休克患者血容量的監(jiān)測(cè)進(jìn)展課件

楊 毅東南大學(xué)醫(yī)學(xué)院附屬中大醫(yī)院ICU東南大學(xué)急診與危重病醫(yī)學(xué)研究所休克患者血容量的監(jiān)測(cè)進(jìn)展1醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2醫(yī)學(xué)ppt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(xì)胞受損臨床綜合征3醫(yī)學(xué)ppt休克治療的首要任務(wù)：

積極、合適補(bǔ)充血容量休克發(fā)生的始動(dòng)因素：

有效循環(huán)血量下降合適的容量管理4醫(yī)學(xué)ppt容量管理的基本目標(biāo)保證容量－合適的心臟前負(fù)荷預(yù)防肺水腫二者必須平衡5醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)6醫(yī)學(xué)ppt容量監(jiān)測(cè)的現(xiàn)狀容量監(jiān)測(cè)：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(cè)：漂浮導(dǎo)管(CVP/PAWP)心臟前負(fù)荷：VEDV7醫(yī)學(xué)ppt8醫(yī)學(xué)pptRVEDP/LVEDP的測(cè)定9醫(yī)學(xué)ppt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(xì)血管通透性機(jī)械通氣對(duì)循環(huán)的影響PAC對(duì)容量監(jiān)測(cè)的有效性和可信性受到置疑？？10醫(yī)學(xué)ppt許多文獻(xiàn)：CVP/PAWP不能準(zhǔn)確反映容量狀態(tài)11醫(yī)學(xué)pptPrincipleofEVLWmeasurementRAEDVLAEDVLVEDVPBVRVEDVEVLWInjectionPiccoThermo-dilutioncatheterSwan-ganz

catheter呼吁容量指標(biāo)的應(yīng)用來(lái)反映容量狀態(tài)及肺水腫12醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)13醫(yī)學(xué)pptAphysiologicalsystemmodelITTV: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14醫(yī)學(xué)ppt容量指標(biāo)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)15醫(yī)學(xué)ppt胸腔內(nèi)血管容量(ITBV)左心舒張末期容量右心舒張末期容量肺血容量16醫(yī)學(xué)ppt搏出量變異率(SVV)SVV=(SVmax–SVmin)/SVmeanSvmax:meanvalueoffourSVmax/30sSVmin:meanvalueoffourSVmin/30sSVmean17醫(yī)學(xué)ppt血管外肺水組成(EVLW)細(xì)胞內(nèi)液間質(zhì)液體肺泡內(nèi)液體18醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)19醫(yī)學(xué)pptITBV—validestimateofpreloadinALIProspectiveanimalstudy15sheepwithALI---salinewashoutMV(PEEP0,7,14,21respectively60min)Measurement:LVEF,LVEDV-----CTscanITBV,RVEDV---PiCCOCVP,PAWP----PACLueckeT,etal.IntensiveCareMed,2004,30:119-12620醫(yī)學(xué)pptLueckeT,etal.IntensiveCareMed,2004,30:119-12621醫(yī)學(xué)pptLueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressure22醫(yī)學(xué)pptITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-7523醫(yī)學(xué)pptITBVI----morereliableindicatorofpreloadthanPAWPDellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-7524醫(yī)學(xué)pptITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.Anesth

Analg.2002,95:835-4325醫(yī)學(xué)pptITBV---superiorthanPAWPinpreloadDellaRG,etal.Anesth

Analg.2002,95:835-43CorrelationofITBV-SVin4phasesNocorrelationofPAWP-SVinanyphases26醫(yī)學(xué)pptProspective,controlled,clinicalstudy18patientswithejectionfraction>50%undergoingcoronaryarterybypassgraftsurgeryAbaselinemeasurement:afterinductionofanesthesia(T1)treatedbyinfusionof6%hydroxyethylstarch200/0.5(7mL/kg)After10minutes,asecondmeasurement(T2)wasperformedWiesenackC,etal.CardiothoracVascAnesth.2001,15:584-8ITBVcorrelatedsignificantlywithCIandSVINCABG27醫(yī)學(xué)pptITBVhasGoodrelationship

betweenCI/SVICVP/PCWP與

CI/SV無(wú)相關(guān)性ITBV與CI的相關(guān)性r=0.55ITBV與

SV的相關(guān)性為r=0.62WiesenackC,etal.CardiothoracVascAnesth.2001,15:584-828醫(yī)學(xué)ppt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,2000,118:775-78129醫(yī)學(xué)pptGoedjeO,etal.Chest,2000,118:775-78130醫(yī)學(xué)pptGoedjeO,etal.Chest,2000,118:775-781^GEDV-^SV:R2=0.4016^ITBV-^SV:R2=0.297931醫(yī)學(xué)pptGoedjeO,etal.Chest,2000,118:775-781^PAWP-^SV:R2=0.0043^CVP-^SV:R2=0.055232醫(yī)學(xué)pptITBV的改變反映肺水含量Prospectivelystudy16patientswithsepticshockandpulmonaryedema(ACCP/SCCM)SAPSII:56Monitor:Picco,PACOptimalPAWP:CInolongerincreasedMonitortime:0,24hIntensiveCareMed,2002,28,712-1833醫(yī)學(xué)pptFromintensiveCareMed,2002,28,712-18CVP與EVLW的相關(guān)性PAWP與EVLW的相關(guān)性34醫(yī)學(xué)pptCorrelationbetweenITBV/TEDVandEVLWFromintensiveCareMed,2002,28,712-18ITBV

與EVLW有良好相關(guān)性優(yōu)于

CVP

與PAWP35醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)36醫(yī)學(xué)pptSVV可以反映機(jī)體前負(fù)荷Prospectivestudy20MVpatientsfollowingcardiacsurgeryVolumeloading(HES20ml*BSA/10min)Measurement:CVP,PAWP---PACLVEDAI----TEEITBV,SVV----PiCCOReuterDA,etal.IntensiveCareMed.2002,28:392-8.37醫(yī)學(xué)ppt血流動(dòng)力學(xué)監(jiān)測(cè)38醫(yī)學(xué)pptSVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVP/PAWPnotcorrelatedwithCI39醫(yī)學(xué)pptSVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVPnotcorrelated40醫(yī)學(xué)pptSVV反映機(jī)體對(duì)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(fù)荷實(shí)驗(yàn)：100mLof6%hydroxyethylstarchgivenfor2min分組：responsive:SV>5%

nonresponsive:SV<5%Atotalof140VLSswereperformedAnesth

Analg.2001,92:984-941醫(yī)學(xué)ppt兩組負(fù)荷試驗(yàn)前血流動(dòng)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.2001,92:984-942醫(yī)學(xué)ppt兩組負(fù)荷試驗(yàn)后血流動(dòng)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.2001,92:984-943醫(yī)學(xué)ppt以上指標(biāo)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.2001,92:984-944醫(yī)學(xué)pptResponsiveVLS:SVV/SV有較高的特異性和敏感性Anesth

Analg.2001,92:984-945醫(yī)學(xué)pptSVV對(duì)失血性休克犬容量狀態(tài)的評(píng)價(jià)成年健康雜種犬共14只，體重12.1±1.1公斤46醫(yī)學(xué)ppt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(dāng)放血維持MAP在50mmHg左右并穩(wěn)定60分鐘，模型成功容量負(fù)荷試驗(yàn)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(fù)荷前及后5分鐘的監(jiān)測(cè)指標(biāo)47醫(yī)學(xué)ppt分組△SV是否大于容量負(fù)荷試驗(yàn)前SV的5％分為兩組反應(yīng)組(△SV＞5％)無(wú)反應(yīng)組(△SV＜5％)直至連續(xù)兩次△SV均小于容量負(fù)荷試驗(yàn)前的5%時(shí)終止實(shí)驗(yàn)監(jiān)測(cè)指標(biāo)HRMAPPiCCO監(jiān)測(cè)儀:CO、ITBVI、SV、SVVSwan-Ganz導(dǎo)管:CO、CVP、PAWP共進(jìn)行容量負(fù)荷試驗(yàn)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(wú)反應(yīng)組48醫(yī)學(xué)ppt容量負(fù)荷實(shí)驗(yàn)前各指標(biāo)的比較

反應(yīng)組

無(wú)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

49醫(yī)學(xué)ppt容量負(fù)荷試驗(yàn)前各指標(biāo)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(%)0.5310.00150醫(yī)學(xué)ppt容量負(fù)荷試驗(yàn)前后各指標(biāo)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(%)–0.3760.00051醫(yī)學(xué)ppt各指標(biāo)對(duì)容量負(fù)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(shí)，對(duì)容量評(píng)價(jià)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(píng)價(jià)優(yōu)于HR、MAP、CVP和PAWP52醫(yī)學(xué)ppt內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)容量監(jiān)測(cè)的現(xiàn)狀及局限性容量監(jiān)測(cè)的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)53醫(yī)學(xué)pptCVP/PAWP能反映EVLW嗎?Prospectivelystudy16patswithsepticshockandpuledema(ACCP/SCCM)SAPSII:56Monitor:PiCCOvsPACOptimalPAWP:CInolongerincreasedMonitortime:0,24hFromintensiveCareMed,2002,28,712-1854醫(yī)學(xué)pptIntensiveCareMed,2002,28,712-18CVP/PAWP能反映EVLW嗎?

No55醫(yī)學(xué)pptIntensiveCareMed,2002,28,712-18delta與EVLW相關(guān)性