休克与血流动力学监测

休克与血流动力学监测西安交大红会医院董恩霞**概念 基本概念　　　休克是不同原因造成急性循环衰竭致使组织血液灌流不足造成细胞水平的一种急性氧代谢障碍，导致细胞及组织器官功能受损的病理过程的综合征。西安交大红会医院**概念 进展概念　　　氧输送与氧耗（DO2VO2）　　　氧摄取与氧利用西安交大红会医院**概念 更深层理解　　点与线的关系 意义:Occultshock的早期发现西安交大红会医院**休克分类 病因分类 血流动力学分类　　　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红会医院**西安交大红会医院基础理论 ＳＴＡＲＬＩＮＧ定律及曲线 ＡＢＣ理论 氧输送理论**西安交大红会医院ＣOSTARLING定律CVP**西安交大红会医院ABC理论PAWPCIABCD**西安交大红会医院氧输送监测 氧输送（DO2）DO2=CI*1.34*Hb*SaO2 氧耗（VO2） VO2=CI*（CaO2-CvO2） **西安交大红会医院血流动力学监测目的 维持组织器官灌注和血流动力学稳定-危重病人全身稳定的核心/基石-血流动力学无处不在 血流动力学不稳定的评估-及时发现异常环节　 指导血流动力学支持治疗-实现滴定式治疗-监测与治疗策略结合**西安交大红会医院血流动力学监测的重点 前负荷　 心输出量 心肌收缩力 后负荷　 心肌顺应性 微循环及组织氧合监测 心率等基础监测**西安交大红会医院血流动力学－监测方法与进展“重中之重” 代 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 前负荷与评估容量反应性的指标 CO的测量及进展 微循环及组织氧合的监测**西安交大红会医院前负荷及评估容量反应性ICU永恒的命 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 压力指标及容量指标 静态指标及动态指标 容量反应性的评估方法背景 持续低血容量 液体过负荷 非最佳容量状态应用强心药物 容量是血流动力学支持的首选*西安交大红会医院液体反应性*PUMCHICU瞬间即时OttoFrankandErnestStarlingwhoover100yearsagoshowedthatthegreaterthepreloadoftheheartthegreatertheforcethegreatertheoutput***西安交大红会医院前负荷及评估容量反应性压力指标－ＣＶＣ及ＰＡＣ可获得 　CVP 　PAWP 　研究结果各异，不佳似乎大于理想MagderS,BafaqeehF.Theclinicalroleofcentralvenouspressuremeasurements.JintensivecareMed2019;22:44-51OsmanD,RidelC,RayP,etal:Cardiacfillingpressuresarenotappropriatetopredicthemodynamicresponsetovolumechallenge.CritCareMed2019;35:295–296**西安交大红会医院Elasticbanddemonstratingtheconceptofunstressedvolume.ThereisnotensioninthewalloftheelasticuntilitisstretchedbeyondtherestingvolumeCritCareMed2019;26:1061-1064深入认识：CVP与静脉回流Bathtubdemonstratingtheconceptofunstressedvolume.Top:Whenthedrainisonthebottom,thenallthewatercanempty.Bottom:Ifthebathtubhasanopeningonthesideofthetub,thenthewaterbelowtheleveloftheopeningwillnotdrainout.Flowoutoftheholeisonlydeterminedbytheheightofthewaterabovethehole,althoughthevolumebelowthatpointisnecessarytoreachtheleveloftheopening**西安交大红会医院前负荷及评估容量反应性容量指标 20世纪80年代后床旁测定　　经食道心超　左心室舒张末容积等 RVEDVI或CEDVI（容积测量肺动脉导管）研究结果欠理想 2000年后PiCCO　　GEDV/ITBV—研究结果较理想BritishJournalofAnaesthesia94(6):748–55(2019)**右室舒张末容积(RVEDV/CEDV)(pulmonaryarterythermodilution)肺动脉漂浮导管左室舒张末面积(LVEDA)(echocardiography)超声心动图Globalend-diastolicvolume(GEDV)全心舒张末容积(transpulmonarythermodilution)胸腔内血液容积(ITBV)(thermo-dyetranspulmonarydilution)热－染料双指示剂法容量指标前负荷及评估容量反应性*越来月完整。越来越简单方便。越来越准确！**西安交大红会医院思考 应用压力指标的原因　　无奈　　需要 容量指标好于压力指标理想？现实？ 两者结合1＋1＞2?*time-course弥补不足**西安交大红会医院思考 压力指标受到越来越多的质疑 以压力指标为指导的治疗策略获得极大成功EGDTARDS--自由与保守的液体策略矛盾!?**西安交大红会医院前负荷及评估容量反应性 静态指标CVPPAOP回顾性 动态指标SVVSPVPPVdelta-DOWN等 广义性及前瞻性 动态指标可能有比静态指标更好的反应性 应用范围局限 HomodynamicEvaluationandMonitoringintheICUCHEST,2019,132,2020-2029**西安交大红会医院容量反应性的方法Fluidchallenge(2种方法4点要求) Immediateadministrationcrystalloidorcolloidequivalent(eventuallyrepeatable,ifindicated） Astraight-legraise（passivelegraising） AgoalofobtainingariseinCVPatleast2mmHg(CVP≥2mmHg) ApositiveresponseimprovedcardiacoutputtissueperfusionIntensiveCareMed(2019)33:575–590VincentJL,WeilMH(2019)Fluidchallengerevisited.CritCareMed34:1333–1337*吸气暂停法？**容量反应性的方法CritCareMed2019Vol.34,No.5PLRasa“reversiblevolumechallenge”Passivelegraising***西安交大红会医院容量反应性的方法 呼气末暂停15秒法最后5秒测量SV或CI等**西安交大红会医院前负荷/容量反应性和治疗策略 目前：CVP为液体复苏目标的EGDT 已有：以SVV结合SV为液体复苏目标的针对ICU低血压和少尿的病人 尚没有：容量指标相关的治疗策略 下一步： 设计 领导形象设计圆作业设计ao工艺污水处理厂设计附属工程施工组织设计清扫机器人结构设计 以不同容量反应性评估方法为指导液体复苏的临床研究动态指标结合策略SPV与胸腔内压对主动脉壁作用关系密切***西安交大红会医院CO的测量及进展 血流动力学监测的关键环节 CO测量方法：有创－微创－无创**PUMCHNiCOCCOLiDCOPiCCOMonitorPAC**西安交大红会医院CO的测量方法－有创临床应用成熟 CO-TDsThermodilutionCO PAC-CO温度(热)稀释法 CO-染料稀释法NewEnglandJournalofMedicine(1970)**西安交大红会医院血流动力学监测革命的第一步 1970年，Ｈ.Ｊ.ＣＳwan和WilliamGanz发明了带套囊的肺动脉漂浮导管Ｓwan-Ganz导管NewEnglandJournalofMedicine(1970)**西安交大红会医院＞**西安交大红会医院Swan-Ganz导管**西安交大红会医院进步 持续ＣＯ监测 1992连续温度稀释法**西安交大红会医院PAC的作用 __________________ ____________________________ _______________________ _________________________________________ ___________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ higher30-daymortality highermeancostofhospitalstay longerlengthofstayintheICU significantincreaseincardiaccomplications 1.ConnorsAFJr,SperoffT,DawsonNV,etal.(2019)Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA276:889–897 2.MackirdyFL,HowieJC(2019)TherelationshipbetweenthepresenceofpulmonaryarterycathetersandthecasemixedadjustedoutcomeofpatientsadmittedtoScottishICU’s.ClinIntensiveCare8:9–133 3.PolanczykCA,RohdeLE,GoldmanL,CookEF,etal(2019)Rightheartcatheterizationandcardiaccomplicationsinpatientsundergoingnoncardiacsurgery:anobservationalstudy.JAMA286:309–3142000年前后几乎被打倒**西安交大红会医院PAC的作用1.危重病人 Ameta-analysisoftheefficacyandsafetyofthePAC(13RCTs；5,051patients) neitherincreasedoverallmortalityordaysinhospital norconferredbenefit2.急性肺损伤：ARDS.NET Nodifferenceinmortality Nodifferencesintimeonventilator,ortimeintheICU最近：不好也不坏**西安交大红会医院PAC何时用？更公正评价－－借专家一句话！**西安交大红会医院基本原理：血管系统与心脏每搏量的相互作用心脏每搏输出量SVCO测量－微创不同的专有计算公式**西安交大红会医院CO测量－微创经肺热稀释方法脉搏波形分析PiCCO最经典内容最丰富全面**西安交大红会医院PiCCO中心静脉注射右心左心肺PiCCO导管插在股动脉内***西安交大红会医院PiCCO与Swan-Ganz热稀释导管测量心输出量的异同Swan-Ganz热稀释测量位置PiCCO动脉热稀释测量位置**西安交大红会医院PiCCO的专有公式“Beattobeat”连续测量CO曲线下面积曲线形态主动脉顺应性心率校正系数（经肺热稀释方法得到）CO测量－微创**西安交大红会医院CO测量－微创FLO-Trac/Vigileosystem简单但指标少LiDCO需要特殊物质**西安交大红会医院CO测量－微创 微创而连续 简便易行 减少并发症时，是否改善预后？ 急需大规模临床研究 应该相当有前途**西安交大红会医院CO的测量方法－无创不易推广：昂贵；技术复杂 UCG----USCOM TEE**西安交大红会医院USCOM**西安交大红会医院超声心动图血流动力学评估全面无创**西安交大红会医院CO的测量方法－无创 ICG-CO　阻抗法--NICOM FICKMETHOD—NICOSystem尚不成熟**西安交大红会医院CO监测应用临床现状 PAC的局限性—相对的金指标 微创方法的春天－以PiCCO为代表 无创方法在期待未来**西安交大红会医院CO测量方法的选择 相关技术知识 方便/安全 准确性 可以获得其他血流动力学指标 目前微创化无创化全面化趋势明显**西安交大红会医院CO监测何时用？ 何时应用CO监测－现有的推荐 意见 文理分科指导河道管理范围浙江建筑工程概算定额教材专家评审意见党员教师互相批评意见 不常规推荐应用CO测量或监测在临床有明显心衰证据同时有诊断需要时应用尽管充足液体复苏后依然持续休克时**西安交大红会医院CO监测的未来研究方向 哪种CO测量方法最佳－影响预后PiCCO为代表的微创方法是否能带来良好预后？ 以CO为血流动力学治疗目标可以改善预后吗？ CO的监测治疗对不同种类的血流动力学不稳定的影响？**西安交大红会医院组织氧合及微循环水平监测－微观代谢水平 PH和BE LAC（乳酸）及LAC清除率 SVO2/SCVO2（混合或中心静脉血氧饱和度）-持续监测-定义整体心血管功能充足性的金 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 **西安较大红会医院LAC清除率Therewasanapproximately11%decreaselikelihoodofmortalityforeach10%increaseinlactateclearance.Patientswithalactateclearance>10%hadagreaterdecreaseinAPACHEIIscoreoverthe72-hrstudyperiodandalower60-daymortalityrate(p.007).**西安交大红会医院SVO2SCVO2Arterialandvenousoxygensaturationsinvariousvascularregions**西安交大红会医院SvO2indicatoroftheVO2/DO2balancealowSvO2mustinciteclinicianstoincreaseDO2(mainlythroughCOincrease)***西安交大红会医院**西安交大红会医院SVO2/SCVO2监测相关的治疗策略 SVO2相关的治疗策略**西安交大红会医院SVO2/SCVO2监测相关的治疗策略 ScVO2----EGDT治疗策略树**西安交大红会医院容量--流量评价 正常2to5mmHg 不能作为组织缺氧的标记 DeltaPCO2canbeconsideredasamarkeroftheadequacyofvenousbloodflow(i.e.cardiacoutput)toremovethetotalCO2producedbytheperipheraltissues 有助于指导以CO为目标的液体治疗 LamiaB,MonnetX,TeboulJL.Meaningofarterio-venousPCO2differenceincirculatoryshock.MinervaAnestesiol.2019Jun;72(6):597-604.P(cv-a)CO2--ausefultoolUnitofMedicalIntensiveCare,BicetreUniversityHospital,UniversityParisXI,Paris,France.*SCVO2与乳酸的结合容量--流量评价**西安交大红会医院组织氧合及微循环水平监测－－MacroscopiclevelFromToetemperaturetoOPS Gastrictonometry Sublingualcapnometry LaserDopplerflowmetry(mucosalperfusion) Indocyaninegreenclearance Near-infraredspectroscopy(NIRS). OPS（orthogonalpolarizationspectralimaging）正交极化光谱图像光源转换为550nm血红蛋白为吸光点－天然造影剂**西安交大红会医院OPS**西安交大红会医院OPS图像正常SepticShockMale47YMAP68mmHg,lactate3.6mEq/Ldopa20,ne0.13**西安交大红会医院血流动力学监测其他重要内容 心肌收缩性---来源于PiCCO/心脏超声 后负荷 血管外肺水/肺血管通透性指数---EVLW/PVPI***西安交大红会医院Contractilityisameasurefortheperformanceoftheheartmuscle心肌收缩性是流量监测CO的必须补充ContractilityparametersofPiCCOtechnology: dPmx(maximumrateoftheincreaseinpressure) GEF(GlobalEjectionFraction) CFI(CardiacFunctionIndex)心肌收缩性kgkg*Besidesthestaticanddynamicpreloadparameters,contractilityisameasureoftheperformanceoftheheartmuscleandisafurtherimportantdeterminantofcardiacoutput.PiCCOtechnologyprovidesseveralparameters: Continuousmeasurementofthemaximumrateofpressureincreaseofthearterialpulsecurve(dPmx) Determinationoftheglobalejectionfraction(GEF)andcardiacfunctionindex(CFI)fromthethermodilution.**西安交大红会医院来源于脉搏轮廓分析的心肌收缩性参数dPmx=maximumvelocityofpressureincreasedPmx代表了左心室压力上升的最大速度心肌收缩性*Themaximumslopeofthearterialpressurerisecanbedeterminedfromthepulsecontourcurve.Thisrepresentsapreload-dependentgaugeforthecontractilityoftheheart.Withaverylow(defectivefilling)andveryhighpreload(overstretching),theriseinpressurewillbeslowerthanwithanormalfillingstateevenwhenthecontractilityitselfisthesame.**西安交大红会医院 反映全心收缩性GEF=GlobalEjectionFraction来源于热稀释法的心肌收缩性参数4xSVGEF=GEDVLALVRARV心肌收缩性*PiCCOmeasuresothercontractilityparametersfromthethermodilutionmeasurement.ThequotientoffourtimesthestrokevolumeandthetotalpreloadvolumeGEDViscalledtheglobalejectionfraction(GEF).GEFthusgivesthetheoreticalrelationshipbetweenthetotalstrokevolumeandtotalpreloadvolumeoftheheart.Thisparameterdoesnotexistphysiologicallysothenormalrange(25-35%)deviatesfromthephysiologicallynormalleftventricularejectionfraction(50-60%).TheGEFisaparameterofglobalmyocardialcontractility;thismeansthatnodifferentiationbetweenaleftventricularandrightventricularreductionincontractilityispossible.**西安交大红会医院 与GEF相似 全心收缩性参数CICFI=GEDVI心肌收缩性来源于经肺热稀释法的心肌收缩性参数CFI=CardiacFunctionIndex心脏功能指数*Anothercontractilityparameterobtainedfromthermodilutionmeasurementisthecardiacfunctionindex(CFI).AswiththeGEF,theejectionvolume(cardiacindex,CI)isbroughtintorelationwiththepreloadvolume.ForcalculatingtheCFI,unliketheGEF,theheartrateistakenintoaccountsothattheCFIisasomewhatmoreglobalparameterofcardiacperformancethanGEF.AswiththeGEF,theCFIdoesnotallowdifferentiationbetweenleftventricularandrightventricularcontractility.**西安交大红会医院 心血管状态信息的重要 控制容量和血管活性药物应用的重要决定因素(MAP–CVP)x80SVR=CO后负荷SVR=SystemicVascularResistanceMAP=MeanArterialPressureCVP=CentralVenousPressureCO=CardiacOutput80=Factorforcorrectionofunits*Afurtherimportanthaemodynamicparameter,whichishelpfulfordifferentiatedvolumeandcatecholaminetherapy,iscalculationofthesystemicvascularresistancebyPiCCO.Thisrequiresinputofthecentralvenouspressure.**西安交大红会医院血流动力学监测的别样选择-------来源于PiCCO技术的EVLW和PVPI 血管外肺水ExtravascularLungWater（EVLW） 肺血管通透性指数PulmonaryvascularPermeability(PVPI)***西安交大红会医院 ITTV– ITBV= EVLWExtravascularLungWater(EVLW)的计算*Todetectandquantifypulmonaryoedema,PiCCOtechnologymeasurestheextravascularlungwater,whichrepresentsthewatercontentofthelungsoutsidethebloodvessels.Itcorrespondstothedifferencebetweenthetotalintrathoracicdistributionvolumeforcold(ITTV)andthebloodvolumeinthethorax(ITBV).**西安交大红会医院PVPI肺血管通透性指数 区分肺水肿类型静水压增高型通透性增高型EVLWPVPI=PBVPBVEVLW*Notonlythedegreeofpulmonaryoedemabutalsoidentificationofitscauseisimportantforguidingtreatment.PiCCOtechnologymeasuresthepulmonaryvascularpermeabilityindex(PVPI),whichprovidesinformationabouttheratiobetweenextravascularlungwaterandpulmonarybloodvolume.Thisratioisameasureofthepermeabilityofthepulmonaryvascularbed,thusallowingdifferentiationbetweenpulmonaryoedemaduetopermeability(e.g.insepsis)andhydrostaticpulmonaryoedema(e.g.incardiogenicshock).ThePVPIcanthereforeprovideimportantadditionalinformationforguidingtreatment.ECHO-HEMOPTOTOCOL长轴、圆周收缩COPAWP液体治疗强心治疗滴定治疗**西安交大红会医院血流动力学监测与治疗 应用理念有监测必有相关的治疗策略基础监测是基石ICU医生名言Chest.2019;132:2020-2029**西安交大红会医院谢谢！OttoFrankandErnestStarlingwhoover100yearsagoshowedthatthegreaterthepreloadoftheheartthegreatertheforcethegreatertheoutput*Bathtubdemonstratingtheconceptofunstressedvolume.Top:Whenthedrainisonthebottom,thenallthewatercanempty.Bottom:Ifthebathtubhasanopeningonthesideofthetub,thenthewaterbelowtheleveloftheopeningwillnotdrainout.Flowoutoftheholeisonlydeterminedbytheheightofthewaterabovethehole,althoughthevolumebelowthatpointisnecessarytoreachtheleveloftheopening*越来月完整。越来越简单方便。越来越准确！*time-course弥补不足*吸气暂停法？*SPV与胸腔内压对主动脉壁作用关系密切***UnitofMedicalIntensiveCare,BicetreUniversityHospital,UniversityParisXI,Paris,France.***Besidesthestaticanddynamicpreloadparameters,contractilityisameasureoftheperformanceoftheheartmuscleandisafurtherimportantdeterminantofcardiacoutput.PiCCOtechnologyprovidesseveralparameters: Continuousmeasurementofthemaximumrateofpressureincreaseofthearterialpulsecurve(dPmx) Determinationoftheglobalejectionfraction(GEF)andcardiacfunctionindex(CFI)fromthethermodilution.*Themaximumslopeofthearterialpressurerisecanbedeterminedfromthepulsecontourcurve.Thisrepresentsapreload-dependentgaugeforthecontractilityoftheheart.Withaverylow(defectivefilling)andveryhighpreload(overstretching),theriseinpressurewillbeslowerthanwithanormalfillingstateevenwhenthecontractilityitselfisthesame.*PiCCOmeasuresothercontractilityparametersfromthethermodilutionmeasurement.ThequotientoffourtimesthestrokevolumeandthetotalpreloadvolumeGEDViscalledtheglobalejectionfraction(GEF).GEFthusgivesthetheoreticalrelationshipbetweenthetotalstrokevolumeandtotalpreloadvolumeoftheheart.Thisparameterdoesnotexistphysiologicallysothenormalrange(25-35%)deviatesfromthephysiologicallynormalleftventricularejectionfraction(50-60%).TheGEFisaparameterofglobalmyocardialcontractility;thismeansthatnodifferentiationbetweenaleftventricularandrightventricularreductionincontractilityispossible.*Anothercontractilityparameterobtainedfromthermodilutionmeasurementisthecardiacfunctionindex(CFI).AswiththeGEF,theejectionvolume(cardiacindex,CI)isbroughtintorelationwiththepreloadvolume.ForcalculatingtheCFI,unliketheGEF,theheartrateistakenintoaccountsothattheCFIisasomewhatmoreglobalparameterofcardiacperformancethanGEF.AswiththeGEF,theCFIdoesnotallowdifferentiationbetweenleftventricularandrightventricularcontractility.*Afurtherimportanthaemodynamicparameter,whichishelpfulfordifferentiatedvolumeandcatecholaminetherapy,iscalculationofthesystemicvascularresistancebyPiCCO.Thisrequiresinputofthecentralvenouspressure.**Todetectandquantifypulmonaryoedema,PiCCOtechnologymeasurestheextravascularlungwater,whichrepresentsthewatercontentofthelungsoutsidethebloodvessels.Itcorrespondstothedifferencebetweenthetotalintrathoracicdistributionvolumeforcold(ITTV)andthebloodvolumeinthethorax(ITBV).*Notonlythedegreeofpulmonaryoedemabutalsoidentificationofitscauseisimportantforguidingtreatment.PiCCOtechnologymeasuresthepulmonaryvascularpermeabilityindex(PVPI),whichprovidesinformationabouttheratiobetweenextravascularlungwaterandpulmonarybloodvolume.Thisratioisameasureofthepermeabilityofthepulmonaryvascularbed,thusallowingdifferentiationbetweenpulmonaryoedemaduetopermeability(e.g.insepsis)andhydrostaticpulmonaryoedema(e.g.incardiogenicshock).ThePVPIcanthereforeprovideimportantadditionalinformationforguidingtreatment.