休克患者血容量的监测进展课件.ppt

1、杨 毅东南大学医学院附属中大医院ICU 东南大学急诊与危重病医学研究所,休克患者血容量的监测进展,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,休克的概念,感染、创伤、烧伤等 引起有效循环血量明显减少 组织器官的灌注不足 氧输送不能满足组织代谢需要 导致组织缺氧 代谢障碍和细胞受损 临床综合征,休克治疗的首要任务： 积极、合适补充血容量,休克发生的始动因素： 有效循环血量下降,合适的容量管理,容量管理的基本目标,保证容量合适的心脏前负荷,预防肺水肿,二者必须平衡,内容简介,容量管理的基本目标 容量监测的现状及局限性 容

2、量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,容量监测的现状,容量监测：TEE，CT，核素扫描 临床表现: 血压、心率、尿量、皮肤粘膜等 压力监测：漂浮导管(CVP/PAWP),心脏前负荷：VEDV,RVEDP/LVEDP的测定,压力反映容量及肺水肿的局限性,心脏顺应性 瓣膜功能 肺毛细血管通透性 机械通气对循环的影响,PAC对容量监测的 有效性和可信性受到置疑？,许多文献：CVP/PAWP 不能准确反映容量状态,Principle of EVLW measurement,RAEDV,LAEDV,LVEDV,PBV,RVEDV,EVLW,Injection,Picco Th

3、ermo-dilution catheter,Swan-ganz catheter,呼吁容量指标的应用 来反映容量状态及肺水肿,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,A physiological system model,ITTV : Intrathoracic total volume,GEDV : Global end-diastolic volume,ITBV : Intrathoracic blood volume,PTV : Pulmonary total volume,EVLW : extra-p

4、ulmonary lung water,胸內总容量,全心舒张期血容量,胸內血液容量,肺部容积,血管外肺水,容量指标的应用,胸腔内血管容量(ITBV) 血管外肺水(EVLW) 搏出量变异率(SVV),胸腔内血管容量(ITBV),左心舒张末期容量右心舒张末期容量肺血容量,搏出量变异率(SVV),SVV=(SVmax SVmin)/SVmean Svmax:mean value of four SVmax/30s SVmin :mean value of four SVmin/30s SVmean,血管外肺水组成(EVLW),细胞内液 间质液体 肺泡内液体,内容简介,管理的基本目标 容量监测的现状及

5、局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,ITBVvalid estimate of preload in ALI,Prospective animal study 15 sheep with ALI -saline washout MV(PEEP 0,7,14,21 respectively 60min) Measurement: LVEF,LVEDV-CT scan ITBV,RVEDV-PiCCO CVP,PAWP-PAC,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,Luecke T, e

6、t al. Intensive Care Med, 2004, 30: 119-126,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,ITBV and RVEDV Provide valid estimate of preload Even at high intrathoracic pressure,ITBV-indicator of preload in liver transplantation,60 patients undergoing Liver transplantation monitored with PiCCO

7、 and PAC the correlation between PAOP and ITBVI with respect to CI and SVI the correlation between ITBVI and PAOP,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - more reliable indicator of preload than PAWP,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - valid i

8、ndicator of preload in lung transplantation,50 patients during lung transplantation Time: 6 phase during operation Correlation between PAWP and SVI Correlation between ITBVI and SVI Correlation between (Delta) ITBVI PAWP and Delta SVI Delta were calculated by subtracting the first from the second me

9、asurement Della RG, et al. Anesth Analg. 2002 , 95: 835-43,ITBV- superior than PAWP in preload,Della RG, et al. Anesth Analg. 2002 , 95: 835-43,Correlation of ITBV - SV in 4 phases,No correlation of PAWP - SV in any phases,Prospective, controlled, clinical study 18 patients with ejection fraction 50

10、% undergoing coronary artery bypass graft surgery A baseline measurement :after induction of anesthesia (T1) treated by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) After 10 minutes, a second measurement (T2) was performed,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,ITBV cor

11、related significantly with CI and SV IN CABG,ITBV has Good relationship between CI/SVI, CVP/ PCWP 与 CI/SV无相关性, ITBV 与 CI的相关性r = 0.55, ITBV 与 SV的相关性为r = 0.62,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,前瞻性临床研究 40例心脏移植术后患者 男34例，女6例 观察术后3、6、12、24、36、48、72h ITBV/GEDV和CVP/PAWP与SV的相关性,ITB

12、V/GEDV-good preload indicator in heart transplantation,Goedje O, et al. Chest, 2000, 118: 775-781,Goedje O, et al. Chest, 2000, 118: 775-781,Goedje O, et al. Chest, 2000, 118: 775-781,GEDV-SV: R2=0.4016 ITBV-SV: R2=0.2979,Goedje O, et al. Chest, 2000, 118: 775-781,PAWP-SV: R2=0.0043 CVP-SV: R2=0.055

13、2,ITBV的改变反映肺水含量,Prospectively study 16 patients with septic shock and pulmonary edema(ACCP/SCCM) SAPS II: 56 Monitor: Picco,PAC Optimal PAWP: CI no longer increased Monitor time: 0, 24hIntensive Care Med, 2002,28,712-18,From intensive Care Med, 2002,28,712-18,CVP与EVLW的相关性,PAWP与EVLW的相关性,Correlation b

14、etween ITBV/TEDV and EVLW,From intensive Care Med, 2002,28,712-18,ITBV 与 EVLW有良好相关性 优于 CVP 与 PAWP,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,SVV可以反映机体前负荷,Prospective study 20 MV patients following cardiac surgery Volume loading(HES 20ml*BSA/10min) Measurement: CVP, PAWP-PAC LVEDAI-

15、TEE ITBV, SVV-PiCCO,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,血流动力学监测,SVV may help to determine the preload condition,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,CVP/PAWP not correlated with CI,SVV may help to determine the preload condition,Reuter DA, et al. Intensive Care M

16、ed. 2002, 28: 392-8.,CVP not correlated,SVV反映机体对容量治疗的反应,15例脑外科手术患者 麻醉诱导后 容量负荷实验： 100 mL of 6% hydroxyethylstarch given for 2 min 分组：responsive: SV5%nonresponsive: SV5% A total of 140 VLSs were performed,Anesth Analg. 2001, 92: 984-9,两组负荷试验前血流动力学状态,Response(70) nonresponse(70) P HR 76 75 NS SBP 102 1

17、16 0.001 CVP 9.3 9.3 NS SVV 12.6 6.8 0.001,Anesth Analg. 2001, 92: 984-9,两组负荷试验后血流动力学改变,Response(70) nonresponse(70) PHR -1 -1 NS SBP 9 2 0.001 CVP 9.8 11.9 NS SVV -25.8 -10 0.001,Anesth Analg. 2001, 92: 984-9,以上指标与SV改变的相关性,Pearsons correlation P HR 0.142 NS SBP -0.448 0.001 SV -0.372 0.001 CVP 0.05

18、5 NS SVV 0.722 0.001 HR -0.089 NS SBP 0.472 0.001 CVP -0.084 NS SVV -0.505 0.001,Anesth Analg. 2001, 92: 984-9,Responsive VLS: SVV/SV有较高的特异性和敏感性,Anesth Analg. 2001, 92: 984-9,SVV对失血性休克犬容量状态的评价,成年健康杂种犬共14只，体重12.11.1公斤,复制犬失血性休克模型 稳定30分钟，改良的 Wiggers法制备失血性休克犬模型 适当放血维持MAP在50 mmHg左右并稳定60分钟，模型成功,容量负荷试验 2分钟

19、内快速滴入林格氏液7ml.kg-1 15分钟后重复，记录容量负荷前及后5分钟的监测指标,分组 SV是否大于容量负荷试验前SV的5分为两组 反应组 (SV5)无反应组 (SV5) 直至连续两次SV均小于容量负荷试验前的5%时终止实验,监测指标 HR MAP PiCCO监测仪: CO、ITBVI 、SV 、SVV Swan-Ganz导管:CO、CVP、PAWP,共进行容量负荷试验134次，每只犬平均9.61.7次， 其中94次为反应组，40次为无反应组,容量负荷实验前各指标的比较,P 0.05,容量负荷试验前各指标与SV的相关性,容量负荷试验前后各指标的变化与SV的相关性,各指标对容量负荷反应(S

20、V)的ROC曲线分析,AUC=曲线下面积, CI =可信区间,SVV大于9.5时，对容量评价的敏感性为92.6，特异性为62.5。,SVV和ITBVI可用于容量状态的评价 优于HR、MAP、CVP和PAWP,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,CVP/PAWP能反映EVLW吗?,Prospectively study 16 pats with septic shock and pul edema (ACCP/SCCM) SAPS II: 56 Monitor: PiCCO vs PAC Optimal PAW

21、P: CI no longer increased Monitor time: 0, 24hFrom intensive Care Med, 2002,28,712-18,Intensive Care Med, 2002,28,712-18,CVP/PAWP能反映EVLW吗? No,Intensive Care Med, 2002,28,712-18,delta与EVLW相关性, FB：fluid balance,CVP/PAWP能反映EVLW吗? No,肺水含量是ARDS的预后指标,Retrospective analysis 373 ICU pats in university hosp

22、1996-2000 Picco Two groups Survivors Non-survivors,Sakka SG, et al. Chest, 2002, 122: 2080-2086,记录和观察指标 两组EVLW的最大值(211例在入院后24h内)EVLW与SAPS II、APACH II、SOFA比较预后价值,肺水含量与病死率正相关,Sakka SG, et al. Chest, 2002, 122: 2080-2086,肺水含量是ARDS的预后指标,EVLW反映疾病严重程度,Sakka SG, et al. Chest, 2002, 122: 2080-2086,肺水含量是ARDS

23、的预后指标,EVLW 指导脱离呼吸机,101 patients with pulmonary edema End point of two groups PAWP18mmHg EVLW7ml/kgAM Rev Respir Dis, 1992,145:990-998,不同指标对MV/ICU时间的影响,AM Rev Respir Dis, 1992,145:990-998,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,小 结,容量指标可以较好反映机体前负荷及肺水肿状态 压力指标需要慎重对待，动态评价 呼吁更多的研究及监测手段,谢谢,