休克患者血容量監(jiān)測(cè)分解課件

1、休克患者血容量監(jiān)測(cè)休克患者血容量監(jiān)測(cè)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)內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)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)胞受損臨床綜合征休克的概念感染、創(chuàng)傷、燒傷等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

2、必內(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)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：VEDV容量監(jiān)測(cè)的現(xiàn)狀容量監(jiān)測(cè)：TEE，CT，核素掃描心臟前負(fù)荷：V休克患者血容量監(jiān)測(cè)分解課件RVEDP/LVEDP的測(cè)定RVEDP/LVEDP的測(cè)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(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？壓力反映容量及肺水腫的局限性心臟順應(yīng)性PAC對(duì)容量監(jiān)測(cè)的

3、許多文獻(xiàn)：CVP/PAWP不能準(zhǔn)確反映容量狀態(tài)許多文獻(xiàn)：CVP/PAWPPrinciple of EVLW measurementRAEDVLAEDVLVEDVPBVRVEDVEVLWInjectionPiccoThermo-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Principle of EVLW measurementR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)內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)A physiological system modelITTV : In

4、trathoracic total volumeGEDV : Global end-diastolic volume ITBV : Intrathoracic blood volume PTV : Pulmonary total volumeEVLW : extra-pulmonary lung water 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A physiological system modelIT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)容量指標(biāo)的應(yīng)用胸腔內(nèi)血管容量(ITBV)胸腔內(nèi)血管容量(ITBV)左心舒張末期容量右心舒張

5、末期容量肺血容量胸腔內(nèi)血管容量(ITBV)左心舒張末期容量搏出量變異率(SVV)SVV=(SVmax SVmin)/SVmeanSvmax:mean value of four SVmax/30sSVmin :mean value of four SVmin/30sSVmean搏出量變異率(SVV)SVV=(SVmax SVmin)血管外肺水組成(EVLW)細(xì)胞內(nèi)液間質(zhì)液體肺泡內(nèi)液體血管外肺水組成(EVLW)細(xì)胞內(nèi)液內(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)內(nèi)容簡(jiǎn)介ITBVvalid estimate of preload in AL

6、IProspective animal study15 sheep with ALI -saline washoutMV(PEEP 0,7,14,21 respectively 60min)Measurement:LVEF,LVEDV-CT scanITBV,RVEDV-PiCCOCVP,PAWP-PACLuecke T, et al. Intensive Care Med, 2004, 30: 119-126ITBVvalid estimate of preloadLuecke T, et al. Intensive Care Med, 2004, 30: 119-126Luecke T,

7、et al. Intensive CaLuecke T, et al. Intensive Care Med, 2004, 30: 119-126ITBV and RVEDV Provide valid estimate of preloadEven at high intrathoracic pressureLuecke T, et al. Intensive CaITBV-indicator of preload in liver transplantation60 patients undergoing Liver transplantation monitored with PiCCO

8、 and PACthe correlation between PAOP and ITBVI with respect to CI and SVIthe correlation between ITBVI and PAOP Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75ITBV-indicator of preload iITBVI - more reliable indicator of preload than PAWP Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19

9、: 868-75ITBVI - more reliable indicITBVI - valid indicator of preload in lung transplantation50 patients during lung transplantationTime: 6 phase during operationCorrelation between PAWP and SVICorrelation between ITBVI and SVICorrelation between (Delta) ITBVI PAWP and Delta SVIDelta were calculated

10、 by subtracting the first from the second measurement Della RG, et al. Anesth Analg. 2002 , 95: 835-43ITBVI - valid indicator of pITBV- superior than PAWP in preload Della RG, et al. Anesth Analg. 2002 , 95: 835-43Correlation of ITBV - SV in 4 phasesNo correlation of PAWP - SV in any phasesITBV- sup

11、erior than PAWP in Prospective, controlled, clinical study18 patients with ejection fraction 50% undergoing coronary artery bypass graft surgeryA baseline measurement :after induction of anesthesia (T1) treated by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) After 10 minutes, a second measur

12、ement (T2) was performedWiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8ITBV correlated significantly with CI and SV IN CABGProspective, controlled, cliniITBV has Good relationship between CI/SVI CVP/ PCWP 與 CI/SV無(wú)相關(guān)性 ITBV 與 CI的相關(guān)性r = 0.55 ITBV 與 SV的相關(guān)性為r = 0.62Wiesenack C, et al. Cardio

13、thorac Vasc Anesth. 2001, 15:584-8ITBV has Good relationship b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、72h ITBV/GEDV和CVP/PAWP與SV的相關(guān)性ITBV/GEDV-good preload indicator in heart transplantation Goedje O, et al. Chest, 2000, 118: 775-781前瞻性臨床研究ITBV/GEDV-good preloaGoedje O, et al. Chest, 2000, 118:

14、775-781Goedje O, et al. Chest, 2000, Goedje O, et al. Chest, 2000, 118: 775-781GEDV-SV: R2=0.4016ITBV-SV: R2=0.2979Goedje O, et al. Chest, 2000, Goedje O, et al. Chest, 2000, 118: 775-781PAWP-SV: R2=0.0043CVP-SV: R2=0.0552Goedje O, et al. Chest, 2000, ITBV的改變反映肺水含量Prospectively study16 patients with

15、 septic shock and pulmonary edema(ACCP/SCCM)SAPS II: 56Monitor: Picco,PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hIntensive Care Med, 2002,28,712-18ITBV的改變反映肺水含量Prospectively stuFrom intensive Care Med, 2002,28,712-18CVP與EVLW的相關(guān)性PAWP與EVLW的相關(guān)性From intensive Care Med, 2002,Correlation b

16、etween ITBV/TEDV and EVLWFrom intensive Care Med, 2002,28,712-18ITBV 與 EVLW有良好相關(guān)性優(yōu)于 CVP 與 PAWPCorrelation between ITBV/TEDV 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)內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)SVV可以反映機(jī)體前負(fù)荷Prospective study20 MV patients following cardiac surgeryVolume loading(HES 20ml*BSA/10min)Measure

17、ment:CVP, PAWP-PACLVEDAI-TEEITBV, SVV-PiCCOReuter DA, et al. Intensive Care Med. 2002, 28: 392-8.SVV可以反映機(jī)體前負(fù)荷Prospective studyR血流動(dòng)力學(xué)監(jiān)測(cè)血流動(dòng)力學(xué)監(jiān)測(cè)SVV may help to determine the preload condition Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.CVP/PAWP not correlated with CISVV may help to determine

18、the SVV may help to determine the preload condition Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.CVPnot correlatedSVV may help to determine theSVV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)： 100 mL of 6% hydroxyethylstarch given for 2 min 分組：responsive: SV5% nonresponsive: SV5%A total of 140 VLSs wer

19、e performedAnesth Analg. 2001, 92: 984-9SVV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Anest兩組負(fù)荷試驗(yàn)前血流動(dòng)力學(xué)狀態(tài)Response(70)nonresponse(70) PHR7675 NSSBP102116 0.001CVP9.39.3 NSSVV12.66.8 0.001Anesth Analg. 2001, 92: 984-9兩組負(fù)荷試驗(yàn)前血流動(dòng)力學(xué)狀態(tài)Response(70)no兩組負(fù)荷試驗(yàn)后血流動(dòng)力學(xué)改變Response(70) nonresponse(70) PHR-1-1NSSBP 92 0.001 CVP9.811.9NSS

20、VV-25.8-100.001Anesth Analg. 2001, 92: 984-9兩組負(fù)荷試驗(yàn)后血流動(dòng)力學(xué)改變Response(70) 以上指標(biāo)與SV改變的相關(guān)性Pearsons correlationPHR0.142NSSBP-0.448 0.001SV-0.3720.001CVP0.055NSSVV0.722 0.001HR-0.089NSSBP 0.472 0.001CVP-0.084NSSVV-0.505 0.001Anesth Analg. 2001, 92: 984-9以上指標(biāo)與SV改變的相關(guān)性Pearsons correlaResponsive VLS: SVV/SV有較高

21、的特異性和敏感性Anesth Analg. 2001, 92: 984-9Responsive VLS: SVV/SV有較高的特異性和SVV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12.11.1公斤SVV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50 mmHg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)復(fù)制犬失血性休克模型容量負(fù)荷試驗(yàn)分組 SV是否大于容量負(fù)荷試驗(yàn)前SV的5分為兩組 反

22、應(yīng)組 (SV5) 無(wú)反應(yīng)組 (SV5)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)HR MAP PiCCO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9.61.7次，其中94次為反應(yīng)組，40次為無(wú)反應(yīng)組分組 監(jiān)測(cè)指標(biāo)共進(jìn)行容量負(fù)荷試驗(yàn)134次，每只犬平均9.6容量負(fù)荷實(shí)驗(yàn)前各指標(biāo)的比較 P 0.05 容量負(fù)荷實(shí)驗(yàn)前各指標(biāo)的比較 P 0.05 容量負(fù)荷試驗(yàn)前各指標(biāo)與SV的相關(guān)性 容量負(fù)荷試驗(yàn)前各指標(biāo)與SV的相關(guān)性 容量負(fù)荷試驗(yàn)前后各指標(biāo)的變化與SV的相關(guān)性 容量負(fù)荷試驗(yàn)前后各指標(biāo)的變化與SV的相

23、關(guān)性 各指標(biāo)對(duì)容量負(fù)荷反應(yīng)(SV)的ROC曲線分析AUC95 CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.4340.6510.2070.3810.3130.5170.3360.5390.5830.7910.8050.939AUC=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PAWP各指標(biāo)對(duì)容量負(fù)荷反應(yīng)(SV)的ROC曲線分析AUC95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S

24、VV的應(yīng)用EVLW的應(yīng)用小結(jié)內(nèi)容簡(jiǎn)介容量管理的基本目標(biāo)CVP/PAWP能反映EVLW嗎?Prospectively study16 pats with septic shock and pul edema (ACCP/SCCM)SAPS II: 56Monitor: PiCCO vs PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hFrom intensive Care Med, 2002,28,712-18CVP/PAWP能反映EVLW嗎?ProspectivelyIntensive Care Med, 2002,28,712-18CVP/PAWP能反映EVLW嗎?NoIntensive Care Med, 2002,28,71Intensive Care Med, 2002,28,712-18delta與EVLW相關(guān)性, FB：fluid balanceCVP/PAWP能反映EVLW嗎?NoIntensive Care Med, 2002,28,71肺水含量是A