危重患者的血流動力學監(jiān)測協(xié)和

1、床旁血流動力學監(jiān)測脈波連續(xù)心排血量(PiCCO)監(jiān)測,北京協(xié)和醫(yī)院ICU 隆云,,基本理論容量反應性-----動態(tài)指標器官平衡------EVLWI/PVPI治療終點----SvO2/ScvO2 乳酸,,我才不管別人說什么，我關心的是….,心功能評價,,心輸出量,,,,,心率,前負荷,后負荷,心肌收縮力,休克的血流動力學分類,低動力型休克高動力型休克,MAP=CI*SVRI,MAP=CI*SVRI,,,SVRI,

2、CI,,,一,二,三,四,休克的分類,低血容量性心源性分布性梗阻性,各種休克的血流動力學特征,A Continuum to Severe Disease,Golden Hour and Silver Day,Detection and Correction of Occult Hypoperfusion within 24 Hrs Improves Outcome from Major Trauma in EDsMorbi

3、dity and survival versus time to correct occult hypoperfusion.,,,Blow O, et al. Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hrs Improves Outcome from Major Trauma. J Trauma

4、, 2019,47:964,血流動力學支持,,低血容量性休克,,補充循環(huán)容量,梗阻性休克,,解除梗阻,心源性休克的ABC理論,,,PAWP,CI,,,,,,,A,B,C,D,,,,,,感染性休克的特征,充足的液體負荷,仍不能糾正的休克,需要血管活性藥循環(huán)高動力狀態(tài)與組織缺氧共存,感染性休克的支持,充足的液體復蘇充足的氧輸送血管收縮藥組織水平缺氧,理想的血流動力學監(jiān)測,持續(xù)、可重復性簡潔、微創(chuàng)人文---反應性

5、器官平衡,,,,,,,,跨肺熱稀釋法+脈波輪廓分析法,RA,LA,RV,LV,,,,,,Surface = Cal. x Stroke volume,PICCO測定的參數(shù),脈波連續(xù)測定每次心臟搏動的心輸出量(PCCO)及指數(shù)(PCCI)動脈壓(AP)心率(HR)每搏量(SV)及指數(shù)(SVI)每搏量變化(SVV)外周血管阻力(SVR)及指數(shù)(SVRI)熱稀釋法心輸出量(CO)及指數(shù)(CI)胸腔內血容量(

6、ITBV)及指數(shù)(ITBI)全心舒張末期容量(GEDV)及指數(shù)(GEDI)血管外肺水(EVLW)及指數(shù)(ELWI)心功能指數(shù)(CFI),反映前負荷 ----靜態(tài)與動態(tài)指標,staticRAP/CVPPAOPRVEDVLVEDA,dynamic inspiratory decrease in RAP [RAP]expiratory decreasein arterial systolic pres

7、sure [?down]respiratory changes in pulse pressure [PP]respiratorychanges in aortic blood velocity [Vpeak],容量反應性（Fluid Responsiveness）,Significant SV/CO↑after Fluid challenge,,Ventricular Preload,,SV/CO,,,,,,,,,,,,,單

8、次的右房壓不能預測容量反應性，反應者與無反應者數(shù)值明顯交叉,右房壓與容量反應性,右室舒張末期容積指數(shù),RVEDVI138 mL/m2 the lack of response,肺動脈楔壓,所有上述研究都沒有發(fā)現(xiàn)PAOP 作為評價容量反應性的閾值,影響靜態(tài)指標的因素,PEEP三尖瓣返流血管活性藥物右室功能不全心室順應性液體分布,無反應組的原因,高靜脈系統(tǒng)順應性低心室順應性 心室功能障礙,動態(tài)指標與容量反應性,,

9、PPmin,,,,Am J Respir Crit Care Med 2000; 162:134-8,PPV (%)before fluidinfusion,,,13%,13%,血管外肺水與液體復蘇,early resuscitation of haemorrhagic shock with NS or LR has little impact on oxygenation when resuscitation volume is

10、 less than 250 ml/kg.,評價肺水腫原因,心源性、肺源性？肺毛細血管靜水壓腦利鈉肽（BNP） 肺血管通透性指數(shù)(PVPI),,Pc is hydrostatic pulmonary capillary pressure…. but is not wedge pressure (PAOP),,,,Chest 2019;131;964-971,,,,Inflammatory vs cardiogenicpulmon

11、ary edema,PVPI=EVLWI / PBV,A clinician, armed with the sepsis bundles, attacks the three heads of severe sepsis: hypotension, hypoperfusion and organ dysfunction. Crit Care Med 2019; 320(Suppl):S595-S597,,Surviving Sep

12、sis Campaign,感染性休克中與預后相關的血流動力學參數(shù),Varpula. Intensive Care Med (2019) 31:1066–1071,,,,,,早期集束化治療,早期血清乳酸水平測定抗生素使用前留取病原學標本急診在3h內，ICU在1h內開始廣譜的抗生素治療如果有低血壓或血乳酸>4mmol/L，立即給予液體復蘇(20ml/kg)，如低血壓不能糾正，加用血管活性藥物，維持MAP≥65mmHg；液體復

13、蘇使CVP≥8mmHg，ScvO2≥70%。積極的血糖控制糖皮質激素應用機械通氣患者平臺壓<30cmH2O,血壓正常時的休克,,Schwaitzberg, J Ped Surg, 1988,隱匿性低灌注,血壓不是復蘇的終點盡管血壓等生命體征正常，乳酸升高仍提示隱匿性低灌注，預示患者的預后不良在手術患者中，改善隱匿性低灌注改善患者預后,治療終點,CVPMAPCO,SvO2 LACTATETiss

14、ue O2 & CO2,SvO2的含義,SvO2=SaO2,,VO2,CO*Hb*13.4,,↓SvO2 = 缺氧,低張性,組織性,等張性,循環(huán)性,,,,,氧輸送,,,閾值,,氧需,,,氧需與氧輸送,,,VO2,DO2,,,SvO2,,,,,,,Optimal EO2 = ?,Optimal EO2 = 30%,,,Optimal EO2 = 40%,,,SvO2 indicator of the VO2/DO2 balance

15、,,Critical DO2 & EO2,,血乳酸范圍,重癥患者乳酸正常值 5mmol/l伴有代謝性酸中毒,乳酸性酸中毒的原因及分類,代謝紊亂組織缺氧藥物、毒素或先天性疾病導致的糖代謝異常Cohen and WoodsType A poor tissue perfusion Type B no clinical evidence of poor tissue perfusion,早期乳酸清除率,從初始發(fā)現(xiàn)到６

16、hr乳酸下降的百分比119pts with severe sepsis or septic shock Survivors & nonsurvivors 38.1 ± 34.6 vs. 12.0 ± 51.6% (p = .005)乳酸清除率明顯與預后負相關 (p = .04),Critical Care Medicine. 32(8):1637-1642,,Critical Care Medicin