休克患者血容量的監(jiān)測進展課件

ICU休克患者血容量的監(jiān)測進展內(nèi)容簡介容量管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)休克的概念感染、創(chuàng)傷、燒傷等引起有效循環(huán)血量明顯減少組織器官的灌注不足氧輸送不能滿足組織代謝需要導(dǎo)致組織缺氧代謝障礙和細胞受損臨床綜合征容量管理的基本目標保證容量－合適的心臟前負荷預(yù)防肺水腫二者必須平衡內(nèi)容簡介容量管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)容量監(jiān)測的現(xiàn)狀容量監(jiān)測：TEE，CT，核素掃描臨床表現(xiàn):血壓、心率、尿量、皮膚粘膜等壓力監(jiān)測：漂浮導(dǎo)管(CVP/PAWP)心臟前負荷：VEDVRVEDP/LVEDP的測定壓力反映容量及肺水腫的局限性心臟順應(yīng)性瓣膜功能肺毛細血管通透性機械通氣對循環(huán)的影響PAC對容量監(jiān)測的有效性和可信性受到置疑？？許多文獻：CVP/PAWP不能準確反映容量狀態(tài)內(nèi)容簡介容量管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)AphysiologicalsystemmodelITTV:IntrathoracictotalvolumeGEDV:

Globalend-diastolicvolume

ITBV:Intrathoracicbloodvolume

PTV:PulmonarytotalvolumeEVLW:extra-pulmonarylungwater

胸內(nèi)總?cè)萘咳氖鎻埰谘萘啃貎?nèi)血液容量肺部容積血管外肺水容量指標的應(yīng)用胸腔內(nèi)血管容量(ITBV)血管外肺水(EVLW)搏出量變異率(SVV)搏出量變異率(SVV)SVV=(SVmax–SVmin)/SVmeanSvmax:meanvalueoffourSVmax/30sSVmin:meanvalueoffourSVmin/30sSVmean血管外肺水組成(EVLW)細胞內(nèi)液間質(zhì)液體肺泡內(nèi)液體內(nèi)容簡介管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)LueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressureITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.Anesth

Analg.2002,95:835-43ITBV---superiorthanPAWPinpreloadDellaRG,etal.Anesth

Analg.2002,95:835-43CorrelationofITBV-SVin4phasesNocorrelationofPAWP-SVinanyphases前瞻性臨床研究40例心臟移植術(shù)后患者男34例，女6例觀察術(shù)后3、6、12、24、36、48、72hITBV/GEDV和CVP/PAWP與SV的相關(guān)性ITBV/GEDV---goodpreloadindicatorinhearttransplantationGoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781^GEDV-^SV:R2=0.4016^ITBV-^SV:R2=0.2979GoedjeO,etal.Chest,2000,118:775-781^PAWP-^SV:R2=0.0043^CVP-^SV:R2=0.0552ITBV的改變反映肺水含量Prospectivelystudy16patientswithsepticshockandpulmonaryedema(ACCP/SCCM)SAPSII:56Monitor:Picco,PACOptimalPAWP:CInolongerincreasedMonitortime:0,24hIntensiveCareMed,2002,28,712-18FromintensiveCareMed,2002,28,712-18CVP與EVLW的相關(guān)性PAWP與EVLW的相關(guān)性CorrelationbetweenITBV/TEDVandEVLWFromintensiveCareMed,2002,28,712-18ITBV

與EVLW有良好相關(guān)性優(yōu)于

CVP

與PAWP內(nèi)容簡介容量管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)SVV可以反映機體前負荷Prospectivestudy20MVpatientsfollowingcardiacsurgeryVolumeloading(HES20ml*BSA/10min)Measurement:CVP,PAWP---PACLVEDAI----TEEITBV,SVV----PiCCOReuterDA,etal.IntensiveCareMed.2002,28:392-8.血流動力學(xué)監(jiān)測SVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVP/PAWPnotcorrelatedwithCISVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVPnotcorrelatedSVV反映機體對容量治療的反應(yīng)15例腦外科手術(shù)患者麻醉誘導(dǎo)后容量負荷實驗：100mLof6%hydroxyethylstarchgivenfor2min分組：responsive:SV>5%

nonresponsive:SV<5%Atotalof140VLSswereperformedAnesth

Analg.2001,92:984-9兩組負荷試驗前血流動力學(xué)狀態(tài) Response(70) nonresponse(70)PHR 76 75 NSSBP 102 116 0.001CVP 9.3 9.3 NSSVV 12.6 6.8 <0.001Anesth

Analg.2001,92:984-9兩組負荷試驗后血流動力學(xué)改變Response(70)nonresponse(70)PHR -1 -1 NSSBP 9 2 <0.001CVP 9.8 11.9 NS SVV -25.8 -10 <0.001Anesth

Analg.2001,92:984-9以上指標與SV改變的相關(guān)性Pearson’scorrelation PHR 0.142 NSSBP -0.448 <0.001SV -0.372 <0.001CVP 0.055 NSSVV 0.722 <0.001HR -0.089 NSSBP 0.472 <0.001CVP -0.084 NSSVV -0.505 <0.001Anesth

Analg.2001,92:984-9ResponsiveVLS:SVV/SV有較高的特異性和敏感性Anesth

Analg.2001,92:984-9SVV對失血性休克犬容量狀態(tài)的評價成年健康雜種犬共14只，體重12.1±1.1公斤復(fù)制犬失血性休克模型穩(wěn)定30分鐘，改良的Wiggers’法制備失血性休克犬模型適當放血維持MAP在50mmHg左右并穩(wěn)定60分鐘，模型成功容量負荷試驗2分鐘內(nèi)快速滴入林格氏液7ml.kg-115分鐘后重復(fù)，記錄容量負荷前及后5分鐘的監(jiān)測指標分組△SV是否大于容量負荷試驗前SV的5％分為兩組反應(yīng)組(△SV＞5％)無反應(yīng)組(△SV＜5％)直至連續(xù)兩次△SV均小于容量負荷試驗前的5%時終止實驗監(jiān)測指標HRMAPPiCCO監(jiān)測儀:CO、ITBVI、SV、SVVSwan-Ganz導(dǎo)管:CO、CVP、PAWP共進行容量負荷試驗134次，每只犬平均9.6±1.7次，其中94次為反應(yīng)組，40次為無反應(yīng)組容量負荷實驗前各指標的比較

反應(yīng)組

無反應(yīng)組

HR111.3±33.6115.6±44.1CVP5.4±2.46.2±2.5PAWP7.9±2.98.6±2.9P<0.05

容量負荷試驗前各指標與△SV的相關(guān)性

rP值HR(bpm)-0.1480.089MAP(mmHg)-0.0910.296CVP(mmHg)-0.0920.292PAWP(mmHg)-0.0910.297ITBVI(ml/m2)0.3560.000SVV(%)0.5310.001容量負荷試驗前后各指標的變化與△SV的相關(guān)性

rP值△HR(bpm)-0.0810.353△MAP(mmHg)0.0200.820△CVP(mmHg)-0.3710.000△PAWP(mmHg)-0.4480.000△ITBVI(ml/m2)0.4380.000△SVV(%)–0.3760.000各指標對容量負荷反應(yīng)(△SV)的ROC曲線分析

AUC95％CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.434－0.6510.207－0.3810.313－0.5170.336－0.5390.583－0.7910.805－0.939AUC=曲線下面積,CI=可信區(qū)間

SVV大于9.5％時，對容量評價的敏感性為92.6％，特異性為62.5％。

SVV和ITBVI可用于容量狀態(tài)的評價優(yōu)于HR、MAP、CVP和PAWP內(nèi)容簡介容量管理的基本目標容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)CVP/PAWP能反映EVLW嗎?Prospectivelystudy16patswithsepticshockandpuledema(ACCP/SCCM)SAPSII:56Monitor:PiCCOvsPACOptimalPAWP:CInolongerincreasedMonitortime:0,24hFromintensiveCareMed,2002,28,712-18IntensiveCareMed,2002,28,712-18CVP/PAWP能反映EVLW嗎?

NoIntensiveCareMed,2002,28,712-18delta與EVLW相關(guān)性,FB：fluidbalanceCVP/PAWP能反映EVLW嗎?

No肺水含量是ARDS的預(yù)后指標Retrospectiveanalysis373ICUpatsinu