危重病微循環(huán)障礙

危重病微循環(huán)障礙第1頁/共71頁KroghA．(1929)《毛細血管的解剖和生理》(TheAnatomyandPhysiologyofCapillaries)“毛細血管是血液和組織間物質(zhì)交換的器官”(…anorganforinterchangeOfsubstancesbe—tweenthebloodandthetissues：thecapillaries)第2頁/共71頁第3頁/共71頁

貝時璋教授：什么是生命活動?根據(jù)生物物理學(xué)的觀點，無非是自然界三個量綜合運動的表現(xiàn)，即物質(zhì)、能量和信息在生命系統(tǒng)中無時無刻地在變化，這三個量有組織、有秩序的活動是生命的基礎(chǔ)。第4頁/共71頁田牛.微循環(huán)學(xué)雜志，1994.1

直接參與組織、細胞的物質(zhì)、信息、能量傳遞的血液、淋巴液、組織液的流動稱之為微循環(huán)。微循環(huán)的本質(zhì)屬性第5頁/共71頁SIRS的臨床特征心輸出量的增加、全身血管阻力的降低動靜脈氧分壓差縮小血乳酸水平增加反映細胞對氧(或底物)的利用障礙。用于產(chǎn)生細胞必需能量的氧和底物的輸送或利用障礙可導(dǎo)致SIRS,并形成MODs第6頁/共71頁第7頁/共71頁第8頁/共71頁第9頁/共71頁第10頁/共71頁第11頁/共71頁第12頁/共71頁第13頁/共71頁第14頁/共71頁第15頁/共71頁微血管構(gòu)型及其微細結(jié)構(gòu)

第16頁/共71頁第17頁/共71頁第18頁/共71頁第19頁/共71頁第20頁/共71頁第21頁/共71頁第22頁/共71頁微循環(huán)障礙的監(jiān)測血乳酸SVO2BEDO2，VO2第23頁/共71頁第24頁/共71頁第25頁/共71頁第26頁/共71頁第27頁/共71頁near-infraredspectroscopy(NIRS),第28頁/共71頁第29頁/共71頁第30頁/共71頁第31頁/共71頁第32頁/共71頁Creteur.CurrOpinCritCare.2008Jun;14(3):361-6.

TheprognosticvalueofmuscleStO2incriticallyillpatientsSUMMARY:Near-infraredspectroscopyprovidesanoninvasivemeasureofmuscleoxygenmetabolismandmicrovasculardysfunctionincriticallyillpatients.Itmaybeusefultoguidethemanagementof第33頁/共71頁第34頁/共71頁PtCO2加熱的氧電極直接置于患者胸骨旁2、3肋間正常皮膚上來測定PtC02。無創(chuàng)性、續(xù)監(jiān)測組織氧合。Ptc02測定的是傳感器下面皮膚組織的P02。組織氧張力除了受PaO2影響外，還受組織血液灌注量的影響。組織血液灌注量正常時，Ptc02與PaO2具有非常好的相關(guān)性。第35頁/共71頁FifeCE;SmartDR;UnderseaHyperbMed.2009V36N1:43-53

Transcutaneousoximetryinclinicalpractice:consensusstatementsfromanexpertpanelbasedonevidence.

第36頁/共71頁IntensiveCareMed.2009Jun;35(6):1106-9.Epub2009Jan29.

Thenaroxygensaturationmeasuredbynearinfraredspectroscopyasanoninvasivepredictoroflowcentralvenousoxygensaturationinsepticpatients.

MesquidaJ,MasipJ,GiliG,ArtigasA,BaigorriF.第37頁/共71頁《2008年嚴(yán)重膿毒癥與膿毒癥休克治療國際指南》

建議僅在成年膿毒癥休克患者對容量復(fù)蘇和血管活性藥物反應(yīng)差時靜脈給予氫化可的松(推薦級別2C)第38頁/共71頁Theeffectofincreasingdosesofnorepinephrineontissueoxygenationandmicrovascularflowinpatientswithsepticshock*ShamanJhanji,CritCareMed2009Vol.37,No.6第39頁/共71頁方法N=16cardiacoutputcutaneoustissuePtO2usingaClarkelectrodecutaneousredbloodcellfluxusinglaserDopplerflowmetry,Sublingualmicrovascularflowusingsidestreamdarkfieldimaging.第40頁/共71頁

ShamanJhanji,CritCareMed2009Vol.37,No.6第41頁/共71頁

ShamanJhanji,CritCareMed2009Vol.37,No.6第42頁/共71頁第43頁/共71頁

ShamanJhanji,CritCareMed2009Vol.37,No.6第44頁/共71頁ShamanJhanji,CritCareMed2009Vol.37,No.6第45頁/共71頁

Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudyArnaldoDubinCriticalCare2009,13:R92第46頁/共71頁方法N=20Sublingualmicrocirculationwasevaluatedbysidestreamdarkfield(SDF)imagingDO2andVO2,lactate,albumin-correctedaniongap,gastricintramucosal-arterialPCO2difference(ΔPCO2).第47頁/共71頁ArnaldoDubin.CriticalCare2009,13:R92

第48頁/共71頁ArnaldoDubin.CriticalCare2009,13:R92

第49頁/共71頁ArnaldoDubin.CriticalCare2009,13:R92第50頁/共71頁ArnaldoDubin.CriticalCare2009,13:R92

第51頁/共71頁ArnaldoDubin.CriticalCare2009,13:R92

第52頁/共71頁《2008年嚴(yán)重膿毒癥與膿

毒癥休克治療國際指南》

NE為糾正膿毒癥休克低血壓首選的一線血管升壓藥,

1C級,

無在膿毒癥治療中選擇何種兒茶酚胺類藥物的最終建議第53頁/共71頁TheeffectsofdobutamineonmicrocirculatoryalterationsinpatientswithsepticshockareindependentofitssystemiceffectsDanielDeBacker,CritCareMed2006Vol.34,No.2第54頁/共71頁方法Intravenousadministrationofdobutamine(5g/kg·min)for2hrs(n

22)followedbytheadditionof102Macetylcholine(topicallyapplied,n

10).Hemodynamicmeasurementssublingualmicrocirculationwasinvestigatedwithanorthogonalpolarizationspectralimagingtechniquebeforeandafterdobutamineadministrationandaftertopicalapplicationofacetylcholine.Dobutamine第55頁/共71頁

DanielDeBacker,CritCareMed2006Vol.34,No.2第56頁/共71頁DanielDeBacker,CritCareMed2006Vol.34,No.2第57頁/共71頁DanielDeBacker,CritCareMed2006Vol.34,No.2第58頁/共71頁不同液體復(fù)蘇條件下多巴酚丁胺對腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulos

SuzanaMLobo

DanielDeFigure1

Changesofarteriallactateconcentrationineachgroup第59頁/共71頁不同液體復(fù)蘇條件下多巴酚丁胺對腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulos

SuzanaMLobo

DanielDe

ChinCritCareMed,Feb.2005,Vol.17,No12Figure2

ChangesofPtaCO2

gapineachgroup第60頁/共71頁不同液體復(fù)蘇條件下多巴酚丁胺對腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulos

SuzanaMLobo

DanielDe

ChinCritCareMed,Feb.2005,Vol.17,No12Figure3

ChangesofintestinalintramucosalpHineachgroup第61頁/共71頁Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4第62頁/共71頁Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4orthogonalpolarizationspectraldevicewasusedtoinvestigatethesublingualmicrocirculationthefirstdose(50mg)ofhydrocortisoneand1,2,4,and24hourslaterGlobalhemodynamicvariablesweresimilaratallstudytimepoints.第63頁/共71頁Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4第64頁/共71頁Effectsofhydrocortisoneonmicrocirculatoryalterationsin

patientswithsepticshock*

GustavoLuizBu¨cheleCritCareMed2009Vol.37,No.4Figure2.Evolutionofmicrocirculationvariablesduringstudytimeperiods.Perfusedsmallvessels.第65頁/共71頁

Theeffectofstoragetimeofhumanredcellsonintestinal

icrocirculatoryoxygenationinaratisovolemicexchangemodel*

N.J.Raat,PhD;A.J.Verhoeven,PhD;E.G.Mik,MSc;C.W.

Isovolemic

exchangewithfreshandintermediateredbloodcellsmaintained

PO2whereasoldcellsdecreasedPO2with26%.Subsequent

transfusionwithredbloodcells(hematocrit60%)untilreaching

ahematocritof32.4

%(