PEEP對(duì)心臟前負(fù)荷的影響

PEEP對(duì)心臟前負(fù)荷的影響北京協(xié)和醫(yī)院

杜斌病例摘要WYG,M/51,1629632DOA:2009/06/18PMHx:HTN,DMCC:發(fā)熱,皮疹2月,憋氣1月Dx:肺間質(zhì)病變?cè)虼榧毙院粑δ芩ソ咝菘瞬±隝CU時(shí)循環(huán)功能HR 88bpmNBP 84/58mmHgCVP 16mmHg呼吸機(jī)設(shè)置FiO2 1.0PS 15cmH2OPEEP 20cmH2OCVP=16mmHg能否除外低血容量是否需要輸液提高前負(fù)荷CVP與前負(fù)荷RVEDV/RVEDP/RAP/CVPCardiacOutput容量負(fù)荷反應(yīng)組與無(wú)反應(yīng)組的CVPPEEP對(duì)CVP的影響SanerFH,PavlakovicG,GuY,etal.Effectsofpositiveend-expiratorypressureonsystemichaemodynamics,withspecialinteresttocentralvenousandcommoniliacvenouspressureinlivertransplantedpatients.EurJAnaesth2006;23:766-771間斷正壓通氣對(duì)心輸出量的影響CournandA,MotleyHL,WerkoL,etal.Physiologicalstudiesoftheeffectsofintermittentpositivepressurebreathingoncardiacoutputinman.AmJPhysiol1948;152:162-174.心輸出量下降右心室充盈受限靜脈回流

胸腔內(nèi)壓(ITP)正壓通氣PEEP誘導(dǎo)的CO改變CO=HRxSVSV的影響因素前負(fù)荷心肌收縮力后負(fù)荷ViqueratCE,RighettiA,SuterPM:BiventricularvolumesandfunctioninpatientswithadultrespiratorydistresssyndromeventilatedwithPEEP.Chest1983;83:509-514.跨壁壓的概念5cmH2O20cmH2O跨壁壓的概念5cmH2O20cmH2O15cmH2O心臟的跨壁壓ThoraxVenousReturnLVEjectionIncreasingITPDecreasesthepressuregradientsforvenousreturnandLVejectionDecreasingITPIncreasesthepressuregradientsforvenousreturnandLVejectionPEEP對(duì)跨壁壓的影響PEEP對(duì)跨壁壓的影響

胸腔內(nèi)壓(ITP)─概念……EsophagealPleuralCardiacfossaCardiacsurfaceIntrathoracicPressureScharfS:Ventilatorysupportincardiacfailure.InTheIllCardiacPatient.EditedbyKvetanV,DantzkerDR.Philadelphia:Lippincott-Raven;1996:29-45.正壓通氣對(duì)肺容積的影響胸腔內(nèi)壓改變肺容積改變正壓通氣氣道阻力呼吸系統(tǒng)順應(yīng)性PEEP對(duì)CVP的影響–測(cè)定方法短暫脫離呼吸機(jī)CVP首先降低到谷值，然后因心室負(fù)荷改變而逐漸升高約在去除PEEP2-3秒內(nèi)CVP達(dá)谷值PinskyMR,VincentJL,DeSmetJM.Estimatingleftventricularfillingpressureduringpositiveend-expiratorypressureinhumans.AmRevRespirDis1991;143:25–31PEEP對(duì)CVP的影響–測(cè)定方法PinskyMR,VincentJL,DeSmetJM.Estimatingleftventricular