(yàn)澳大利亞和新西蘭16個(gè)ICU的7000名患者2001/11至2003/6入選標(biāo)準(zhǔn): 需要輸液治療 + 1項(xiàng)低血容量的客觀指標(biāo)排除標(biāo)準(zhǔn): 肝臟移植, 心臟手術(shù), 燒傷4%白蛋白(n = 3499) vs. 生理鹽水(n = 3501)The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56The SAFE Study Investigators. A compa

12、rison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.白蛋白 vs. 晶體液: SAFE研究多中心, 隨機(jī), 雙盲白蛋白 vs. 晶體液: SAFE研究白蛋白生理鹽水28天病死率(%)20.921.1ICU住院日(d)6.5 6.66.2 6.2機(jī)械通氣時(shí)間(d)4.5 6.14.3 5.7腎臟替代治療時(shí)間(d)0.48 2.280.39 2.00新發(fā)器官功能衰竭無52.753.31個(gè)器官30.029.82個(gè)器官13.91

13、3.53個(gè)器官2.62.84個(gè)器官0.70.65個(gè)器官0.10The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl

14、J Med 2004; 350: 2247-2256.白蛋白 vs. 晶體液: SAFE研究白蛋白生理鹽水28天病白蛋白 vs. 晶體液: SAFE研究The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56The SAFE Study Investigators. A comparison of albumin and saline for fluid resu

15、scitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.白蛋白 vs. 晶體液: SAFE研究The SAFE St乳酸林格液 vs 羥乙基淀粉: VISEP強(qiáng)化胰島素治療傳統(tǒng)胰島素治療羥乙基淀粉247290乳酸林格液Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳

16、酸林格液 vs 羥乙基淀粉: VISEP強(qiáng)化胰島素治療傳統(tǒng)乳酸林格液 vs 羥乙基淀粉: VISEP強(qiáng)化胰島素治療傳統(tǒng)胰島素治療羥乙基淀粉262乳酸林格液275Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳酸林格液 vs 羥乙基淀粉: VISEP強(qiáng)化胰島素治療傳統(tǒng)乳酸林格液 vs 羥乙基淀粉: VISEP乳酸林格液(n = 275)HES (n =

17、262)P28天病死率n/N66/27470/2620.48%24.1 (19.0 29.2)26.7 (21.4 32.1)90天病死率n/N93/274107/2610.09%33.9 (28.3 39.6)41.0 (35.0 47.0)凝血系統(tǒng)SOFA評分0.11 (0 0.83)0.46 (0 1.30) 0.001腎臟SOFA評分0.42 (0 1.33)0.67 (0 1.94)0.02急性腎功能衰竭n/N62/27291/2610.002%22.8 (17.8 27.8)34.9 (29.1 40.7)腎臟替代治療n/N51/27281/2610.001%18.8 (14.1

18、23.4)31.0 (25.4 36.7)輸注RBC單位4 (2 8)6 (4 12) 0.001Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳酸林格液 vs 羥乙基淀粉: VISEP乳酸林格液(n =乳酸林格液 vs 羥乙基淀粉: VISEPBrunkhorst FM, Engel C, Bloos F, et al. Intensive insu

19、lin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳酸林格液 vs 羥乙基淀粉: VISEPBrunkhors血流動(dòng)力學(xué)監(jiān)測: 前負(fù)荷前負(fù)荷不足危重病人中非常普遍臨床表現(xiàn)缺乏特異性可能需要試驗(yàn)性治療不同種類液體有差異血流動(dòng)力學(xué)監(jiān)測: 前負(fù)荷前負(fù)荷不足血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷Preload3組織灌注Tissue Perfusion2灌注壓MAP血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷3組織灌注2灌注壓血流動(dòng)力學(xué)中的歐姆定律R = P / flowPinPout

20、flowR血流動(dòng)力學(xué)中的歐姆定律R = P / flowPinPou器官灌注壓腎臟灌注RPP = MAP IAPFG = GFP PTP = MAP IAP x 2腦灌注CPP = MAP ICP器官灌注壓腎臟灌注腦灌注健康與疾病時(shí)的自身調(diào)節(jié)015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope健康與疾病時(shí)的自身調(diào)節(jié)015050100Organ bloo疾病時(shí)的自身調(diào)節(jié)機(jī)制015050100Organ

21、blood flow(% Baseline)010020406080Organ artery pressure (mmHg)control3 weeks1 week疾病時(shí)的自身調(diào)節(jié)機(jī)制015050100Organ blood升壓藥物: 指南建議維持MAP 65 mmHg (1C)首選升壓藥物應(yīng)為去甲腎上腺素或多巴胺, 并經(jīng)中心靜脈輸注(1C)腎上腺素, 苯腎上腺素或血管加壓素不應(yīng)作為感染性休克的一線用藥(2C)在去甲腎上腺素基礎(chǔ)上加用血管加壓素0.03 U/min, 可能與單純應(yīng)用去甲腎上腺素效果相等感染性休克時(shí)如血壓對去甲腎上腺素反應(yīng)不佳, 可首選腎上腺素或多巴胺(2B)不應(yīng)使用小劑量多巴胺

22、進(jìn)行腎臟保護(hù)(1A)需要升壓藥的患者應(yīng)留置動(dòng)脈導(dǎo)管(1D)Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.升壓藥物: 指南建議維持MAP 65 mmHg (1C)平均動(dòng)脈壓應(yīng)當(dāng)多少

23、?無創(chuàng)血壓不準(zhǔn)確高血壓時(shí)讀數(shù)低低血壓時(shí)讀數(shù)高有創(chuàng)血壓與無創(chuàng)血壓經(jīng)常不一致 平均動(dòng)脈壓應(yīng)當(dāng)多少?無創(chuàng)血壓不準(zhǔn)確 血流動(dòng)力學(xué)監(jiān)測: 技巧確認(rèn)患者的平均動(dòng)脈壓家屬病歷記錄檢查患者平均動(dòng)脈壓的測定方法無創(chuàng) vs. 有創(chuàng)確定無創(chuàng)血壓與有創(chuàng)血壓的差值血流動(dòng)力學(xué)監(jiān)測: 技巧確認(rèn)患者的平均動(dòng)脈壓病例2: 基本情況男性, 74歲, 病歷號既往史I型糖尿病18年糖尿病腎病高血壓病史5年口服絡(luò)活喜, 倍他樂克等藥物平素BP 160 180 / 70 90 mmHg病例2: 基本情況男性, 74歲, 病歷號病例2: 現(xiàn)病史2007年7月25日入院主因發(fā)現(xiàn)惡心, 嘔吐1周, 伴心前區(qū)疼痛及少尿3天1周前出現(xiàn)惡心, 嘔吐

24、, 予對癥治療3天前出現(xiàn)心前區(qū)疼痛, 憋悶, 尿量減少靜脈泵入NG 100 g/min, 控制BP 134/56 mmHg血Cr 861 mol/L, UO 500 ml/d (速尿400 mg/d)血液透析, 透析過程中出現(xiàn)心絞痛, 持續(xù)不緩解病例2: 現(xiàn)病史2007年7月25日入院病例2: 體格檢查GCSE4V5M6BT36.2CHR70 bpmRR20 bpmBP103/45 mmHgSpO298 100% (鼻導(dǎo)管吸氧5 lpm)病例2: 體格檢查GCSE4V5M6病例2: 實(shí)驗(yàn)室檢查CBC: WCC 14.79, Hb 102, plt 215Chemistry (8 2):Na14

25、0mmol/LCl 97mmol/LK 4.2mmol/LCr745mol/LBUN 31.14mmol/LCK-MB 6.8u/LcTnI 11.56g/LGLU 21.5mmol/L病例2: 實(shí)驗(yàn)室檢查CBC: WCC 14.79, Hb 1病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3-6導(dǎo)聯(lián)ST段壓低0.1 0.2 mv病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3-6病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3-6導(dǎo)聯(lián)ST段壓低0.1 0.2 mv病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3-6病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3

26、-6導(dǎo)聯(lián)ST段壓低0.1 0.2 mv病例2: MAP與組織灌注心絞痛*發(fā)作時(shí)EKG: V3-6感染性休克: NE + DB vs. Epi滿足以下標(biāo)準(zhǔn) 7 d感染證據(jù)SIRS標(biāo)準(zhǔn) 2/4組織低灌注或器官功能不全( 2)PaO2/FiO2 280UO 2 mmol/LPlt 100 x 109/L滿足以下標(biāo)準(zhǔn) 24 hSBP 90 mmHg或MAP 1000 ml或PCWP 12 18 mmHg血管活性藥物多巴胺 15 g/kg/minEpi或NE: 任何劑量Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine

27、 versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. Epi滿足以下標(biāo)準(zhǔn) 15 g/kg/min63 (19%)38 (24%)25 (15%)Epi137 (42%)61 (38%)76 (45%)NE102 (31%)48 (30%)54 (32%)早期適當(dāng)抗生素(%)250 (76%)119 (74%)131 (78%)RRT (%)31 (9%)15 (9%)16 (10%)皮質(zhì)激素(%)263 (

28、80%)133 (83%)130 (77%)APC (%)25 (21%)11 (19%)14 (23%)Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. Epi總計(jì)(n = 3感染性休克: NE + DB vs. EpiEpi (n = 161)NE + DB (n

29、= 169)P值7天病死率(%)40 (25%)34 (20%)0.3014天病死率(%)56 (35%)44 (26%)0.0828天病死率(%)64 (40%)58 (34%)0.31ICU病死率(%)75 (47%)75 (44%)0.69住院病死率(%)84 (52%)82 (49%)0.5190天病死率(%)84 (52%)85 (50%)0.73ORHR所有變量(n = 308)0.90 (0.54 1.49)0.87 (0.59 1.28)除適當(dāng)抗生素外的所有變量(n = 319)0.82 (0.51 1.34)0.84 (0.58 1.22)除適當(dāng)抗生素及乳酸外的所有變量(n

30、= 330)0.82 (0.51 1.31)0.87 (0.61 1.24)Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. EpiEpi (n =感染性休克: NE + DB vs. EpiAnnane D, Vignon P, Renault A, et al. N

31、orepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. EpiAnnane D感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J

32、 Med 2008; 358: 877-87.感染性休克需要血管活性藥物(NE 5 g/min) (n = 779)起始劑量0.01 U/min增加劑量0.005 U/min最大劑量0.03 U/min (n = 397)起始劑量5 g/min增加劑量2.5 g/min最大劑量15 g/min) (n = 382)血管加壓素(VP)(0.12 U/ml) (n = 397)去甲腎上腺素(NE)(60 g/ml) (n = 382)感染性休克: VP vs. NERussell JA, Wa感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et a

33、l. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.NE (n = 382)VP (n = 397)P值年齡(歲)61.8 1659.3 16.40.03男性(%)229 (59.9)246 (62.0)0.56APACHE II27.1 6.927.0 7.70.84MAP (mmHg)73 1072 90.23LA (mmol/L)3.5 3.03.5 3.20.96DA (g/kg/min)7.3 5.37.6 6.40.88

34、DB (g/kg/min)5.1 3.76.4 5.20.18Epi (g/kg/min)0.12 0.150.20 0.290.12NE (g/kg/min)0.28 0.260.26 0.270.97 2種升壓藥物111 (29.1)124 (31.2)0.51皮質(zhì)激素(%)293 (76.7)296 (74.6)0.49APC (%)56 (14.7)61 (15.4)0.78感染性休克: VP vs. NERussell JA, Wa感染性休克: VP vs. NENE組(n = 382)VP組(n = 396)PARR(95% CI)RR(95% CI)校正OR28天病死率150/3

35、82(39.3)140/396(35.4)0.263.9(-2.9 to 10.7)0.90(0.75 1.08)0.88(0.62 1.26)90天病死率188/379(49.6)172/392(43.9)0.115.7(-1.3 to 12.8)0.88(0.76 1.03)0.81(0.57 1.16)Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.

36、感染性休克: VP vs. NENE組VP組PARRRR校正感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.感染性休克: VP vs. NERussell JA, WaParrillo JE. Septic shock vasopressin, norepinephrine, and urgency. N Engl J Me

37、d 2008; 358: 954-956Parrillo JE. Septic shock va血流動(dòng)力學(xué)監(jiān)測: 灌注壓灌注壓不足灌注壓沒有固定數(shù)值注意有創(chuàng)及無創(chuàng)血壓的差異根據(jù)患者情況確定目標(biāo)血壓排除低血容量時(shí)應(yīng)用升壓藥具有受體激動(dòng)作用的藥物(多巴胺, 去甲腎上腺素等)血流動(dòng)力學(xué)監(jiān)測: 灌注壓灌注壓不足血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷Preload3組織灌注Tissue Perfusion2灌注壓MAP血流動(dòng)力學(xué)監(jiān)測: 基本內(nèi)容1前負(fù)荷3組織灌注2灌注壓病例3一名25歲體重70 kg肺炎患者, BP 100/50 (65) mmHg, CVP 0 mmHg, 尿量50 ml/hr, pH 7

38、.4. 患者神志清楚, 四肢溫暖. 最適宜的血流動(dòng)力學(xué)處理措施為:IV輸注膠體液250 ml無需任何處理IV輸注5%葡萄糖250 ml小劑量多巴胺輸注多巴酚丁胺輸注病例3一名25歲體重70 kg肺炎患者, BP 100/50組織灌注不足的表現(xiàn)皮膚花斑四肢冰冷毛細(xì)血管再充盈時(shí)間延長尿量減少意識(shí)障礙代謝性酸中毒乳酸酸中毒ScvO2 4.5 L/min/m2DO2I 600 ml/min/m2VO2I 170 ml/min/m2 Velmahos GC, Demetriades D, Shoemaker WC, et al.: Endpoints of resuscitation of critic

39、ally injured patients: normal or supranormal? A prospective randomized trial. Ann Surg 2000, 232: 409-418.血流動(dòng)力學(xué)指標(biāo): 超正常值CI 4.5 L/min/m2Boyd O, Hayes M. The oxygen trial: the goal. Br Med Bull 1999; 55(1): 125-1391101000.10.01Tuschmidt26 (50)25 (72)0.39 (0.12 1.24)Yu, 199335 (34)32 (34)1.00 (0.36 2.73

40、)Hayes50 (54)50 (34)2.28 (1.02 5.11)Gattinoni252 (48)253 (49)0.99 (0.70 1.41)Yu, 199545 (38)44 (41)0.88 (0.37 2.05)Yu, 1998 ( 75 yo)21 (57)18 (61)0.85 (0.24 3.06)Yu, 1998 (50 75 yo)43 (21)23 (52)0.24 (0.08 1.18)TrialProtocolControlOR (95%CI)Mortality n(%)Favor ProtocolFavor Control超正常值與患者預(yù)后Boyd O, H

41、ayes M. The oxygen tr循環(huán)支持治療: 指南建議正性肌力藥物治療心肌功能障礙(心臟充盈壓力升高及心輸出量降低)時(shí)使用多巴酚丁胺(1C)不應(yīng)使心臟指數(shù)增加到預(yù)先確定的超正常水平(1B)Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Cri

42、t Care Med 2008; 36(4): 1394-1396.循環(huán)支持治療: 指南建議正性肌力藥物治療Dellinger 隱性低灌注與創(chuàng)傷預(yù)后The Golden Hour and the Silver Day入選標(biāo)準(zhǔn):成年創(chuàng)傷患者存活時(shí)間 24小時(shí)ISS 20血流動(dòng)力學(xué)穩(wěn)定SBP 100HR 1 mL/kg/h乳酸 2.5 mmol/L或其他灌注不足表現(xiàn)Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occ

43、ult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964隱性低灌注與創(chuàng)傷預(yù)后The Golden Hour and 隱性低灌注與創(chuàng)傷預(yù)后嚴(yán)重創(chuàng)傷患者兩次LA 2.5輸注液體或血液制品重復(fù)LA 2.5Swan-Ganz, 動(dòng)脈插管, 腎臟劑量多巴胺將PCWP提高到12 15將Hct提高到30%重復(fù)LA 2.5升壓藥物(多巴酚丁胺)心臟超聲檢查若LA仍 2.5Blow O, Magliore L, Claridge J, Butler K, Young J. The

44、 Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964隱性低灌注與創(chuàng)傷預(yù)后嚴(yán)重創(chuàng)傷患者兩次LA 2.5輸注液體隱性低灌注與創(chuàng)傷預(yù)后Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964隱性低灌注與創(chuàng)傷預(yù)后B