1、休克與血流動(dòng)力學(xué)監(jiān)測(cè),西安交大紅會(huì)醫(yī)院董恩霞,2024/3/13,2,概念,基本概念　　　休克是不同原因造成急性循環(huán)衰竭致使組織血液灌流不足造成細(xì)胞水平的一種急性氧代謝障礙，導(dǎo)致細(xì)胞及組織器官功能受損的病理過(guò)程的綜合征。,西安交大紅會(huì)醫(yī)院,2024/3/13,3,概念,進(jìn)展概念　　　氧輸送與氧耗（DO2 VO2）　　　氧攝取與氧利用,西安交大紅會(huì)醫(yī)院,2024/3/13,4,概念,更深層理解　　點(diǎn)與線的關(guān)系意義:Occul

2、t shock的早期發(fā)現(xiàn),西安交大紅會(huì)醫(yī)院,2024/3/13,5,休克分類,病因分類血流動(dòng)力學(xué)分類　　　低血容量性休克　　　心源性休克　　　分布性休克　　　梗阻性休克,西安交大紅會(huì)醫(yī)院,2024/3/13,6,西安交大紅會(huì)醫(yī)院,基礎(chǔ)理論,ＳＴＡＲＬＩＮＧ定律及曲線ＡＢＣ理論氧輸送理論,2024/3/13,7,西安交大紅會(huì)醫(yī)院,,,,,ＣO,STARLING 定律,,CVP,2024/3/13,8,西安交大紅會(huì)醫(yī)院,ABC

3、理論,,,PAWP,CI,,,,,,,A,B,C,D,,,,,,2024/3/13,9,西安交大紅會(huì)醫(yī)院,氧輸送監(jiān)測(cè),氧輸送（DO2） DO2 =CI*1.34*Hb*SaO2氧耗（ VO2 ） VO2 =CI*（CaO2-CvO2）,2024/3/13,10,西安交大紅會(huì)醫(yī)院,血流動(dòng)力學(xué)監(jiān)測(cè)目的,維持組織器官灌注和血流動(dòng)力學(xué)穩(wěn)定 -危重病人全身穩(wěn)定的核心/基石 -血流動(dòng)力學(xué)無(wú)處不在血流動(dòng)力學(xué)

4、不穩(wěn)定的評(píng)估 -及時(shí)發(fā)現(xiàn)異常環(huán)節(jié)　指導(dǎo)血流動(dòng)力學(xué)支持治療 -實(shí)現(xiàn)滴定式治療 -監(jiān)測(cè)與治療策略結(jié)合,2024/3/13,11,西安交大紅會(huì)醫(yī)院,血流動(dòng)力學(xué)監(jiān)測(cè)的重點(diǎn),前負(fù)荷　心輸出量心肌收縮力后負(fù)荷　心肌順應(yīng)性微循環(huán)及組織氧合監(jiān)測(cè) 心率等基礎(chǔ)監(jiān)測(cè),2024/3/13,12,西安交大紅會(huì)醫(yī)院,血流動(dòng)力學(xué)－監(jiān)測(cè)方法與進(jìn)展,“重中之重”代表前負(fù)荷與評(píng)估容量反應(yīng)性的指標(biāo)CO的測(cè)量及進(jìn)展微循環(huán)及組織氧合

5、的監(jiān)測(cè),2024/3/13,13,西安交大紅會(huì)醫(yī)院,前負(fù)荷及評(píng)估容量反應(yīng)性,ICU永恒的命題壓力指標(biāo)及容量指標(biāo)靜態(tài)指標(biāo)及動(dòng)態(tài)指標(biāo)容量反應(yīng)性的評(píng)估方法,背景,持續(xù)低血容量液體過(guò)負(fù)荷非最佳容量狀態(tài)應(yīng)用強(qiáng)心藥物容量是血流動(dòng)力學(xué)支持的首選,14,西安交大紅會(huì)醫(yī)院,液體反應(yīng)性,15,PUMCH ICU,瞬間即時(shí),,,2024/3/13,16,西安交大紅會(huì)醫(yī)院,前負(fù)荷及評(píng)估容量反應(yīng)性,壓力指標(biāo)－ＣＶＣ及ＰＡＣ可獲得　CVP　

6、PAWP　研究結(jié)果各異，不佳似乎大于理想,Magder S, Bafaqeeh F. The clinical role of central venous pressure measurements.J intensive care Med 2007;22:44-51Osman D, Ridel C, Ray P, et al: Cardiac filling pressures are not appropriate t

7、o predict hemodynamic response to volume challenge. Crit Care Med 2007;35:295–296,2024/3/13,17,西安交大紅會(huì)醫(yī)院,Elastic band demonstrating the concept of unstressed volume. There is no tension in the wall of the elastic until i

8、t isstretched beyond the resting volume,Crit Care Med 1998; 26:1061-1064,深入認(rèn)識(shí)：CVP與靜脈回流,,,2024/3/13,18,西安交大紅會(huì)醫(yī)院,前負(fù)荷及評(píng)估容量反應(yīng)性,容量指標(biāo)20世紀(jì)80年代后床旁測(cè)定　　 經(jīng)食道心超　左心室舒張末容積等RVEDVI或CEDVI（容積測(cè)量肺動(dòng)脈導(dǎo)管） 研究結(jié)果欠理想2000年后PiCCO 　　GEDV/I

9、TBV—研究結(jié)果較理想,British Journal of Anaesthesia 94 (6): 748–55 (2005),2024/3/13,19,,,,,,,,,,,,,,,右室舒張末容積(RVEDV/CEDV)(pulmonary artery thermodilution)肺動(dòng)脈漂浮導(dǎo)管,左室舒張末面積(LVEDA)(echocardiography)超聲心動(dòng)圖,,,,,Global end-diastolic vo

10、lume (GEDV)全心舒張末容積(transpulmonary thermodilution),胸腔內(nèi)血液容積(ITBV)(thermo-dye transpulmonary dilution)熱－染料雙指示劑法,容量指標(biāo),前負(fù)荷及評(píng)估容量反應(yīng)性,2024/3/13,20,西安交大紅會(huì)醫(yī)院,思 考,應(yīng)用壓力指標(biāo)的原因　　無(wú)奈　　需要容量指標(biāo)好于壓力指標(biāo) 理想？現(xiàn)實(shí)？ 兩者結(jié)合 1＋1＞2 ?,2024

11、/3/13,21,西安交大紅會(huì)醫(yī)院,思 考,壓力指標(biāo)受到越來(lái)越多的質(zhì)疑 以壓力指標(biāo)為指導(dǎo)的治療策略獲得極大成功 EGDT ARDS.net--自由與保守的液體策略,矛盾!?,2024/3/13,22,西安交大紅會(huì)醫(yī)院,前負(fù)荷及評(píng)估容量反應(yīng)性,靜態(tài)指標(biāo) CVP PAOP 回顧性動(dòng)態(tài)指標(biāo) SVV SPV PPV delta-DOWN 等

12、 廣義性及前瞻性 動(dòng)態(tài)指標(biāo)可能有比靜態(tài)指標(biāo)更好的反應(yīng)性 應(yīng)用范圍局限,Homodynamic Evaluation and Monitoring in the ICU CHEST, 2007,132,2020-2029,2024/3/13,23,西安交大紅會(huì)醫(yī)院,容量反應(yīng)性的方法,Fluid challenge (2種方法4點(diǎn)要求)Immediate administrat

13、ion crystalloid or colloid equivalent (eventually repeatable, if indicated） A straight-leg raise（passive leg raising）A goal of obtaining a rise in CVP at least 2 mmHg(CVP≥2mmHg)A positive response

14、 improved cardiac output tissue perfusion,Intensive Care Med (2007) 33:575–590,Vincent JL, Weil MH (2006) Fluid challenge revisited. Crit Care Med 34:1333–1337,2024/3/13,24,容量反應(yīng)性的方法,Crit Care Med 2006 Vo

15、l. 34, No. 5,PLR as a “reversible volume challenge”,,Passive leg raising,2024/3/13,26,西安交大紅會(huì)醫(yī)院,容量反應(yīng)性的方法,呼氣末暫停15秒法 最后5秒測(cè)量SV或CI等,2024/3/13,27,西安交大紅會(huì)醫(yī)院,前負(fù)荷/容量反應(yīng)性和治療策略,目前： CVP為液體復(fù)蘇目標(biāo)的EGDT已有： 以SVV結(jié)合SV為液體復(fù)蘇目標(biāo)的針對(duì)

16、ICU 低血壓和少尿的病人尚沒(méi)有：容量指標(biāo)相關(guān)的治療策略下一步：設(shè)計(jì)以不同容量反應(yīng)性評(píng)估方法為指導(dǎo) 液體復(fù)蘇的臨床研究,動(dòng)態(tài)指標(biāo)結(jié)合策略,2024/3/13,29,西安交大紅會(huì)醫(yī)院,CO的測(cè)量及進(jìn)展,血流動(dòng)力學(xué)監(jiān)測(cè)的關(guān)鍵環(huán)節(jié)CO測(cè)量方法：有創(chuàng)－微創(chuàng)－無(wú)創(chuàng),2024/3/13,30,PUMCH,,,,NiCO,CCO,LiDCO,PiCCO,,,,,Monitor,PAC,,2024/3/1

17、3,31,西安交大紅會(huì)醫(yī)院,CO的測(cè)量方法－有創(chuàng),臨床應(yīng)用成熟CO-TDs Thermodilution CO PAC-CO溫度(熱)稀釋法 CO-染料稀釋法,New England Journal of Medicine (1970),2024/3/13,32,西安交大紅會(huì)醫(yī)院,血流動(dòng)力學(xué)監(jiān)測(cè)革命的第一步,1970年，Ｈ.Ｊ. Ｃ Ｓwan和William Ganz發(fā)明了帶套囊的肺動(dòng)脈漂浮導(dǎo)管 Ｓ

18、wan-Ganz導(dǎo)管 New England Journal of Medicine (1970),2024/3/13,33,西安交大紅會(huì)醫(yī)院,＞,2024/3/13,34,西安交大紅會(huì)醫(yī)院,Swan-Ganz導(dǎo)管,2024/3/13,35,西安交大紅會(huì)醫(yī)院,進(jìn) 步,持續(xù)ＣＯ監(jiān)測(cè)1992連續(xù)溫度稀釋法,2024/3/13,36,西安交大紅會(huì)醫(yī)院,,PAC的作用,______ ___ _________ ______ ___

19、_ ____ __ ________ ____ ______ ______ __ ____ __ ___ ___________ ________ __ _______ _____________ ______ _ ______ _____ __ __ __ _____________ __ _____ _____ _______________ __ ___

20、 _______ ____ __ __________ ___ ________ ____________ _______ ____ __ ____________ _______ ___ ________ __ _________ ______ _________ ___ ___ ____ _____ ________ ___

21、____ __ ________ ________ __ _______ _ ___ ________ ___ ________ ____ ______ ___ __ __ ____ _____ _______________ ___ _______ _____________ __ ________ __________ _______

22、___ _______ __ _____________ _____,higher 30-day mortality higher mean cost of hospital stay longer length of stay in the ICUsignificant increase in cardiac complications 1.Connors AF Jr, Speroff T, Dawson N

23、V,et al. (1996) The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 276:889–897 2 .Mackirdy FL, Howie JC (1997) The relationship between the

24、 presence of pulmonary artery catheters and the case mixed adjusted outcome of patients admitted to Scottish ICU’s. Clin Intensive Care 8:9–133 3.Polanczyk CA, Rohde LE, Goldman L,Cook EF,et al(2001) Right heart c

25、atheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 286:309–314,,2000年前后幾乎被打倒,2024/3/13,37,西安交大紅會(huì)醫(yī)院,PAC的作用,1.危重病人A meta-analysis of the efficacy and safety o

26、f the PAC (13 RCTs； 5,051 patients)neither increased overall mortality or days in hospital nor conferred benefit2.急性肺損傷：ARDS.NETNo difference in mortalityNo differences in time on ventilator, or time in the ICU

27、,最近：不好也不壞,2024/3/13,38,西安交大紅會(huì)醫(yī)院,PAC何時(shí)用？,更公正評(píng)價(jià)－－借專家一句話！,2024/3/13,39,西安交大紅會(huì)醫(yī)院,基本原理：血管系統(tǒng)與心臟每搏量的相互作用,心臟每搏輸出量SV,CO測(cè)量－微創(chuàng),不同的專有計(jì)算公式,2024/3/13,40,西安交大紅會(huì)醫(yī)院,CO測(cè)量－微創(chuàng),經(jīng)肺熱稀釋方法脈搏波形分析,PiCCO,最經(jīng)典內(nèi)容最豐富全面,2024/3/13,41,西安交大紅會(huì)醫(yī)院,PiCCO,中心

28、靜脈注射,右心,左心,肺,PiCCO導(dǎo)管插在股動(dòng)脈內(nèi),2024/3/13,42,西安交大紅會(huì)醫(yī)院,PiCCO與Swan-Ganz熱稀釋導(dǎo)管測(cè)量心輸出量的異同,Swan-Ganz熱稀釋 測(cè)量位置,PiCCO動(dòng)脈熱稀釋測(cè)量位置,2024/3/13,43,西安交大紅會(huì)醫(yī)院,PiCCO的專有公式,,,,“Beat to beat” 連續(xù)測(cè)量CO,,曲線下面積,曲線形態(tài),主動(dòng)脈順應(yīng)性,,,,心率,,校正系數(shù)（經(jīng)肺熱稀釋方法得到）,

29、,CO測(cè)量－微創(chuàng),2024/3/13,44,西安交大紅會(huì)醫(yī)院,CO測(cè)量－微創(chuàng),FLO-Trac/Vigileosystem,簡(jiǎn)單但指標(biāo)少,LiDCO,需要特殊物質(zhì),2024/3/13,45,西安交大紅會(huì)醫(yī)院,CO測(cè)量－微創(chuàng),微創(chuàng)而連續(xù)簡(jiǎn)便易行減少并發(fā)癥時(shí)，是否改善預(yù)后？急需大規(guī)模臨床研究應(yīng)該相當(dāng)有前途,2024/3/13,46,西安交大紅會(huì)醫(yī)院,CO的測(cè)量方法－無(wú)創(chuàng),不易推廣：昂貴；技術(shù)復(fù)雜UCG----USCOMTEE

30、,2024/3/13,47,西安交大紅會(huì)醫(yī)院,USCOM,2024/3/13,48,西安交大紅會(huì)醫(yī)院,,超聲心動(dòng)圖,血流動(dòng)力學(xué)評(píng)估全面無(wú)創(chuàng),2024/3/13,49,西安交大紅會(huì)醫(yī)院,CO的測(cè)量方法－無(wú)創(chuàng),ICG-CO　阻抗法--NICOMFICK METHOD—NICO System,尚不成熟,2024/3/13,50,西安交大紅會(huì)醫(yī)院,CO監(jiān)測(cè)應(yīng)用臨床現(xiàn)狀,PAC的局限性—相對(duì)的金指標(biāo)微創(chuàng)方法的春天 －以PiCCO為代表

31、無(wú)創(chuàng)方法在期待未來(lái),2024/3/13,51,西安交大紅會(huì)醫(yī)院,CO測(cè)量方法的選擇,相關(guān)技術(shù)知識(shí)方便/安全準(zhǔn)確性可以獲得其他血流動(dòng)力學(xué)指標(biāo)目前微創(chuàng)化無(wú)創(chuàng)化全面化趨勢(shì)明顯,2024/3/13,52,西安交大紅會(huì)醫(yī)院,CO監(jiān)測(cè)何時(shí)用？,何時(shí)應(yīng)用CO監(jiān)測(cè)－現(xiàn)有的推薦意見(jiàn) 不常規(guī)推薦應(yīng)用CO測(cè)量或監(jiān)測(cè) 在臨床有明顯心衰證據(jù)同時(shí)有診斷需要時(shí)應(yīng)用 盡管充足液體復(fù)蘇后依然持續(xù)休克時(shí),2024/3/13,5

32、3,西安交大紅會(huì)醫(yī)院,CO監(jiān)測(cè)的未來(lái)研究方向,哪種CO測(cè)量方法最佳－影響預(yù)后 PiCCO為代表的微創(chuàng)方法是否能帶來(lái)良好預(yù)后？以CO為血流動(dòng)力學(xué)治療目標(biāo)可以改善預(yù)后嗎？CO的監(jiān)測(cè)治療對(duì)不同種類的血流動(dòng)力學(xué)不穩(wěn)定的影響？,2024/3/13,54,西安交大紅會(huì)醫(yī)院,組織氧合及微循環(huán)水平監(jiān)測(cè)－微觀代謝水平,PH和BELAC（乳酸）及LAC清除率SVO2/SCVO2（混合或中心靜脈血氧飽和度） -持續(xù)監(jiān)測(cè) -定義整體心

33、血管功能充足性的金標(biāo)準(zhǔn),2024/3/13,55,西安較大紅會(huì)醫(yī)院,LAC清除率,There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance.Patients with a lactate clearance >10% had a greater decrease in APA

34、CHE II score over the 72-hr study period and a lower 60-day mortality rate (p .007).,2024/3/13,56,西安交大紅會(huì)醫(yī)院,SVO2SCVO2,Arterial and venous oxygen saturations in various vascular regions,,,,,2024/3/13,57,西安交大紅會(huì)醫(yī)院,SvO2 i

35、ndicator of the VO2 / DO2 balance,a low SvO2 must incite clinicians to increase DO2 (mainly through CO increase),,2024/3/13,58,西安交大紅會(huì)醫(yī)院,,,,2024/3/13,59,西安交大紅會(huì)醫(yī)院,SVO2/SCVO2監(jiān)測(cè)相關(guān)的治療策略,SVO2相關(guān)的治療策略,2024/3/13,60,西安交大紅會(huì)醫(yī)院,SVO2

36、/SCVO2監(jiān)測(cè)相關(guān)的治療策略,ScVO2----EGDT治療策略樹(shù),,2024/3/13,61,西安交大紅會(huì)醫(yī)院,,,,容量--流量評(píng)價(jià),正常 2 to 5 mmHg 不能作為組織缺氧的標(biāo)記 DeltaPCO2 can be considered as a marker of the adequacy of venous blood flow (i.e. cardiac output) to rem

37、ove the total CO2 produced by the peripheral tissues 有助于指導(dǎo)以CO為目標(biāo)的液體治療,Lamia B, Monnet X, Teboul JL. Meaning of arterio-venous PCO2 difference in circulatory shock. Minerva Anestesiol. 2006 Jun; 72(6): 597-604.,P(cv-a

38、)CO2-- a useful tool,,,SCVO2與乳酸的結(jié)合,,容量--流量評(píng)價(jià),2024/3/13,64,西安交大紅會(huì)醫(yī)院,組織氧合及微循環(huán)水平監(jiān)測(cè)－－ Macroscopic level,From Toe temperature to OPSGastric tonometry Sublingual capnometry Laser Doppler flowmetry(mucosal perfusion)Indocy

39、anine green clearance Near-infrared spectroscopy (NIRS).OPS（orthogonal polarization spectral imaging） 正交極化光譜圖像 光源轉(zhuǎn)換為550nm 血紅蛋白為吸光點(diǎn)－天然造影劑,臨床評(píng)估非常重要 皮膚溫度 外周灌注指數(shù),2024/3/13,65,西安交大紅會(huì)醫(yī)院,OPS,2024

40、/3/13,66,西安交大紅會(huì)醫(yī)院,OPS圖像,正 常,Septic ShockMale 47 YMAP 68 mmHg, lactate 3.6 mEq/Ldopa 20 , ne 0.13,2024/3/13,67,西安交大紅會(huì)醫(yī)院,,血流動(dòng)力學(xué)監(jiān)測(cè)其他重要內(nèi)容,心肌收縮性 ---來(lái)源于PiCCO/心臟超聲后負(fù)荷血管外肺水/肺血管通透性指數(shù) ---EVLW/PVPI,2024/3/13,68,

41、西安交大紅會(huì)醫(yī)院,,,,,,Contractility is a measure for the performance of the heart muscle 心肌收縮性是流量監(jiān)測(cè)CO的必須補(bǔ)充,Contractility parameters of PiCCO technology: dPmx (maximum rate of the increase in pressure) GEF (Global Ejection

42、Fraction) CFI (Cardiac Function Index),心肌收縮性,,kg,kg,2024/3/13,69,西安交大紅會(huì)醫(yī)院,,,,,,來(lái)源于脈搏輪廓分析的心肌收縮性參數(shù),dPmx = maximum velocity of pressure increase,dPmx代表了左心室壓力上升的最大速度,,心肌收縮性,2024/3/13,70,西安交大紅會(huì)醫(yī)院,,,,,,,,,反映全心收縮性,,,,,GEF = G

43、lobal Ejection Fraction,來(lái)源于熱稀釋法的心肌收縮性參數(shù),4 x SV,,GEF =,GEDV,,LA,LV,RA,RV,,,,心肌收縮性,2024/3/13,71,西安交大紅會(huì)醫(yī)院,,與 GEF 相似 全心收縮性參數(shù),,,,,,CI,,CFI =,GEDVI,心肌收縮性,來(lái)源于經(jīng)肺熱稀釋法的心肌收縮性參數(shù)CFI = Cardiac Function Index心臟功能指數(shù),2024/3/13,72,西安交大紅

44、會(huì)醫(yī)院,,心血管狀態(tài)信息的重要 控制容量和血管活性藥物應(yīng)用的重要決定因素,(MAP – CVP) x 80,,SVR =,CO,,,后負(fù)荷,SVR = Systemic Vascular Resistance,MAP = Mean Arterial PressureCVP = Central Venous PressureCO = Cardiac Output80 = Factor for correction of unit

45、s,2024/3/13,73,西安交大紅會(huì)醫(yī)院,,血流動(dòng)力學(xué)監(jiān)測(cè)的別樣選擇,-------來(lái)源于 PiCCO 技術(shù)的EVLW和PVPI,血管外肺水 Extravascular Lung Water（EVLW）肺血管通透性指數(shù) Pulmonary vascular Permeability (PVPI),2024/3/13,74,西安交大紅會(huì)醫(yī)院,,,ITTV – ITBV

46、= EVLW,Extravascular Lung Water (EVLW)的計(jì)算,,,,2024/3/13,75,西安交大紅會(huì)醫(yī)院,,,,PVPI肺血管通透性指數(shù),,區(qū)分肺水腫類型 靜水壓增高型 通透性增高型,EVLW,,PVPI =,PBV,,,,,,,,,,,PBV,EVLW,ECHO-HEMO PTOTOCOL,長(zhǎng)軸、圓周收縮,CO,PAWP,液體治療,強(qiáng)心治療,滴定治