動(dòng)脈血?dú)夥治黾案呷樗嵫Y課件

1、動(dòng)脈血?dú)夥治黾案呷樗嵫Y病例摘要男性，45歲，病歷號(hào)1612296入院日期2021/02/21入ICU日期2021/02/24既往史24年前因感冒后頸部淋巴結(jié)腫大行左頸部淋巴結(jié)活檢術(shù)，自述病理陰性8年前闌尾切除術(shù)1年前行鼻中隔彎曲矯正術(shù)病例摘要2021/12/30大量飲酒后頭昏、惡心，右脅肋部及后背部脹痛胃鏡：糜爛性胃炎伴膽汁返流2021/01/18生化檢查：ALT、AST、LDH、HBDH、尿淀粉酶進(jìn)行性升高腹部超聲檢查提示膽囊炎病例摘要2021/01/24靜滴脂肪乳過(guò)程中出現(xiàn)氣促、胸悶抗過(guò)敏、改善循環(huán)、補(bǔ)液及對(duì)癥處理后緩解2021/01/28胸悶、氣促，深大呼吸伴酸堿平衡紊亂無(wú)創(chuàng)通氣病例摘

2、要WCC2.46 6.26 x 109/LPlt30 115 x109/LALT 137 U/LAST 97 U/LUA 680 mol/LaPTT/PT明顯延長(zhǎng)糾正后PT 13.6 sec, aPTT 48.0 sec, Fib 1.41 g/L血淀粉酶237 588 U/L尿淀粉酶839 3330 U/L腫瘤指標(biāo)未見(jiàn)異常CA199, CEA, NSE, CA242, AFP, PSA, CA125病例摘要ABG7.435 / 6.2 / 116 / 4.1 / -19.2AG20 27血乳酸14.8 16.0 mmol/L血丙酮酸6.62 mg/dL (0.3 - 0.9)0.83 mmo

3、l/LL/P17.8 19.3病例摘要胸部CT左下肺多發(fā)肺大皰腹部增強(qiáng)CT肝左外葉及右后葉多發(fā)海綿狀血管瘤, 肝右后葉囊腫, 脾稍大胃十二指腸鏡膽汁返流性胃炎伴糜爛, 重度膽汁返流, 返流性食管炎1級(jí)病理結(jié)果胃竇兩塊粘膜組織, 中度慢性炎癥, 另見(jiàn)小片炎性滲出物胃底兩塊粘膜組織, 重度慢性炎癥, 活動(dòng)+, 另見(jiàn)小片炎性滲出物病例摘要診斷：重癥胰腺炎?治療按胰腺炎治療，惡心、嘔吐病癥緩解輸血漿及冷沉淀糾正DIC亞甲藍(lán)中和乳酸病例摘要呼吸困難深大呼吸合并代謝性酸中毒2021/02/12血液透析乳酸可短暫下降至7 mmol/L病例摘要2021/02/21轉(zhuǎn)入北京協(xié)和醫(yī)院內(nèi)分泌科ABG: 7.496

4、/ 8.7 / 142 / 6.6 / -15.3Na 137, Cl 95, K 3.7血乳酸 19.6 mmol/L血淀粉酶241 U/L，脂肪酶2430 U/LALT 126 U/L, TBil 23.3 mol/L, Cr 157 mol/L, BUN 8.82 mmol/L血?dú)饨Y(jié)果分析Step 1pH = 7.496 7.45原發(fā)性酸堿失衡應(yīng)包括堿中毒ABGpH7.496pCO28.7pO2142HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L血?dú)饨Y(jié)果分析Step 2判定堿中毒為呼吸性抑或代謝性ABGpH7.496pCO28.7pO2142

5、HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L血?dú)饨Y(jié)果分析Step 3AG = Na Cl HCO3= 137 95 6.6 = 35 20 高AG代酸ABGpH7.496pCO28.7pO2142HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L血?dú)饨Y(jié)果分析Step 4AG = 35 12 = 23HCO3 + AG = 6.6 + 23= 29.6 26代謝性堿中毒ABGpH7.496pCO28.7pO2142HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L血

6、氣結(jié)果分析Step 5pCO2 = 1.5 x HCO3 + 8 2= 1.5 x 6.6 + 8 2= 9.9 + 8 2= 15.9 to 19.9呼吸性堿中毒ABGpH7.496pCO28.7pO2142HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L血?dú)饨Y(jié)果分析診斷高AG代謝性酸中毒代謝性堿中毒呼吸性堿中毒ABGpH7.496pCO28.7pO2142HCO36.6BE-15.3LytesNa137Cl95K3.7血乳酸19.6 mmol/L高AG代酸的常見(jiàn)原因甲醇(methanol)中毒尿毒癥酮癥酸中毒糖尿病*酒精性饑餓性三聚乙醛(para

7、ldehyde)中毒異煙肼乳酸酸中毒*乙醇(ethanol)中毒*乙二醇(ethylene glycol)中毒*水楊酸(salicylic acid)中毒* 高AG代酸最常見(jiàn)的原因* 常伴滲透壓間隙升高病例診斷高AG代酸 高乳酸血癥高乳酸血癥的病因?病例摘要2021/03/01ABG 7.525 / 26.9 / 121 / 22.1 / -0.5Lac 9.6血滲透壓312Na 146, Cl 101, BUN 3.32, Glu 7.4AG = 22.9Osmcalc = 146 x 2 + 3.32 + 7.4 = 302.7Osmolarity gap = 9.3傳統(tǒng)觀點(diǎn)認(rèn)為缺氧可以導(dǎo)

8、致無(wú)氧代謝無(wú)氧代謝產(chǎn)生乳酸無(wú)氧代謝是有害的缺氧是有害的現(xiàn)階段臨床思維認(rèn)為，高乳酸血癥是缺氧的后果治療上采取提高心輸出量和氧輸送的方法因此，這是否意味著?高乳酸是有害的?高乳酸提示存在缺氧?高乳酸提示存在無(wú)氧代謝 高乳酸 = 預(yù)后不佳 乳酸是如何生成的?GlucoseGlycogenGlucose 6-PFructose 6-PFructose-1,6-BisphosphateTriose PhosphatesPhosphoenolpyruvatePyruvateLactateOxidation InCitric Acid CyclePhosphofructonasePyruvate kinas

9、ePDHLactate dehydrogenaseAnaerobic Metabolism乳酸根底生成率肌肉腦RBCWBC血小板腎臟髓質(zhì)胃腸道粘膜皮膚0.13 mmol/kg/hr0.14 mmol/kg/hr0.18 mmol/kg/hr0.11 mmol/kg/hr0.11 mmol/kg/hrTotal = 1290 mmol / 24 hours for 70 kg乳酸的代謝Excretion renal threshold = 5-6 mmol/L高乳酸血癥( 2 mmol/L)生成利用/排出因此一旦丙酮酸氧化過(guò)程受到影響, 任何能夠增加糖酵解的因素都能夠?qū)е赂呷樗嵫Y不僅僅是無(wú)氧代

10、謝!感染性休克時(shí)的高乳酸血癥Curtis SE, Cain SM. Regional and systemic oxygen delivery/uptake relations and lactate flux in hyperdynamic, endotoxin-treated dogs. Am Rev Respir Dis 1992; 145: 348-35402468Serum Lactate (mEq/L)04080120160Time (min)輸注內(nèi)毒素FiO2 = 12%dichloroacetate二氯乙酸(dichloroacetate)僅在有氧情況下激活PDH乳酸/丙酮酸比

11、值Lactate/Pyruvate = K x (NADH/NAD) x H+缺氧能夠阻斷氧化磷酸化過(guò)程組織NADH氧化為NAD增加NADH/NAD比值增加乳酸/丙酮酸比值正常值約為10:1心源性休克L/P比值 = 40:1符合組織缺氧表現(xiàn)經(jīng)過(guò)復(fù)蘇的感染性休克L/P比值 = 14:1不符合組織缺氧表現(xiàn)何時(shí)乳酸 = 組織灌注缺乏心源性休克出血性休克以下情況的感染性休克兒茶酚胺抵抗 + 心輸出量降低未經(jīng)過(guò)復(fù)蘇 (參見(jiàn)Rivers)何時(shí)乳酸 組織灌注缺乏有氧糖酵解加速碳水化合物代謝 線粒體氧化能力兒茶酚胺 / 細(xì)胞因子刺激e.g. 血液 / 肺的白細(xì)胞乳酸 (ARDS)丙酮酸蓄積全身性感染時(shí)PDH功

12、能障礙何時(shí)乳酸 組織灌注缺乏乳酸去除減少結(jié)果相互矛盾：測(cè)定方法與初始乳酸水平的影響可能導(dǎo)致輕度高乳酸血癥當(dāng)乳酸生成率接近正常時(shí)通常并不重要丙酮酸脫氫酶功能障礙PDH使丙酮酸進(jìn)入Kreb循環(huán), 而不產(chǎn)生乳酸全身性感染時(shí)肌肉中PDH水平低于正常應(yīng)用二氯乙酸可恢復(fù)功能, 從而導(dǎo)致乳酸水平下降蛋白質(zhì)分解代謝氨基酸轉(zhuǎn)化為丙酮酸, 隨后產(chǎn)生乳酸線粒體呼吸抑制全身性感染, 藥物如二甲雙胍(罕見(jiàn)), 氰化物, 抗逆轉(zhuǎn)錄病毒藥物乳酸酸中毒的分類(lèi)Type A Lactic AcidosisAssociated with malperfusion / dysoxiaType B Lactic AcidosisIn

13、the absence of malperfusion / dysoxiaB1 Disease states e.g. DKA, leukaemia, lymphoma, thiamine deficiencyB2 Drugs e.g. metformin, cyanide, beta-agonists, HARRTB3 inborn errors of metabolismClassification of Lactic AcidosisTissue hypoperfusionAbnormal vascular tone or permeability, left ventricular f

14、ailure, decreased cardiac outputReduced arterial oxygen contentAsphyxia, hypoxemia (PaO2 35), carbon monoxide poisoning, life-threatening anemiaB1 (common disorders)SepsisHepatic failureRenal failureDiabetes mellitusCancerMalariaCholeraB2 (drug or toxins)Vitamin deficiencyAcetaminophenEthanol, Metha

15、nolCocaineSalicylatesIsoniazidCatecholaminesEthylene glycolPapaverineCyanideParenteral nutritionNitroprussideLactuloseTheophyllineB3 (other conditions)Strenuous muscle exerciseGrand mal seizuresD-lactic acidosisType ADue to tissue hypoxiaType BNot due to tissue hypoxia預(yù)后價(jià)值來(lái)源并不重要高乳酸仍然為嚴(yán)重生理應(yīng)激和死亡危險(xiǎn)的標(biāo)志高

16、乳酸常與低氧無(wú)關(guān), 但仍提示嚴(yán)重應(yīng)激下存在代謝改變因此, 我們應(yīng)當(dāng)?尋找組織灌注缺乏的證據(jù)如果存在組織灌注缺乏, 應(yīng)提高CO和氧輸送但是, 不應(yīng)僅僅針對(duì)乳酸水平進(jìn)行上述治療治療組織灌注缺乏而非高乳酸考慮導(dǎo)致高乳酸的其他原因Lactate is the messengerdont shoot it!病例診斷全身血流動(dòng)力學(xué)穩(wěn)定組織灌注無(wú)明顯異常意識(shí)清楚皮膚無(wú)花斑毛細(xì)血管再充盈時(shí)間正常尿量正常藥物因素患病前未使用任何藥物中毒毒物監(jiān)測(cè)未發(fā)現(xiàn)異常先天性因素Classification of Lactic AcidosisTissue hypoperfusionAbnormal vascular tone

17、 or permeability, left ventricular failure, decreased cardiac outputReduced arterial oxygen contentAsphyxia, hypoxemia (PaO2 35), carbon monoxide poisoning, life-threatening anemiaB1 (common disorders)SepsisHepatic failureRenal failureDiabetes mellitusCancerMalariaCholeraB2 (drug or toxins)Vitamin d

18、eficiencyAcetaminophenEthanol, MethanolCocaineSalicylatesIsoniazidCatecholaminesEthylene glycolPapaverineCyanideParenteral nutritionNitroprussideLactuloseTheophyllineB3 (other conditions)Strenuous muscle exerciseGrand mal seizuresD-lactic acidosisType ADue to tissue hypoxiaType BNot due to tissue hypoxia病例診斷骨髓活檢淋巴瘤骨髓侵犯診斷非霍杰金氏淋巴瘤病例摘