容量負荷試驗

1、CVP (mmHg)CO (L/min)容量缺乏更為嚴重低容量表現(xiàn)低容量表現(xiàn)心動過速心動過速低血壓低血壓(嚴重者嚴重者)高乳酸高乳酸(嚴重者嚴重者)肢端溫度降低肢端溫度降低脫水表現(xiàn)脫水表現(xiàn)皮膚充盈下降皮膚充盈下降口渴口渴口干口干腋窩干燥腋窩干燥高血鈉高血鈉高蛋白血癥高蛋白血癥高血紅蛋白高血紅蛋白高血球壓積高血球壓積體位性低血壓體位性低血壓動脈血壓或每動脈血壓或每搏輸出量的呼搏輸出量的呼吸波動吸波動下肢被動抬高下肢被動抬高容量負荷試驗容量負荷試驗結(jié)果陽性結(jié)果陽性腎臟灌注減少腎臟灌注減少濃縮尿濃縮尿(低尿鈉低尿鈉,高尿滲高尿滲)BUN升高升高(與肌酐升高不與肌酐升高不成比例成比例)持續(xù)性代謝性持續(xù)

2、性代謝性酸中毒酸中毒動態(tài)指標動態(tài)指標靜態(tài)指標靜態(tài)指標容量狀態(tài)評價容量狀態(tài)評價Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-55301015191915100Predicted PAWP (mmHg)Observed PAWP (mmHg)No change in

3、planned therapy after catheterizationChange in planned therapy after catheterization004.57.0Predicted CO (L/min)Observed CO (L/min)4.57.0Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Cri

4、t Care Med 1984; 12(7): 549-553參數(shù)參數(shù)預測正確比例預測正確比例預測正確百分比預測正確百分比Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553心輸出量PAWPConnors(NEJM 83)ICU pts44% 42%Eisenbe

5、rg(CCM 84)ICU pts50% 33%Bayliss(BMJ 83)CCU pts71% 62%RVEDV (ml)CVP (mmHg)Kumar A, Anel R, Bunnell E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardia

6、c performance, or the response to volume infusion in normal subjects. Crit Care Med 2004; 32: 691-699 Lichtwarck-Aschoff et al, Intensive Care Med 1992; 18: 142-14735-30-25-20-15-10-5-0-CO (l/min)-5 0 5 10 15 20 25 30 35 40CVP (mmHg)Notarius et al Am Heart J 1998PraQQPraPraQPraQ7Pra (mmHg)Q (L/min)7

7、05Pms干預或治療干預或治療對心功能曲對心功能曲線的影響線的影響對靜脈回流對靜脈回流曲線的影響曲線的影響高動力或低動力高動力或低動力體循環(huán)平均充盈壓體循環(huán)平均充盈壓靜脈回流阻力靜脈回流阻力Pra (mmHg)Q (L/min)交感張力的改變應用正性肌力藥心肌梗塞其他心臟病變?nèi)缧募〔』蛐陌昴げra (mmHg)Q (L/min)705Pms血容量增加(輸血, 液體潴留)血管容量減少(兒茶酚胺增加, 骨骼肌張力增加, 按壓腹部)血容量減少(失血, 脫水)血管容量增加Pms Pms Pra (mmHg)Q (L/min)705Pms血管擴張血液稀釋(貧血)動靜脈瘺血管收縮血液粘滯度增加(真紅細胞

8、增多癥)Rvr Rvr PraPraQQPraQ靜脈回流曲線心功能曲線PraQPraQ高心輸出量正常容量正?；亓鞴δ苷Ｐ妮敵隽康腿萘康突亓鞴δ躊raQPraQ低心輸出量正常回流功能正常心輸出量高容量高回流功能RVEDV (ml)CVP (mmHg)時間(hr)血管內(nèi)容量Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med 2006; 34Dellinger RP, Carlet JM, Masur H, et al: Surviving Sepsis Campaign guidelines for management o

9、f severe sepsis and septic shock. Crit Care Med 2004; 32: 858-873Mateer JR, et al. Rapid fluid resuscitation with central venous catheters. Ann Emerg Med 1983; 12: 149-52.外周靜脈置管中心靜脈插管每10分鐘測定CVPnCVP 2 mmHg繼續(xù)快速補液nCVP 2 5 mmHg暫停快速補液, 等待10分鐘后再次評估nCVP 5 mmHg停止快速補液每10分鐘測定PAWPnPAWP 3 mmHg繼續(xù)快速補液nPAWP 3 7 mm

10、Hg暫停快速補液, 等待10分鐘后再次評估nPAWP 7 mmHg停止快速補液Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:1241320105201073CVP2 5 rulePAWP3 7 rule血管內(nèi)容量CVP (mmHg) 5 mmHg10CVP (mmHg)時間(hr)容量不足容量足夠容量過多每搏輸出量每搏輸出量心輸出量