休克患者血容量的監(jiān)測進展課件

ICU休克患者血容量的監(jiān)測進展內容簡介容量管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結休克的概念感染、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致組織缺氧代謝障礙和細胞受損臨床綜合征容量管理的基本目標保證容量－合適的心臟前負荷預防肺水腫二者必須平衡內容簡介容量管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結容量監(jiān)測的現狀容量監(jiān)測：TEE，CT，核素掃描臨床表現:血壓、心率、尿量、皮膚粘膜等壓力監(jiān)測：漂浮導管(CVP/PAWP)心臟前負荷：VEDVRVEDP/LVEDP的測定壓力反映容量及肺水腫的局限性心臟順應性瓣膜功能肺毛細血管通透性機械通氣對循環(huán)的影響PAC對容量監(jiān)測的有效性和可信性受到置疑？？許多文獻：CVP/PAWP不能準確反映容量狀態(tài)內容簡介容量管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結AphysiologicalsystemmodelITTV:IntrathoracictotalvolumeGEDV:

Globalend-diastolicvolume

ITBV:Intrathoracicbloodvolume

PTV:PulmonarytotalvolumeEVLW:extra-pulmonarylungwater

胸內總容量全心舒張期血容量胸內血液容量肺部容積血管外肺水容量指標的應用胸腔內血管容量(ITBV)血管外肺水(EVLW)搏出量變異率(SVV)搏出量變異率(SVV)SVV=(SVmax–SVmin)/SVmeanSvmax:meanvalueoffourSVmax/30sSVmin:meanvalueoffourSVmin/30sSVmean血管外肺水組成(EVLW)細胞內液間質液體肺泡內液體內容簡介管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結LueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressureITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.Anesth

Analg.2002,95:835-43ITBV---superiorthanPAWPinpreloadDellaRG,etal.Anesth

Analg.2002,95:835-43CorrelationofITBV-SVin4phasesNocorrelationofPAWP-SVinanyphases前瞻性臨床研究40例心臟移植術后患者男34例，女6例觀察術后3、6、12、24、36、48、72hITBV/GEDV和CVP/PAWP與SV的相關性ITBV/GEDV---goodpreloadindicatorinhearttransplantationGoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781^GEDV-^SV:R2=0.4016^ITBV-^SV:R2=0.2979GoedjeO,etal.Chest,2000,118:775-781^PAWP-^SV:R2=0.0043^CVP-^SV:R2=0.0552ITBV的改變反映肺水含量Prospectivelystudy16patientswithsepticshockandpulmonaryedema(ACCP/SCCM)SAPSII:56Monitor:Picco,PACOptimalPAWP:CInolongerincreasedMonitortime:0,24hIntensiveCareMed,2002,28,712-18FromintensiveCareMed,2002,28,712-18CVP與EVLW的相關性PAWP與EVLW的相關性CorrelationbetweenITBV/TEDVandEVLWFromintensiveCareMed,2002,28,712-18ITBV

與EVLW有良好相關性優(yōu)于

CVP

與PAWP內容簡介容量管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結SVV可以反映機體前負荷Prospectivestudy20MVpatientsfollowingcardiacsurgeryVolumeloading(HES20ml*BSA/10min)Measurement:CVP,PAWP---PACLVEDAI----TEEITBV,SVV----PiCCOReuterDA,etal.IntensiveCareMed.2002,28:392-8.血流動力學監(jiān)測SVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVP/PAWPnotcorrelatedwithCISVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVPnotcorrelatedSVV反映機體對容量治療的反應15例腦外科手術患者麻醉誘導后容量負荷實驗：100mLof6%hydroxyethylstarchgivenfor2min分組：responsive:SV>5%

nonresponsive:SV<5%Atotalof140VLSswereperformedAnesth

Analg.2001,92:984-9兩組負荷試驗前血流動力學狀態(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.2001,92:984-9兩組負荷試驗后血流動力學改變Response(70)nonresponse(70)PHR -1 -1 NSSBP 9 2 <0.001CVP 9.8 11.9 NS SVV -25.8 -10 <0.001Anesth

Analg.2001,92:984-9以上指標與SV改變的相關性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.2001,92:984-9ResponsiveVLS:SVV/SV有較高的特異性和敏感性Anesth

Analg.2001,92:984-9SVV對失血性休克犬容量狀態(tài)的評價成年健康雜種犬共14只，體重12.1±1.1公斤復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放血維持MAP在50mmHg左右并穩(wěn)定60分鐘，模型成功容量負荷試驗2分鐘內快速滴入林格氏液7ml.kg-115分鐘后重復，記錄容量負荷前及后5分鐘的監(jiān)測指標分組△SV是否大于容量負荷試驗前SV的5％分為兩組反應組(△SV＞5％)無反應組(△SV＜5％)直至連續(xù)兩次△SV均小于容量負荷試驗前的5%時終止實驗監(jiān)測指標HRMAPPiCCO監(jiān)測儀:CO、ITBVI、SV、SVVSwan-Ganz導管:CO、CVP、PAWP共進行容量負荷試驗134次，每只犬平均9.6±1.7次，其中94次為反應組，40次為無反應組容量負荷實驗前各指標的比較

反應組

無反應組

HR111.3±33.6115.6±44.1CVP5.4±2.46.2±2.5PAWP7.9±2.98.6±2.9P<0.05

容量負荷試驗前各指標與△SV的相關性

rP值HR(bpm)-0.1480.089MAP(mmHg)-0.0910.296CVP(mmHg)-0.0920.292PAWP(mmHg)-0.0910.297ITBVI(ml/m2)0.3560.000SVV(%)0.5310.001容量負荷試驗前后各指標的變化與△SV的相關性

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(%)–0.3760.000各指標對容量負荷反應(△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，對容量評價的敏感性為92.6％，特異性為62.5％。

SVV和ITBVI可用于容量狀態(tài)的評價優(yōu)于HR、MAP、CVP和PAWP內容簡介容量管理的基本目標容量監(jiān)測的現狀及局限性容量監(jiān)測的進展ITBV的應用SVV的應用EVLW的應用小結CVP/PAWP能反映EVLW嗎?Prospectivelystudy16patswithsepticshockandpuledema(ACCP/SCCM)SAPSII:56Monitor:PiCCOvsPACOptimalPAWP:CInolongerincreasedMonitortime:0,24hFromintensiveCareMed,2002,28,712-18IntensiveCareMed,2002,28,712-18CVP/PAWP能反映EVLW嗎?

NoIntensiveCareMed,2002,28,712-18delta與EVLW相關性,FB：fluidbalanceCVP/PAWP能反映EVLW嗎?

No肺水含量是ARDS的預后指標Retrospectiveanalysis373ICUpatsinu