危重患者的血流動(dòng)力學(xué)監(jiān)測(cè)-協(xié)和PPT課件

.,1,床旁血流動(dòng)力學(xué)監(jiān)測(cè)脈波連續(xù)心排血量(PiCCO)監(jiān)測(cè),北京協(xié)和醫(yī)院ICU隆云,.,2,基本理論容量反應(yīng)性-動(dòng)態(tài)指標(biāo)器官平衡-EVLWI/PVPI治療終點(diǎn)-SvO2/ScvO2乳酸,.,3,我才不管別人說(shuō)什么，我關(guān)心的是.,.,4,心功能評(píng)價(jià),心輸出量,心率,前負(fù)荷,后負(fù)荷,心肌收縮力,.,5,休克的血流動(dòng)力學(xué)分類(lèi),低動(dòng)力型休克高動(dòng)力型休克,MAP=CI*SVRI,.,6,MAP=CI*SVRI,SVRI,CI,一,二,三,四,.,7,休克的分類(lèi),低血容量性心源性分布性梗阻性,.,8,各種休克的血流動(dòng)力學(xué)特征,.,9,AContinuumtoSevereDisease,.,10,GoldenHourandSilverDay,DetectionandCorrectionofOccultHypoperfusionwithin24HrsImprovesOutcomefromMajorTraumainEDsMorbidityandsurvivalversustimetocorrectocculthypoperfusion.,BlowO,etal.GoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HrsImprovesOutcomefromMajorTrauma.JTrauma,1999,47:964,.,11,血流動(dòng)力學(xué)支持,低血容量性休克,補(bǔ)充循環(huán)容量,梗阻性休克,解除梗阻,.,12,心源性休克的ABC理論,PAWP,CI,A,B,C,D,.,13,感染性休克的特征,充足的液體負(fù)荷,仍不能糾正的休克,需要血管活性藥循環(huán)高動(dòng)力狀態(tài)與組織缺氧共存,.,14,感染性休克的支持,充足的液體復(fù)蘇充足的氧輸送血管收縮藥組織水平缺氧,.,15,理想的血流動(dòng)力學(xué)監(jiān)測(cè),持續(xù)、可重復(fù)性簡(jiǎn)潔、微創(chuàng)人文-反應(yīng)性器官平衡,.,16,.,17,跨肺熱稀釋法+脈波輪廓分析法,RA,LA,RV,LV,Surface=Cal.xStrokevolume,.,18,PICCO測(cè)定的參數(shù),脈波連續(xù)測(cè)定每次心臟搏動(dòng)的心輸出量(PCCO)及指數(shù)(PCCI)動(dòng)脈壓(AP)心率(HR)每搏量(SV)及指數(shù)(SVI)每搏量變化(SVV)外周血管阻力(SVR)及指數(shù)(SVRI)熱稀釋法心輸出量(CO)及指數(shù)(CI)胸腔內(nèi)血容量(ITBV)及指數(shù)(ITBI)全心舒張末期容量(GEDV)及指數(shù)(GEDI)血管外肺水(EVLW)及指數(shù)(ELWI)心功能指數(shù)(CFI),.,19,反映前負(fù)荷-靜態(tài)與動(dòng)態(tài)指標(biāo),staticRAP/CVPPAOPRVEDVLVEDA,dynamicinspiratorydecreaseinRAPRAPexpiratorydecreaseinarterialsystolicpressuredownrespiratorychangesinpulsepressurePPrespiratorychangesinaorticbloodvelocityVpeak,.,20,容量反應(yīng)性（FluidResponsiveness）,SignificantSV/COafterFluidchallenge,VentricularPreload,SV/CO,.,21,.,22,.,23,單次的右房壓不能預(yù)測(cè)容量反應(yīng)性，反應(yīng)者與無(wú)反應(yīng)者數(shù)值明顯交叉,右房壓與容量反應(yīng)性,.,24,右室舒張末期容積指數(shù),RVEDVI138mL/m2thelackofresponse,.,25,肺動(dòng)脈楔壓,所有上述研究都沒(méi)有發(fā)現(xiàn)PAOP作為評(píng)價(jià)容量反應(yīng)性的閾值,.,26,影響靜態(tài)指標(biāo)的因素,PEEP三尖瓣返流血管活性藥物右室功能不全心室順應(yīng)性液體分布,.,27,無(wú)反應(yīng)組的原因,高靜脈系統(tǒng)順應(yīng)性低心室順應(yīng)性心室功能障礙,.,28,動(dòng)態(tài)指標(biāo)與容量反應(yīng)性,.,29,PPmin,.,30,AmJRespirCritCareMed2000;162:134-8,PPV(%)beforefluidinfusion,13%,13%,.,31,血管外肺水與液體復(fù)蘇,earlyresuscitationofhaemorrhagicshockwithNSorLRhaslittleimpactonoxygenationwhenresuscitationvolumeislessthan250ml/kg.,.,32,評(píng)價(jià)肺水腫原因,心源性、肺源性？肺毛細(xì)血管靜水壓腦利鈉肽（BNP）肺血管通透性指數(shù)(PVPI),.,33,.,34,.,35,Pcishydrostaticpulmonarycapillarypressure.butisnotwedgepressure(PAOP),.,36,.,37,Chest2007;131;964-971,.,38,.,39,Inflammatoryvscardiogenicpulmonaryedema,.,40,PVPI=EVLWI/PBV,.,41,Aclinician,armedwiththesepsisbundles,attacksthethreeheadsofseveresepsis:hypotension,hypoperfusionandorgandysfunction.CritCareMed2004;320(Suppl):S595-S597,SurvivingSepsisCampaign,.,42,感染性休克中與預(yù)后相關(guān)的血流動(dòng)力學(xué)參數(shù),Varpula.IntensiveCareMed(2005)31:10661071,.,43,.,44,早期集束化治療,早期血清乳酸水平測(cè)定抗生素使用前留取病原學(xué)標(biāo)本急診在3h內(nèi)，ICU在1h內(nèi)開(kāi)始廣譜的抗生素治療如果有低血壓或血乳酸4mmol/L，立即給予液體復(fù)蘇(20ml/kg)，如低血壓不能糾正，加用血管活性藥物，維持MAP65mmHg；液體復(fù)蘇使CVP8mmHg，ScvO270%。積極的血糖控制糖皮質(zhì)激素應(yīng)用機(jī)械通氣患者平臺(tái)壓30cmH2O,.,45,血壓正常時(shí)的休克,Schwaitzberg,JPedSurg,1988,.,46,隱匿性低灌注,血壓不是復(fù)蘇的終點(diǎn)盡管血壓等生命體征正常，乳酸升高仍提示隱匿性低灌注，預(yù)示患者的預(yù)后不良在手術(shù)患者中，改善隱匿性低灌注改善患者預(yù)后,.,47,治療終點(diǎn),CVPMAPCO,SvO2LACTATETissueO2&CO2,.,48,SvO2的含義,SvO2=SaO2,VO2,CO*Hb*13.4,.,49,SvO2=缺氧,低張性,組織性,等張性,循環(huán)性,.,50,.,51,.,52,氧輸送,閾值,氧需,氧需與氧輸送,.,53,VO2,DO2,SvO2,OptimalEO2=,OptimalEO2=30%,OptimalEO2=40%,SvO2indicatoroftheVO2/DO2balance,CriticalDO2&EO2,.,54,血乳酸范圍,重癥患者乳酸正常值5mmol/l伴有代謝性酸中毒,.,55,乳酸性酸中毒的原因及分類(lèi),代謝紊亂組織缺氧藥物、毒素或先天性疾病導(dǎo)致的糖代謝異常CohenandWoodsTypeApoortissueperfusionTypeBnoclinicalevidenceofpoortissueperfusion,.,56,早期乳酸清除率,從初始發(fā)現(xiàn)到hr乳酸下降的百分比119ptswithseveresepsisorsepticshockSurvivors&nonsurvivors38.134.6vs.12.051.6%(p=.005)乳酸清除率明顯與預(yù)后負(fù)相關(guān)(p=.04),CriticalCareMedicine.32(8):1637-1642,Cri