危重病微循環(huán)障礙課件

危重病與微循環(huán)

KroghA．(1929)《毛細(xì)血管的解剖和生理》(TheAnatomyandPhysiologyofCapillaries)“毛細(xì)血管是血液和組織間物質(zhì)交換的器官”(…anorganforinterchangeOfsubstancesbe—tweenthebloodandthetissues：thecapillaries)田牛.微循環(huán)學(xué)雜志，1994.1

直接參與組織、細(xì)胞的物質(zhì)、信息、能量傳遞的血液、淋巴液、組織液的流動(dòng)稱之為微循環(huán)。微循環(huán)的本質(zhì)屬性SIRS的臨床特征心輸出量的增加、全身血管阻力的降低動(dòng)靜脈氧分壓差縮小血乳酸水平增加反映細(xì)胞對(duì)氧(或底物)的利用障礙。用于產(chǎn)生細(xì)胞必需能量的氧和底物的輸送或利用障礙可導(dǎo)致SIRS,并形成MODs微循環(huán)障礙的監(jiān)測(cè)血乳酸SVO2BEDO2，VO2Creteur.CurrOpinCritCare.2008Jun;14(3):361-6.

TheprognosticvalueofmuscleStO2incriticallyillpatientsSUMMARY:Near-infraredspectroscopyprovidesanoninvasivemeasureofmuscleoxygenmetabolismandmicrovasculardysfunctionincriticallyillpatients.ItmaybeusefultoguidethemanagementofPtCO2加熱的氧電極直接置于患者胸骨旁2、3肋間正常皮膚上來測(cè)定PtC02。無創(chuàng)性、續(xù)監(jiān)測(cè)組織氧合。Ptc02測(cè)定的是傳感器下面皮膚組織的P02。組織氧張力除了受PaO2影響外，還受組織血液灌注量的影響。組織血液灌注量正常時(shí)，Ptc02與PaO2具有非常好的相關(guān)性。FifeCE;SmartDR;UnderseaHyperbMed.2009V36N1:43-53

Transcutaneousoximetryinclinicalpractice:consensusstatementsfromanexpertpanelbasedonevidence.

IntensiveCareMed.2009Jun;35(6):1106-9.Epub2009Jan29.

Thenaroxygensaturationmeasuredbynearinfraredspectroscopyasanoninvasivepredictoroflowcentralvenousoxygensaturationinsepticpatients.

MesquidaJ,MasipJ,GiliG,ArtigasA,BaigorriF.《2008年嚴(yán)重膿毒癥與膿毒癥休克治療國(guó)際指南》建議僅在成年膿毒癥休克患者對(duì)容量復(fù)蘇和血管活性藥物反應(yīng)差時(shí)靜脈給予氫化可的松(推薦級(jí)別2C)Theeffectofincreasingdosesofnorepinephrineontissueoxygenationandmicrovascularflowinpatientswithsepticshock*ShamanJhanji,CritCareMed2009Vol.37,No.6方法N=16cardiacoutputcutaneoustissuePtO2usingaClarkelectrodecutaneousredbloodcellfluxusinglaserDopplerflowmetry,Sublingualmicrovascularflowusingsidestreamdarkfieldimaging.

ShamanJhanji,CritCareMed2009Vol.37,No.6

ShamanJhanji,CritCareMed2009Vol.37,No.6

ShamanJhanji,CritCareMed2009Vol.37,No.6ShamanJhanji,CritCareMed2009Vol.37,No.6

Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudyArnaldoDubinCriticalCare2009,13:R92方法N=20Sublingualmicrocirculationwasevaluatedbysidestreamdarkfield(SDF)imagingDO2andVO2,lactate,albumin-correctedaniongap,gastricintramucosal-arterialPCO2difference(ΔPCO2).ArnaldoDubin.CriticalCare2009,13:R92

ArnaldoDubin.CriticalCare2009,13:R92

ArnaldoDubin.CriticalCare2009,13:R92ArnaldoDubin.CriticalCare2009,13:R92

ArnaldoDubin.CriticalCare2009,13:R92

《2008年嚴(yán)重膿毒癥與膿

毒癥休克治療國(guó)際指南》

NE為糾正膿毒癥休克低血壓首選的一線血管升壓藥,

1C級(jí),

無在膿毒癥治療中選擇何種兒茶酚胺類藥物的最終建議TheeffectsofdobutamineonmicrocirculatoryalterationsinpatientswithsepticshockareindependentofitssystemiceffectsDanielDeBacker,CritCareMed2006Vol.34,No.2方法Intravenousadministrationofdobutamine(5g/kg·min)for2hrs(n

22)followedbytheadditionof102Macetylcholine(topicallyapplied,n

10).Hemodynamicmeasurementssublingualmicrocirculationwasinvestigatedwithanorthogonalpolarizationspectralimagingtechniquebeforeandafterdobutamineadministrationandaftertopicalapplicationofacetylcholine.Dobutamine

DanielDeBacker,CritCareMed2006Vol.34,No.2DanielDeBacker,CritCareMed2006Vol.34,No.2DanielDeBacker,CritCareMed2006Vol.34,No.2不同液體復(fù)蘇條件下多巴酚丁胺對(duì)腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulosSuzanaMLoboDanielDeFigure1Changesofarteriallactateconcentrationineachgroup不同液體復(fù)蘇條件下多巴酚丁胺對(duì)腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulosSuzanaMLoboDanielDeChinCritCareMed,Feb.2005,Vol.17,No12Figure2ChangesofPtaCO2gapineachgroup不同液體復(fù)蘇條件下多巴酚丁胺對(duì)腸缺血再灌注休克的療效比較

涂自智孫慶華GeorgeDimopoulosSuzanaMLoboDanielDeChinCritCareMed,Feb.2005,Vol.17,No12Figure3ChangesofintestinalintramucosalpHineachgroupEffectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4orthogonalpolarizationspectraldevicewasusedtoinvestigatethesublingualmicrocirculationthefirstdose(50mg)ofhydrocortisoneand1,2,4,and24hourslaterGlobalhemodynamicvariablesweresimilaratallstudytimepoints.Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock

GustavoLuizBuCritCareMed2009Vol.37,No.4Effectsofhydrocortisoneonmicrocirculatoryalterationsin

patientswithsepticshock*

GustavoLuizBu¨cheleCritCareMed2009Vol.37,No.4Figure2.Evolutionofmicrocirculationvariablesduringstudytimeperiods.Perfusedsmallvessels.

Theeffectofstoragetimeofhumanredcellsonintestinal

icrocirculatoryoxygenationinaratisovolemicexchangemodel*

N.J.Raat,PhD;A.J.Verhoeven,PhD;E.G.Mik,MSc;C.W.

IsovolemicexchangewithfreshandintermediateredbloodcellsmaintainedPO2whereasoldcellsdecreasedPO2with26%.Subsequenttransfusionwithredbloodcells(hematocrit60%)untilreachingahematocritof32.4

%(n

24)increasedintestinalPO2inallthreegroupstothesameextentbetween28%and32%.

Effectsofpropofolonhumanmicrocirculation

M.Koch1,BritishJournalofAnaesthesia101(4):473–8(2008)15patientsanaesthetizedbypropofolfortransvaginaloocyteretrieval.Thesublingualmicrocirculatorynetworkw