微循環(huán)與血管活性藥

Sepsis微循環(huán)

與血管活性藥奚佳瑞2011年2月5/8/20241微循環(huán)與血管活性藥引言Sepsis：疑問：臨床上血流動力學(xué)穩(wěn)定、氧傳遞指標(biāo)等均可，但依然進(jìn)展、乳酸升高？早期亦已存在微循環(huán)功能障礙??！

5/8/20242微循環(huán)與血管活性藥引言微循環(huán)：如此重要、關(guān)鍵應(yīng)成為危重患者復(fù)蘇中的一個關(guān)鍵指標(biāo)但：傳統(tǒng)的評價指標(biāo)難以準(zhǔn)確評價微循環(huán)！5/8/20243微循環(huán)與血管活性藥主要問題：1.有什么新的方法監(jiān)測微循環(huán)？2.現(xiàn)有血管活性藥物微循環(huán)的影響如何？5/8/20244微循環(huán)與血管活性藥微循環(huán)的結(jié)構(gòu)直徑<300um的血管100億個毛細(xì)血管血管表面積>500m2組成：微動脈，后微動脈，毛細(xì)血管前括約肌，真毛細(xì)血管、通血毛細(xì)血管、動靜脈交通支、微靜脈

5/8/20245微循環(huán)與血管活性藥微循環(huán)的功能及分類1.迂回通路：物質(zhì)交換，交替開放（又稱營養(yǎng)通路）2.直捷通路：不進(jìn)行物質(zhì)交換，血液快速回流，骨骼肌多見3.動靜脈短路：不進(jìn)行物質(zhì)交換，皮膚多見5/8/20246微循環(huán)與血管活性藥5/8/20247微循環(huán)與血管活性藥Sepsis時微循環(huán)的改變1994年，LamC等對血壓穩(wěn)定的鼠sepsis微循環(huán)活體顯微鏡在體觀察，發(fā)現(xiàn)sepsis時：1.灌注毛細(xì)血管密度減少，血流停止的毛細(xì)血管數(shù)增加；2.灌注毛細(xì)血管空間分布不均，平均毛細(xì)血管間距增加2002年，DeBacker等利用OPS成像觀察sepsis舌下微循環(huán)，發(fā)現(xiàn)：1.微血管密度顯著減少，血流停滯和血流灌注間斷的小血管比例增加；2.各區(qū)域間灌注血管的變異系數(shù)明顯大于健康志愿者

DeBackerD,CreteurJ,PreiserJC,etal.Microvascularbloodflowisalteredinpatientswithsepsis.AMJRespirCritCareMed,2002,166:98-1045/8/20248微循環(huán)與血管活性藥

OPS圖像5/8/20249微循環(huán)與血管活性藥Sepsis時微循環(huán)的改變特征：1.adecreaseincapillarydensity2.anincreaseinheterogeneityofperfusionwithnon-perfusedinclosevicinitytowell-perfusedcapillaries后果？5/8/202410微循環(huán)與血管活性藥Tissuestoleratebetterahomogeneous

decreaseinbloodflowbetterthanaheterogeneousoneDanielDeBacker，GustavoOspina-Tascon，etal.IntensiveCareMed(2010)36:1813–1825.5/8/202411微循環(huán)與血管活性藥5/8/202412微循環(huán)與血管活性藥HowtoevaluatethemicrocirculationIntensiveCareMed(2010)36:1813–1825.5/8/202413微循環(huán)與血管活性藥NailfoldvideocapillaroscopyThefirstmethodusedatthebedsidethenailfoldareaisverysensitivetochangesintemperature:onecancontrolambientbutnotbodytemperature.PeripheralvasoconstrictioncanalsooccurduringchillsandacutecirculatoryfailureOflimiteduseincriticallyillpatients.5/8/202414微循環(huán)與血管活性藥LaserDopplerMainlimitation：measuresflowinavariablevolumeoftissue，unabletodetectitinindividualvesselsSamplingvolume:0.5and1mm3,about50vesselsCannotshowtheheterogeneity5/8/202415微循環(huán)與血管活性藥SvO2VenousO2saturationcanbehighorlowforthesamedegreeofmicrovascularshunting—canbemisleadingSeveralstudieshaveshownthatmeasuringSvO2doesnotprovidemuchinformationaboutmicrovascularalterations---PodbregarM,MozinaH.Skeletalmuscleoxygensaturationdoesnotestimatemixedvenousoxygensaturationinpatientswithsevereleftheartfailureandadditionalseveresepsisorsepticshock.CritCare2007,11:R6MarikPE,BankovA,Sublingualcapnometryversustraditionalmarkersoftissueoxygenationincriticallyillpatients.CritCareMed2003,31:818–8225/8/202416微循環(huán)與血管活性藥GastrictonometryAgastricPCO2gapabove20mmHgdiscriminatedsurvivorsfromnon-survivors-------LevyB,GawalkiewiczP.CritCareMed2003,31:474–48

GastricPCO2gap---mostlyreflectsgutmucosalmicrocirculation----Insepsis,nocorrelationbetweenthegastricPCO2gapandtotalsplanchnicperfusionDuodeno-gastricrefluxandfeedingcaninterfere5/8/202417微循環(huán)與血管活性藥LactateTimelag-------Cannotdetectalterationsinmicrovascularperfusionbeforetheyareassociatedwithcellularhypoxia5/8/202418微循環(huán)與血管活性藥OPS/SDFOPS成像：正交偏振光譜成像orthogonalpolarizationspectralimaging原理：利用血細(xì)胞對偏振入射綠光產(chǎn)生消偏振光散射和對正偏振光的成像特征，能在皮下0.5mm深度內(nèi)產(chǎn)生高清晰度和高分辨率的成像。局限性：敏感性偏差；需具備高能光源，難以應(yīng)用到臨床。5/8/202419微循環(huán)與血管活性藥OPS/SDFSDF成像：旁流暗場成像，sidestreamdark-field，2007年開始應(yīng)用于臨床優(yōu)點(diǎn)：更加清晰所需能量小，可以方便的使用電池床邊操作

5/8/202420微循環(huán)與血管活性藥SDFimage5/8/202421微循環(huán)與血管活性藥OPS/SDFAdvantage:1.visible2.differentvariablescanbeobservedandbemeasured---vasculardensity,heterogeneityofperfusion,microvascularbloodflowTheconsensusadvisesreportingofPVD,PPV,MFIandheterogeneityindex,inordertodescribethefunctionalperfusionofthemicrocirculation.-------Howtoevaluatethemicrocirculation:reportofaroundtableconference,CriticalCare2007,11:R101

5/8/202422微循環(huán)與血管活性藥血管活性藥物對微循環(huán)的影響Vasopressors:Norepinephrine,Epinephrine,VasopressinInotropes:Dopamine,Dobutamine,Vasodilators:Nitroglycerin,Prostacyclin5/8/202423微循環(huán)與血管活性藥NEdoesnotimprovemicrocirculatorybloodflow20septicshockpatientsBasalmeasurementofMAP65mmHg,NEwastitratedtoreachaMAPof75mmHg,then85mmHgSublingualmicrocirculationwasevaluatedbySDFimagingDubinA,PozoMO,etal.Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudy.Critcare,2009,13(3):R925/8/202424微循環(huán)與血管活性藥NEdoesnotimprovemicrocirculatorybloodflow5/8/202425微循環(huán)與血管活性藥NEdoesnotimprovemicrocirculatorybloodflow5/8/202426微循環(huán)與血管活性藥NEdoesnotimprovemicrocirculatorybloodflow1.NEdoesnotimprovemicrocirculataryperfusionfurtherincreaseMAPfrom65mmHg.2.ReductionsintheperfusedcapillarydensitiesfurtherincreaseMAPfrom65mmHg.結(jié)論：使用去甲升高M(jìn)AP并不是改善感染性休克患者微循環(huán)的一個恰當(dāng)方法，反而可能對患者有害。5/8/202427微循環(huán)與血管活性藥TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshock16septicshockpatientsNEfrom0.18to0.25,0.35,0.41ug/kg.minMAPfrom60-70-80-90mmHgSDFimaging

ShamanJhanji,etal.CritcareMed2009;37:1961-19665/8/202428微循環(huán)與血管活性藥TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshockMAP高于60-65mmHg不能改善感染性休克患者微循環(huán)增加NE對感染性休克患者微循環(huán)無明顯影響

ShamanJhanji,etal.CritcareMed2009;37:1961-19665/8/202429微循環(huán)與血管活性藥多巴胺對微循環(huán)的影響1.1Meier-HellmannA,BredleDL,SpechtM,SpiesC,HannemannL,ReinhartK(1997)Theeffectsoflow-dosedopamineonsplanchnicbloodflowandoxygenuptakeinpatientswithsepticshock.IntensiveCareMed23:31–371.2OlsonD,PohlmanA,HallJB(1996)Administrationoflow-dosedopaminetononoliguricpatientswithsepsissyndromedoesnotraiseintramucosalgastricpHnorimprovecreatinineclearance.AmJRespirCritCareMed154:1664–16702.MarikPE,MohedinM(1994)Thecontrastingeffectsofdopamineandnorepinephrineonsystemicandsplanchnicoxygenutilizationinhyperdynamicsepsis.JAMA272:1354–13575/8/202430微循環(huán)與血管活性藥NG對微循環(huán)的影響5/8/202431微循環(huán)與血管活性藥NGinsepticshockafterintravascularvolumeresuscitation8septicshockpatientsMAPwasgreaterthan60mmHgandCVPgreaterthan12mmHgafterinfusionofcrystalloidsandcolloids,andthelowestpossibledoseofdopamineNG：anintravenousloadingdoseof0·5mg,thensubsequentcontinuousinfusionof2mg/hOPS：usedtoproduceimagesofsublingualmicrocirculationLancet2002;360:1395-13965/8/202432微循環(huán)與血管活性藥NGinsepticshockafterintravascularvolumeresuscitation5/8/202433微循環(huán)與血管活性藥OPSimages5/8/202434微循環(huán)與血管活性藥70個Severesepsis和septicshock患者充分復(fù)蘇后給予硝酸甘油或安慰劑SDF評估舌下微循環(huán)主要終點(diǎn)：sublingualmicrocirculatorybloodflowofsmallvesselsCritCareMed2010;38:93-1005/8/202435微循環(huán)與血管活性藥Microvascularvariablesovertime5/8/202436微循環(huán)與血管活性藥TakeHomeMessage1.重視微循環(huán)檢測2.s