醫(yī)學(xué)專題休克患者血容量監(jiān)測

1、休克患者血容量監(jiān)測2021/7/20 星期二1內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二2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(dǎo)致組織缺氧代謝障礙和細(xì)胞受損臨床綜合征2021/7/20 星期二3休克治療的首要任務(wù)：積極、合適補(bǔ)充血容量休克發(fā)生的始動因素： 有效循環(huán)血量下降合適的容量管理2021/7/20 星期二4容量管理的基本目標(biāo)保證容量合適的心臟前負(fù)荷預(yù)防肺水腫二者必須平衡2021/7/20 星期二5內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局

2、限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二6容量監(jiān)測的現(xiàn)狀容量監(jiān)測：TEE，CT，核素掃描臨床表現(xiàn): 血壓、心率、尿量、皮膚粘膜等壓力監(jiān)測：漂浮導(dǎo)管(CVP/PAWP)心臟前負(fù)荷：VEDV2021/7/20 星期二72021/7/20 星期二8RVEDP/LVEDP的測定2021/7/20 星期二9壓力反映容量及肺水腫的局限性心臟順應(yīng)性瓣膜功能肺毛細(xì)血管通透性機(jī)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？2021/7/20 星期二10許多文獻(xiàn)：CVP/PAWP不能準(zhǔn)確反映容量狀態(tài)2021/7/20 星期二11Principle of

3、 EVLW measurementRAEDVLAEDVLVEDVPBVRVEDVEVLWInjectionPiccoThermo-dilutioncatheterSwan-ganz catheter呼吁容量指標(biāo)的應(yīng)用來反映容量狀態(tài)及肺水腫2021/7/20 星期二12內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二13A physiological system modelITTV : Intrathoracic total volumeGEDV : Global end-diastolic volume IT

4、BV : Intrathoracic blood volume PTV : Pulmonary total volumeEVLW : extra-pulmonary lung water 胸內(nèi)總?cè)萘咳氖鎻埰谘萘啃貎?nèi)血液容量肺部容積血管外肺水2021/7/20 星期二14容量指標(biāo)的應(yīng)用胸腔內(nèi)血管容量(ITBV)血管外肺水(EVLW)搏出量變異率(SVV)2021/7/20 星期二15胸腔內(nèi)血管容量(ITBV)左心舒張末期容量右心舒張末期容量肺血容量2021/7/20 星期二16搏出量變異率(SVV)SVV=(SVmax SVmin)/SVmeanSvmax:mean value of fou

5、r SVmax/30sSVmin :mean value of four SVmin/30sSVmean2021/7/20 星期二17血管外肺水組成(EVLW)細(xì)胞內(nèi)液間質(zhì)液體肺泡內(nèi)液體2021/7/20 星期二18內(nèi)容簡介管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二19ITBVvalid estimate of preload in ALIProspective animal study15 sheep with ALI -saline washoutMV(PEEP 0,7,14,21 respectively 60

6、min)Measurement:LVEF,LVEDV-CT scanITBV,RVEDV-PiCCOCVP,PAWP-PACLuecke T, et al. Intensive Care Med, 2004, 30: 119-1262021/7/20 星期二20Luecke T, et al. Intensive Care Med, 2004, 30: 119-1262021/7/20 星期二21Luecke T, et al. Intensive Care Med, 2004, 30: 119-126ITBV and RVEDV Provide valid estimate of prelo

7、adEven at high intrathoracic pressure2021/7/20 星期二22ITBV-indicator of preload in liver transplantation60 patients undergoing Liver transplantation monitored with PiCCO and PACthe correlation between PAOP and ITBVI with respect to CI and SVIthe correlation between ITBVI and PAOP Della Rocca G, et al.

8、 Eur J Anaesthesiol. 2002, 19: 868-752021/7/20 星期二23ITBVI - more reliable indicator of preload than PAWP Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-752021/7/20 星期二24ITBVI - valid indicator of preload in lung transplantation50 patients during lung transplantationTime: 6 phase during oper

9、ationCorrelation between PAWP and SVICorrelation between ITBVI and SVICorrelation between (Delta) ITBVI PAWP and Delta SVIDelta were calculated by subtracting the first from the second measurement Della RG, et al. Anesth Analg. 2002 , 95: 835-432021/7/20 星期二25ITBV- superior than PAWP in preload Dell

10、a RG, et al. Anesth Analg. 2002 , 95: 835-43Correlation of ITBV - SV in 4 phasesNo correlation of PAWP - SV in any phases2021/7/20 星期二26Prospective, controlled, clinical study18 patients with ejection fraction 50% undergoing coronary artery bypass graft surgeryA baseline measurement :after induction

11、 of anesthesia (T1) treated by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) After 10 minutes, a second measurement (T2) was performedWiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8ITBV correlated significantly with CI and SV IN CABG2021/7/20 星期二27ITBV has Good relationship betwe

12、en CI/SVI CVP/ PCWP 與 CI/SV無相關(guān)性 ITBV 與 CI的相關(guān)性r = 0.55 ITBV 與 SV的相關(guān)性為r = 0.62Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-82021/7/20 星期二28前瞻性臨床研究40例心臟移植術(shù)后患者男34例，女6例觀察術(shù)后3、6、12、24、36、48、72h ITBV/GEDV和CVP/PAWP與SV的相關(guān)性ITBV/GEDV-good preload indicator in heart transplantation Goedje O, et al.

13、 Chest, 2000, 118: 775-7812021/7/20 星期二29Goedje O, et al. Chest, 2000, 118: 775-7812021/7/20 星期二30Goedje O, et al. Chest, 2000, 118: 775-781GEDV-SV: R2=0.4016ITBV-SV: R2=0.29792021/7/20 星期二31Goedje O, et al. Chest, 2000, 118: 775-781PAWP-SV: R2=0.0043CVP-SV: R2=0.05522021/7/20 星期二32ITBV的改變反映肺水含量Pros

14、pectively study16 patients with septic shock and pulmonary edema(ACCP/SCCM)SAPS II: 56Monitor: Picco,PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hIntensive Care Med, 2002,28,712-182021/7/20 星期二33From intensive Care Med, 2002,28,712-18CVP與EVLW的相關(guān)性PAWP與EVLW的相關(guān)性2021/7/20 星期二34Correlation

15、between ITBV/TEDV and EVLWFrom intensive Care Med, 2002,28,712-18ITBV 與 EVLW有良好相關(guān)性優(yōu)于 CVP 與 PAWP2021/7/20 星期二35內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二36SVV可以反映機(jī)體前負(fù)荷Prospective study20 MV patients following cardiac surgeryVolume loading(HES 20ml*BSA/10min)Measurement:CVP, PA

16、WP-PACLVEDAI-TEEITBV, SVV-PiCCOReuter DA, et al. Intensive Care Med. 2002, 28: 392-8.2021/7/20 星期二37血流動力學(xué)監(jiān)測2021/7/20 星期二38SVV may help to determine the preload condition Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.CVP/PAWP not correlated with CI2021/7/20 星期二39SVV may help to determine the

17、preload condition Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.CVPnot correlated2021/7/20 星期二40SVV反映機(jī)體對容量治療的反應(yīng)15例腦外科手術(shù)患者麻醉誘導(dǎo)后容量負(fù)荷實驗： 100 mL of 6% hydroxyethylstarch given for 2 min 分組：responsive: SV5% nonresponsive: SV5%A total of 140 VLSs were performedAnesth Analg. 2001, 92: 984-92021/7/2

18、0 星期二41兩組負(fù)荷試驗前血流動力學(xué)狀態(tài)Response(70)nonresponse(70) PHR7675 NSSBP102116 0.001CVP9.39.3 NSSVV12.66.8 0.001Anesth Analg. 2001, 92: 984-92021/7/20 星期二42兩組負(fù)荷試驗后血流動力學(xué)改變Response(70) nonresponse(70) PHR-1-1NSSBP 92 0.001 CVP9.811.9NSSVV-25.8-100.001Anesth Analg. 2001, 92: 984-92021/7/20 星期二43以上指標(biāo)與SV改變的相關(guān)性Pear

19、sons correlationPHR0.142NSSBP-0.448 0.001SV-0.3720.001CVP0.055NSSVV0.722 0.001HR-0.089NSSBP 0.472 0.001CVP-0.084NSSVV-0.505 0.001Anesth Analg. 2001, 92: 984-92021/7/20 星期二44Responsive VLS: SVV/SV有較高的特異性和敏感性Anesth Analg. 2001, 92: 984-92021/7/20 星期二45SVV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12.11.1公斤2021/7/20

20、星期二46復(fù)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(dāng)放血維持MAP在50 mmHg左右并穩(wěn)定60分鐘，模型成功容量負(fù)荷試驗2分鐘內(nèi)快速滴入林格氏液7ml.kg-115分鐘后重復(fù)，記錄容量負(fù)荷前及后5分鐘的監(jiān)測指標(biāo)2021/7/20 星期二47分組 SV是否大于容量負(fù)荷試驗前SV的5分為兩組 反應(yīng)組 (SV5) 無反應(yīng)組 (SV5)直至連續(xù)兩次SV均小于容量負(fù)荷試驗前的5%時終止實驗 監(jiān)測指標(biāo)HR MAP PiCCO監(jiān)測儀: CO、ITBVI 、SV 、SVVSwan-Ganz導(dǎo)管:CO、CVP、PAWP共進(jìn)行容量負(fù)荷試驗134次，每只犬平均9.61.7次

21、，其中94次為反應(yīng)組，40次為無反應(yīng)組2021/7/20 星期二48容量負(fù)荷實驗前各指標(biāo)的比較 反應(yīng)組 無反應(yīng)組 HR111.333.6 115.644.1 CVP5.42.4 6.22.5 PAWP7.92.98.62.9P 0.05 2021/7/20 星期二49容量負(fù)荷試驗前各指標(biāo)與SV的相關(guān)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(%)0.5310.0012021/7/20 星期二50容量負(fù)荷試驗前后各指標(biāo)的變

22、化與SV的相關(guān)性 rP值HR(bpm)-0.0810.353MAP(mmHg)0.0200.820CVP(mmHg)-0.3710.000PAWP(mmHg)-0.4480.000ITBVI(ml/m2)0.4380.000SVV(%)0.3760.0002021/7/20 星期二51各指標(biāo)對容量負(fù)荷反應(yīng)(SV)的ROC曲線分析AUC95 CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.4340.6510.2070.3810.3130.5170.3360.5390.5830.7910.8050.939AUC=曲線下面積, CI =可信

23、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PAWP2021/7/20 星期二52內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進(jìn)展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)2021/7/20 星期二53CVP/PAWP能反映EVLW嗎?Prospectively study16 pats with septic shock and pul edema (ACCP/SCCM)SAPS II: 56Monitor: PiCCO vs PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hFrom intensive Care Med, 2002,28,712-182021/7/20 星期二54Intensive Care Med, 2002,28,712-18CVP/PAWP能反映EVLW嗎?No2021/7/20 星期二55Intensive Care Med, 2002,28,712-18delta與EVLW相關(guān)性, FB：fluid balanceCV