感染性休克的循環(huán)功能支持PPT學習教案

1、會計學1感染性休克的循環(huán)功能支持感染性休克的循環(huán)功能支持第1頁/共74頁第2頁/共74頁第3頁/共74頁第4頁/共74頁第5頁/共74頁第6頁/共74頁第7頁/共74頁第8頁/共74頁0 02 24 46 68 8101012121414MAPMAPCICIPAWPPAWPPlaceboPlaceboDobuDobuDopaDopa第9頁/共74頁0 02020404060608080100100120120140140160160CcrCcrUOUOFna%Fna%PlaceboPlaceboDobuDobuDopaDopa第10頁/共74頁第11頁/共74頁第12頁/共74頁0501001

2、50060120180240MAPEpiDopaEpi + Dopa第13頁/共74頁-250255075100125060120180240-250255075100125060120180240-250255075100125060120180240多巴胺和腎上腺素對腎臟血管阻力的影響健康對照腹腔感染DOPADOPA + EpiEpi第14頁/共74頁-250255075100125060120180240-250255075100125060120180240多巴胺和腎上腺素對腎臟血管阻力的影響多巴胺腎上腺素多巴胺 + 腎上腺素健康對照腹腔感染第15頁/共74頁0255075060120

3、18002550750601201800255075060120180多巴胺和腎上腺素對腎臟血流的影響健康對照腹腔感染DOPADOPA + EpiEpi第16頁/共74頁025507506012018002550060120180健康對照腹腔感染多巴胺和腎上腺素對腎臟血流的影響多巴胺腎上腺素多巴胺 + 腎上腺素第17頁/共74頁102030405060baseline15 min180 minCcr (ml/min)健康對照-Epi感染-Epi健康對照-Epi+DA感染-Epi+DA第18頁/共74頁第19頁/共74頁第20頁/共74頁第21頁/共74頁第22頁/共74頁Weighted ev

4、ent ratesOutcomeRCTNo. ptsdopaminecontrolRRR (95%CI)P valueMortality115084.9%5.6%14% (-66 to 56)0.69Development of ARF1151117.9%19.5%20% (-14 to 44)0.50Need for hemodialysis1061816.2%16.5%10% (-21 to 34)0.86Kellum JA, Decker JM. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med.

5、 2001 Aug;29:1526-31 第23頁/共74頁0.1110MortalityOnset of ARFNeed for dialysisKellum JA, Decker JM. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med. 2001 Aug;29:1526-31 第24頁/共74頁第25頁/共74頁Dopamine(n = 161)Placebo(n = 163)P valuePeak Scr245 144249 1470.93Delta Scr62 10766 1080.82No.

6、 of pts with Scr 30056560.92No. of pts requiring RRT35400.55Duration of ICU stay13 1414 150.67Hospital stay29 2733 390.29No. of deaths6966Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zeala

7、nd Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000 Dec 23-30;356(9248):2139-43第26頁/共74頁第27頁/共74頁Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31第28頁/共74頁Martin C, et al. Norepinephrine or dopamine for the treatmen

8、t of hyperdynamic septic shock. Chest 1993; 103: 1826-31第29頁/共74頁NEDOPA劑量(g/kg/min)1.5 1.210 25有效率93% (15/16)31% (5/16)換用藥物后有效率0% (0/1)91% (10/11)存活率59%17%出院病人數(shù)96Martin C, et al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31第30頁/共74頁Martin C, et

9、al. Norepinephrine or dopamine for the treatment of hyperdynamic septic shock. Chest 1993; 103: 1826-31第31頁/共74頁From：JAMA 1994; 272: 1354第32頁/共74頁第33頁/共74頁NEDOPAbaseline3 hrbaseline3 hrMAP55876387CI4.24.74.25.3PAWP15161516SVRI1110140510351221DO2498569573703VO2145162183221pHi7.167.237.247.18第34頁/共74頁

10、作者病人數(shù)NEDOPADOBU結(jié)果Desjars220.5 1.52 3Cr , BUN , CH2O , FNa UO , Clcr Martin241.16 178 14MAP , UO , Cr , Clcr Redl-Wenzl560.1 2.02.5Clcr 75 35 102 43第35頁/共74頁第36頁/共74頁0.650.330.160.2800.10.20.30.40.50.60.7DopaNEdeltaDO2gutdeltaVO2gutCritical Care Med 1993; 21: 1296第37頁/共74頁第38頁/共74頁第39頁/共74頁Crit Care

11、Med 1999; 27: 893第40頁/共74頁NEEpiMAP7474PAWP1514CI4.45.2DO2563671VO2150158O2ER0.280.24pHi7.247.25DeltaPCO21313GMP256350GMP/DO20.520.46第41頁/共74頁Ann Surg 1998; 228: 239第42頁/共74頁01020304050%damage ileum%damage colon%damage sigmoidControlDopexEpiNE第43頁/共74頁Intensive Care Med 1997; 23: 282第44頁/共74頁MAP/mmHg

12、406080100Base1h6h12h24hEpiNE+DobuCI/L/min.m223456Base1h6h12h24h第45頁/共74頁Lactate/mmol/L23456Base1h6h12h24hL/P ratio04812162024Base1h6h12h24hEpiNE+Dobu第46頁/共74頁pHi7.17.27.37.4Base1h6h12h24hEpiNE+DobuPCO2 GAP0481216Base1h6h12h24h第47頁/共74頁第48頁/共74頁Crit Care Med 1999; 27: 893第49頁/共74頁NENE + DobuEpiMAP747

13、474PAWP151414CI4.44.75.2DO2563621671VO2150152158O2ER0.280.250.24GMP256419350GMP/DO20.520.610.46第50頁/共74頁Crit Care Med 1994; 150: 324 第51頁/共74頁pHi7.17.27.37.40510High lactateNormal lactatepHi7.17.27.37.4510600670DO2第52頁/共74頁第53頁/共74頁Lactate/mmol/L0246Base1h6h12h24hEpiNE+DobuL/P ratio04812162024Base1h

14、6h12h24h第54頁/共74頁pHi7.17.27.37.4Base1h6h12h24hEpiNE+DobuPCO2 GAP0246810121416Base1h6h12h24h第55頁/共74頁第56頁/共74頁Intensive Care Med 1997; 23: 31第57頁/共74頁第58頁/共74頁第59頁/共74頁血管活性藥物 爭論4：超正常的氧輸送是否有益？ Is supranormal level the right endpoint?第60頁/共74頁第61頁/共74頁第62頁/共74頁第63頁/共74頁第64頁/共74頁第65頁/共74頁第66頁/共74頁第67頁/共74頁第68頁/共74頁第69頁/共74頁第70頁/共74頁第71頁/共74頁第72頁/共74頁AgentTypical Dosages121Isoproterenol0.01 0.1 g/kg/min+Norepinephrine0.05 1.0 g/kg/min+Epinephrine0.05 2.0 g/kg/min+Phenylephrine0.5 5.0 g/kg/min+Dopamine*1 20 g/kg/min+ (+)+ (+)Dobutamine2.5 20 g/kg/min+*Dopamine effects at “high-do