周樹生---經胸壁心臟超聲容量評估及指導快速補液試驗.ppt

1、Series PPT of Intensive care unit（20140919）,安徽省立醫(yī)院重癥醫(yī)學科 副主任醫(yī)師、副教授 安徽醫(yī)科大學 碩士研究生導師 周樹生,1,This study of 2,289 patients included prospectively from two different cohorts in a quaternary-level provincial referral hospital in BC,Canada.(47.75%),Crit Care Med.2014 Jul 22,在管理血流動力學不穩(wěn)定的患者中，常見策略是提高心排血量和組織灌注，故評

2、估患者的容量狀態(tài)極其重要； 對評估容量狀態(tài)容量無反應的患者，增加容量負荷不但不能引起心輸出量的增加，反而會增加組織水腫及缺氧，故在進行快速補液時應首先對患者進行容量評估。,J Intensive Care Med. 2009 Sep-Oct;24(5):329-37,Techniques for assessment of intravascular volume in critically ill patients,德國生理學家Otto Frank 英國生理學家Starling,Frank-Starling機制,靜態(tài)前負荷參數(shù)：前負荷壓力指標（CVP）及前負荷容量指標（全心舒張末期容積，GE

3、DV）； 動態(tài)前負荷參數(shù)：收縮壓變異率（SPV）、脈壓變異率（PPV）、每搏變異率（SVV）及被動抬腿試驗（PLR）等。,Cardiovasc Ultrasound. 2008 Oct 6;6:49.,World Interactive Network Focused on CriticalUltrasound(WINFOCUS),血壓（BP）：失血量達18%仍然可以通過提高血管阻力來維持相對正常的MAP; 中心靜脈壓（CVP）和肺動脈楔壓(PAWP)：通過壓力代容積來反應心臟前負荷，均受到心臟順應性，機械通氣和血管張力等因素影響；,超聲FATE(focus assessed transtho

4、racic echo )草案,Research has suggested that volume responsiveness can be defined as a 15% increase in stroke volume(SV) or cardiac output(CO)after a 500ml infusion.,Anesth Analg.2010 Nov;111(5):1180-92,A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac

5、 output,床旁超聲下腔靜脈直徑（IVCD）測量方法,Korean J Intern Med 2014;29:241-245,一、床旁超聲預測容量反應之下腔靜脈直徑（IVCD）,J Emerg Med.2012 Apr;42(4):429-36,一、床旁超聲預測容量反應之下腔靜脈直徑（IVCD）,在容量反應時，下腔靜脈直徑變化與CVP具有相關性(P0.001)，下腔靜脈直徑在1-2CM范圍具有較高的特異性和敏感性.,(A) Subxiphoid, transverse orientation, at end inspiration. (B) Subxiphoid, longitudinal

6、 orientation, at end inspiration.,inferior vena cava diameter(IVCD) and central venous pressure value(CVP),Pak J Med Sci. 2014 Mar;30(2):310-5.,下腔靜脈長軸切面,IVC= inferior vena cava; CVP= central venous pressure.,Statistically relationship between IVC and CVP pressures,Pak J Med Sci. 2014 Mar;30(2):310-5

7、.,結論：自主呼吸患者，下腔靜脈直徑變化可以預測容量反應,下腔靜脈擴張指數(shù)(dIVC)(Dmax(吸氣末)-Dmin(呼氣末)Dmin,Intensive Care Med. 2004 Sep;30(9):1740-6,30-min volume expansion (7 ml/kg) using 4% modified fluid gelatin,二、床旁超聲預測容量反應之下腔靜脈擴張指數(shù)(dIVC),Baseline,After volume expansion,Respiratory changes in inferior vena cava diameter are helpful i

8、n predicting fluid responsiveness in ventilated septic patients,Intensive Care Med. 2004 Sep;30(9):1740-6,機械通氣患者，dIVC18，預測容量反應性敏感性和特異性均在90以上.,下腔靜脈呼吸變化率（DIVC）=（Dmax-Dmin)/(Dmax+Dmin),Intensive Care Med. 2004 Sep;30(9):1834-7,三、床旁超聲預測容量反應之下腔靜脈呼吸變化率（DIVC）,A studied 39 mechanically ventilated patients w

9、ith septic shock.,Individual values (open circles) and mean SD (closed circles) of the minimum DIVC, maximum DIVC and DIVC befor volume loading in responder (R) and non-responder (NR) patients.*P0.05 R vs NR,下腔靜脈呼吸變化率12，預測容量反應性的陽性和陰性分別為93和92.,Intensive Care Med. 2004 Sep;30(9):1834-7,四、床旁超聲預測容量反應之下腔

10、靜脈塌陷指數(shù)（IVCC）,下腔靜脈塌陷指數(shù)(IVC-CI):（Dmax-Dmin）/Dmax,J Am Coll Surg. 2009 Jul;209(1):55-61,JACC Cardiovasc Imaging. 2011 Sep;4(9):938-45,下腔靜脈2cm(精確度88)和下腔靜脈塌陷40(精確度68)是確定右心房壓10mmHg較高精度 比組合（RAP=08mmHg）,下腔靜脈塌陷指數(shù)預測右心房壓力（RAP）,Intensive Care Med. 2010 Apr;36(4):692-6,IVC-CI指導心衰患者緩慢超濾（SCUF）治療,Hypotension was ob

11、served only in those patients (2/24) who reached an IVCCI30%.In all the other patients,a significant increase in IVC-CI was obtained without hemodynamic instability,Mean UF time was 20.34.6h with a mean volume of 287.696.2ml h-1 and a total ultrafiltrate production of 5,780.8 1,994.6 ml.,IVC-CI to g

12、uide fluid removal in slow continuous ultrafiltration: a pilot study,Intensive Care Med. 2010 Apr;36(4):692-6,IVC ultrasound is a rapid, simple, and non-invasive means for bedside monitoring of intravascular volume during SCUF and may guide fluid removal velocity.,Am J Emerg Med. 2013 Aug;31(8):1208

13、-14,Cutoff values=ADHF were LVEF45%, IVC-CI 20%, and 10 B-lines.,LVEF、IVC-CI and B-lines聯(lián)合診斷急性呼吸困難心衰患者,鎖骨下靜脈和下腔靜脈的塌陷指數(shù)（IVC-CI and SCV-CI）,J Surg Res. 2013 Sep;184(1):561-6,SCV-CI versus IVC-CI. Linear regression demonstrates acceptable correlation between the two measurement modalities (R2 0.61). (C

14、olor version of figure is available online.),Measurement bias plot comparing IVC-CI and SCV-CI across a broad range of collapsibility values.,J Surg Res. 2013 Sep;184(1):561-6,鎖骨下靜脈和下腔靜脈的塌陷指數(shù)（IVC-CI and SCV-CI）,Crit Care Med. 2013 Mar;41(3):833-41,Point-of-care ultrasound to estimate central venous

15、pressure: a comparison of three techniques,下腔靜脈直徑比下腔靜脈塌陷指數(shù)與CVP更具有相關性,R2 = 0.58,R2 = 0.21,R2 = 0.16,Test Characteristics of Three Ultrasound Techniques in Predicting CVP10mmHg,Crit Care Med. 2013 Mar;41(3):833-41,Among spontaneously breathing patients without vasopressor support, the maximal ICVD is

16、a more robust estimate of CVP than the IVCCI or the IJVSR（頸內靜脈的縱橫比）.,五、床旁超聲預測容量反應之舒張末期容積（LVEDA、GEDV）,*p Value baseline v hemorrhage;p Value hemorrhage v hypervolemia;p Value baseline v hypervolemia,J Cardiothorac Vasc Anesth.2007 Oct;21(5):650-4,J Crit Care. 2012 Jun;27(3):325.e7-13,全心舒張末期容積（GEDV）預測

17、容量反應,P0.05(BL nonresponder vs BL responder),全心舒張末期容積（GEDV）預測容量反應,J Crit Care. 2012 Jun;27(3):325.e7-13,六、床旁超聲預測容量反應之主動脈(AO),Peak 是用從左室流出道水平測得的吸氣時主動脈內最大峰值血流速和呼氣時最小峰值血流速之差與兩者平均值的比率。公式如下(Vpeakmax和Vpeakmin分別表示最大和最小峰值血流速): peak(Vpeakmax-Vpeakmin)(Vpeakmax+Vpeakmin/2100。,機械通氣患者主動脈峰值血流速度呼吸變異率(peak)或主動脈速度時間

18、積分呼 吸變化率(VTI)代表了容量反應性變化的幅度及前負荷。,六、床旁超聲預測容量反應之主動脈(AO),在心尖五腔心斷面，左心室流出道可以測量主動脈瓣的速度時間積分（VTI） 公式如下(VTImax和VTImin分別表示主動脈瓣的速度時間積分最大和最小值): VTI（VTImax-VTImin)/(VTImax+VTImin)/2100%,機械通氣患者主動脈峰值血流速度呼吸變異率(peak)或主動脈速度時間積分呼 吸變化率(VTI)代表了容量反應性變化的幅度及前負荷。,機械通氣患者主動脈峰值血流速度呼吸變異率(peak)能夠預測容量反應,Pediatr Cardiol. 2010 Nov;3

19、1(8):1166-70.,主動脈峰值血流速度呼吸變異率(peak)預測容量反應,Chest.2001 Mar;119(3):867-73.,peak預測機械通氣膿毒癥患者容量反應,The best cut-off for Vpeak ao was 12%, with sensitivity, specificity,and positive and negative predictive values of 81.2%, 85.7%, 93% and 66.6%.,PS=respiratory variations in systolic arterial pressure(SPV); PP

20、=respiratory variations in pulse pressure(PPV),Chest.2001 Mar;119(3):867-73.,peak預測機械通氣膿毒癥患者容量反應,peak,PS=respiratory variations in systolic arterial pressure(SPV); PP=respiratory variations in pulse pressure(PPV),PP,PS,Pulsed Doppler before VE accurately predict the effects of VE, PS and PP are of l

21、ittle value in ventilated children,A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness,研究方法： 前瞻性研究，55例機械通氣患者。 10秒以上輸液晶體溶液50毫升，另外450毫升15分鐘輸注。 心輸出量（CO），每搏量（SV），主動脈速度時間指數(shù)（VTI），與左室射血分數(shù)（LVEF）被記錄。 評估內容：特征曲線下面積（AUC）：Co50，co500，vti50,Wu Y,Zhou S,Liu B.et al.

22、 Critical Care 2014, 18:R108,對機械通氣患者VTI可以評估容量反應性,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness,Patient characteristics stratified by fluid responders and non-responders at baseline,Wu Y,Zhou

23、S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness,Hemodynamic variables were measured at baseline, during volume expansion,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge g

24、uided by transthoracic echocardiography can predict fluid responsiveness,(A) Correlation between VTI50 (%) and VTI500 (%). (B) Correlation between CO50 (%) and CO500 (%),Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can pred

25、ict fluid responsiveness,Bland and Altman diagram between variation of cardiac output (A) and variation of velocity time index (B) after 50-ml or 500-ml volume expansion.,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can pre

26、dict fluid responsiveness,A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness,Individual values of VTI50 (%) (A), SV50 (%) (B), and CO50 (%) (C) after infusion of 50ml of fluid over 10seconds changed in patients with volume expansion-induced changes

27、in stroke volume (SV) of at least 10% (responders) and less than 10%(non-responders).,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,In critically ill patients, the variation of CO and VTI after the administration of 50-ml crystalloid solution over 10 seconds (CO50 and VTI50) can accurately pr

28、edict fluid responsiveness.,對機械通氣血流動力學不穩(wěn)定患者VTI可以評估容量反應性,Anesthesiology. 2011 Sep;115(3):541-7.,VTI=主動脈速度時間積分呼吸變化率,Kardiol Pol. 2009 Mar;67(3):265-71.,Variability of aortic blood flow predicts fluid responsiveness in spontaneously breathing healthy volunteers,研究背景： Echo measurement of respiratory var

29、iations of aortic blood velocity in ventilated shock patients can accurately predict the effect of volume expansion. 目的： To assess whether respiratory variability of peak aortic blood flow velocity (Vpeak) and of aortic velocity time integral(VTI)reflects preload-dependent changes of cardiac index(CI)and whether it predicts fluid responsiveness in healthy spontaneously breathing volunteers. 結論： Vpeak和VTI 與前負荷改變時的CI密切相關，并證實在自主呼吸的患者也同樣可以預測容量反應性.,Vpeak=主動脈峰值血流速度呼吸變異率；VTI =主動脈速度時間積分呼吸變化率,Crit Care.2009;13(5):R142.doi:10.1186/cc8027,機械通氣患者肱動脈峰值流速變化率預測容量反應性,PPrad=橈動脈脈搏壓力變化率;Vpeakbrach=肱動脈峰值流速呼吸變