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1、Effects of fluid administration on renal perfusion in critically ill patients危重病人液體管理對腎灌注的影響1；.ContentsIntroduction1Methods 2Results3Conclusions42；.Diagramoxygen deliveryoxygen demandIntroductionImbalance in oxygen delivery and oxygen demand is common in critically ill patients, especially those wit

2、h acute circulatory failure of septic, hypovolemic or cardiogenic origin.3；.IntroductionAcute kidney injury (AKI) is a frequent complication of circulatory failure and associated with increased morbidity and mortality .急性腎損傷是循環(huán)衰竭狀態(tài)下的常見并發(fā)癥，它與發(fā)病率及死亡率的升高密切相關(guān)。4；.IntroductionFluid resuscitation is a firs

3、t-line therapy used to restore oxygen delivery to the organs and prevent AKI and yet the renal effects of fluid resuscitation are not easily assessed.液體復(fù)蘇是恢復(fù)器官血氧輸送及預(yù)防AKI的一線治療方法，然而液體復(fù)蘇對于腎臟的影響是不容易評估的。5；.IntroductionPhysicians generally evaluate the effectiveness of fluid therapy by looking at systemic

4、 hemodynamic variables, such as mean arterial pressure (MAP) or cardiac output, because the increase in urine output may be delayed or inconsistent and the decrease in serum creatinine may be even slower. A direct evaluation of renal hemodynamics would be valuable.醫(yī)師通常通過全身血流動力學(xué)變量來評估液體治療的效果，比如：平均動脈壓、

5、心輸出量，因為尿量增加可能會延遲或者與實際情況不一致，血肌酐的下降也非常慢，這些指標(biāo)都不能及時有效的反應(yīng)腎灌注情況。一種可以直接評估腎臟血流動力學(xué)的方法將非常有價值。6；.IntroductionWe used Doppler techniques to investigate the effects of fluid administration on intrarenal hemodynamics and the relationship between changes in renal hemodynamics and urine output.我們用多普勒技術(shù)研究液體管理對腎內(nèi)血流動力

6、學(xué)的影響以及腎臟血流動力學(xué)與尿量的關(guān)系。7；.Fig. 1 Summary of the study design. The intervention was a fluid challenge that consisted of infusion of a minimum volume of 500 ml at a minimum rate of 1,000 ml/hour. Interlobar artery Doppler variables, blood pressure, heart rate and urine output were recorded before and aft

7、er the fluid challenge and stabilization of hemodynamic variables. UO/3H: urine output volumes measured over 3 hours.8；.腎臟血管的測量和正常值腎臟血管的測量和正常值阻力指數(shù)（阻力指數(shù)（RI，Resistance Index ）= （Vmax-Vmin）/ Vmax正常腎各段腎動脈的阻力指數(shù)（正常腎各段腎動脈的阻力指數(shù)（RIRI）各段腎動脈RI0.65 0.02 0.63 0.04 0.59 0.02 0.54 0.03 0.51 0.049；.10；.Fig. 2 Study

8、 Consort diagram. *Six patients had two Doppler waves instead of three or more, two patients had 5 % difference in RI between the kidneys. RIAD renal interlobar artery Doppler.11；.Criteria-Control groupThe control groups included ICU patients with stable systemic hemodynamics receiving no specific i

9、ntervention.對照組包括全身血流動力學(xué)穩(wěn)定且沒有接受特殊干預(yù)的ICU病人。12；.Control group A評價觀察者在測量腎葉間動脈腎葉間動脈RI自身偏差 測量3次（3個心動周期），每次間隔15min 同一超聲醫(yī)師測量，RI計算由統(tǒng)計員負(fù)責(zé)。13；.Control group B評價多普勒變量的穩(wěn)定性 測量2次，間隔60min 由同一超聲醫(yī)師測量，RI計算由統(tǒng)計員負(fù)責(zé)。14；.Criteria-Intervention group需要液體沖擊治療的急性循環(huán)衰竭患者：并且至少包含以下一條標(biāo)準(zhǔn)：a.低動脈壓：收縮期動脈壓90mmHg or MAP65mmHgb.需要升壓藥糾正低血壓

10、c.少尿（尿量0.5ml/kg/hour）15；.Diagram age 40 kg/m2Exclusive criteria16；.Diagramgiven diureticsExcluded from the studychanges in vasopressor administrationduring the study period17；.研究期間監(jiān)測項目研究期間監(jiān)測項目1.持續(xù)動態(tài)心電圖監(jiān)測2.心率3.有創(chuàng)平均動脈壓、脈壓（橈動脈or股動脈）4.血乳酸5.ScvO2 及SvO218；.DiagramAdd Your TextAdd Your TextAdd Your Text停止液

11、體管理停止液體管理0.9%Nacl 500ml or 6% 羥乙基淀粉在動脈壓指導(dǎo)下維持最低1000ml/h.補(bǔ)液要求補(bǔ)液要求MAP65mmHgMAP stroke volume increase10-15%基礎(chǔ)值CVP15mmHg19；.Fig. 3Individual changes in RI over time in the non-intervention group (Control group B). Each line corresponds to the change in RI in one stable ICU patient. Measurements were per

12、formed at baseline and 1 hour later in stable hemodynamic conditions with no interventionResults20；.ResultsFluid administration resulted in increases in MAP from 75 15 to 80 14 mmHg (p 0.01)PP from 49 19 to 55 19 mmHg (p 0.01). RI decreased concurrently from 0.73 0.09 to 0.71 0.09 (p 0.01)urine outp

13、ut increased from 55 76 to 81 87 ml/hour (p 0.01).21；.ResultsFig. 4 Changes in hemodynamic variables before and after fluid challenge. A Changes in resistivity index (RI). B Changes in mean arterial pressure (MAP) and in pulse pressure (PP). The y-axes show the mean values standard deviation. MAP1,

14、PP1, RI1 are values before fluid challenge and MAP2, PP2, RI2 are values after fluid challenge.22；.At baseline, RI predicted an increase in urine output following a fluid challenge at all thresholds and MAP predicted an increase at thresholds of 0.2 ml/kg/hour and 0.3 ml/kg/hour, but not 0.1 ml/kg/h

15、our (Table 3).23；.ConclusionsWe showed that fluid administration reduces intrarenal vasoconstriction and that changes in RI are more effective than changes in MAP and PP to predict an increase in urine output after fluid challenge. Dynamic analysis of intrarenal hemodynamics using RIAD can identify renal responsive patients. However, the use of RI to guide fluid therapy for ren