微循環(huán)和血管活性藥培訓(xùn)課件

微循環(huán)和血管活性藥引言Sepsis：疑問：臨床上血流動(dòng)力學(xué)穩(wěn)定、氧傳遞指標(biāo)等均可，但依然進(jìn)展、乳酸升高？早期亦已存在微循環(huán)功能障礙??！

2微循環(huán)和血管活性藥引言微循環(huán)：如此重要、關(guān)鍵應(yīng)成為危重患者復(fù)蘇中的一個(gè)關(guān)鍵指標(biāo)但：傳統(tǒng)的評(píng)價(jià)指標(biāo)難以準(zhǔn)確評(píng)價(jià)微循環(huán)！3微循環(huán)和血管活性藥主要問題：1.有什么新的方法監(jiān)測(cè)微循環(huán)？2.現(xiàn)有血管活性藥物微循環(huán)的影響如何？4微循環(huán)和血管活性藥微循環(huán)的結(jié)構(gòu)直徑<300um的血管100億個(gè)毛細(xì)血管血管表面積>500m2組成：微動(dòng)脈，后微動(dòng)脈，毛細(xì)血管前括約肌，真毛細(xì)血管、通血毛細(xì)血管、動(dòng)靜脈交通支、微靜脈

5微循環(huán)和血管活性藥微循環(huán)的功能及分類1.迂回通路：物質(zhì)交換，交替開放（又稱營養(yǎng)通路）2.直捷通路：不進(jìn)行物質(zhì)交換，血液快速回流，骨骼肌多見3.動(dòng)靜脈短路：不進(jìn)行物質(zhì)交換，皮膚多見6微循環(huán)和血管活性藥7微循環(huán)和血管活性藥Sepsis時(shí)微循環(huán)的改變1994年，LamC等對(duì)血壓穩(wěn)定的鼠sepsis微循環(huán)活體顯微鏡在體觀察，發(fā)現(xiàn)sepsis時(shí)：1.灌注毛細(xì)血管密度減少，血流停止的毛細(xì)血管數(shù)增加；2.灌注毛細(xì)血管空間分布不均，平均毛細(xì)血管間距增加2002年，DeBacker等利用OPS成像觀察sepsis舌下微循環(huán)，發(fā)現(xiàn)：1.微血管密度顯著減少，血流停滯和血流灌注間斷的小血管比例增加；2.各區(qū)域間灌注血管的變異系數(shù)明顯大于健康志愿者

DeBackerD,CreteurJ,PreiserJC,etal.Microvascularbloodflowisalteredinpatientswithsepsis.AMJRespirCritCareMed,2002,166:98-1048微循環(huán)和血管活性藥

OPS圖像9微循環(huán)和血管活性藥Sepsis時(shí)微循環(huán)的改變特征：1.adecreaseincapillarydensity2.anincreaseinheterogeneityofperfusionwithnon-perfusedinclosevicinitytowell-perfusedcapillaries后果？10微循環(huán)和血管活性藥Tissuestoleratebetterahomogeneous

decreaseinbloodflowbetterthanaheterogeneousoneDanielDeBacker，GustavoOspina-Tascon，etal.IntensiveCareMed(2010)36:1813–1825.11微循環(huán)和血管活性藥12微循環(huán)和血管活性藥HowtoevaluatethemicrocirculationIntensiveCareMed(2010)36:1813–1825.13微循環(huán)和血管活性藥NailfoldvideocapillaroscopyThefirstmethodusedatthebedsidethenailfoldareaisverysensitivetochangesintemperature:onecancontrolambientbutnotbodytemperature.PeripheralvasoconstrictioncanalsooccurduringchillsandacutecirculatoryfailureOflimiteduseincriticallyillpatients.14微循環(huán)和血管活性藥LaserDopplerMainlimitation：measuresflowinavariablevolumeoftissue，unabletodetectitinindividualvesselsSamplingvolume:0.5and1mm3,about50vesselsCannotshowtheheterogeneity15微循環(huán)和血管活性藥SvO2VenousO2saturationcanbehighorlowforthesamedegreeofmicrovascularshunting—canbemisleadingSeveralstudieshaveshownthatmeasuringSvO2doesnotprovidemuchinformationaboutmicrovascularalterations---PodbregarM,MozinaH.Skeletalmuscleoxygensaturationdoesnotestimatemixedvenousoxygensaturationinpatientswithsevereleftheartfailureandadditionalseveresepsisorsepticshock.CritCare2007,11:R6MarikPE,BankovA,Sublingualcapnometryversustraditionalmarkersoftissueoxygenationincriticallyillpatients.CritCareMed2003,31:818–82216微循環(huán)和血管活性藥GastrictonometryAgastricPCO2gapabove20mmHgdiscriminatedsurvivorsfromnon-survivors-------LevyB,GawalkiewiczP.CritCareMed2003,31:474–48

GastricPCO2gap---mostlyreflectsgutmucosalmicrocirculation----Insepsis,nocorrelationbetweenthegastricPCO2gapandtotalsplanchnicperfusionDuodeno-gastricrefluxandfeedingcaninterfere17微循環(huán)和血管活性藥LactateTimelag-------Cannotdetectalterationsinmicrovascularperfusionbeforetheyareassociatedwithcellularhypoxia18微循環(huán)和血管活性藥OPS/SDFOPS成像：正交偏振光譜成像orthogonalpolarizationspectralimaging原理：利用血細(xì)胞對(duì)偏振入射綠光產(chǎn)生消偏振光散射和對(duì)正偏振光的成像特征，能在皮下0.5mm深度內(nèi)產(chǎn)生高清晰度和高分辨率的成像。局限性：敏感性偏差；需具備高能光源，難以應(yīng)用到臨床。19微循環(huán)和血管活性藥OPS/SDFSDF成像：旁流暗場(chǎng)成像，sidestreamdark-field，2007年開始應(yīng)用于臨床優(yōu)點(diǎn)：更加清晰所需能量小，可以方便的使用電池床邊操作

20微循環(huán)和血管活性藥SDFimage21微循環(huán)和血管活性藥OPS/SDFAdvantage:1.visible2.differentvariablescanbeobservedandbemeasured---vasculardensity,heterogeneityofperfusion,microvascularbloodflowTheconsensusadvisesreportingofPVD,PPV,MFIandheterogeneityindex,inordertodescribethefunctionalperfusionofthemicrocirculation.-------Howtoevaluatethemicrocirculation:reportofaroundtableconference,CriticalCare2007,11:R101

22微循環(huán)和血管活性藥血管活性藥物對(duì)微循環(huán)的影響Vasopressors:Norepinephrine,Epinephrine,VasopressinInotropes:Dopamine,Dobutamine,Vasodilators:Nitroglycerin,Prostacyclin23微循環(huán)和血管活性藥NEdoesnotimprovemicrocirculatorybloodflow20septicshockpatientsBasalmeasurementofMAP65mmHg,NEwastitratedtoreachaMAPof75mmHg,then85mmHgSublingualmicrocirculationwasevaluatedbySDFimagingDubinA,PozoMO,etal.Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudy.Critcare,2009,13(3):R9224微循環(huán)和血管活性藥NEdoesnotimprovemicrocirculatorybloodflow26微循環(huán)和血管活性藥NEdoesnotimprovemicrocirculatorybloodflow1.NEdoesnotimprovemicrocirculataryperfusionfurtherincreaseMAPfrom65mmHg.2.ReductionsintheperfusedcapillarydensitiesfurtherincreaseMAPfrom65mmHg.結(jié)論：使用去甲升高M(jìn)AP并不是改善感染性休克患者微循環(huán)的一個(gè)恰當(dāng)方法，反而可能對(duì)患者有害。27微循環(huán)和血管活性藥TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshock16septicshockpatientsNEfrom0.18to0.25,0.35,0.41ug/kg.minMAPfrom60-70-80-90mmHgSDFimaging

ShamanJhanji,etal.CritcareMed2009;37:1961-196628微循環(huán)和血管活性藥TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshockMAP高于60-65mmHg不能改善感染性休克患者微循環(huán)增加NE對(duì)感染性休克患者微循環(huán)無明顯影響

ShamanJhanji,etal.CritcareMed2009;37:1961-196629微循環(huán)和血管活性藥多巴胺對(duì)微循環(huán)的影響1.1Meier-HellmannA,BredleDL,SpechtM,SpiesC,HannemannL,ReinhartK(1997)Theeffectsoflow-dosedopamineonsplanchnicbloodflowandoxygenuptakeinpatientswithsepticshock.IntensiveCareMed23:31–371.2OlsonD,PohlmanA,HallJB(1996)Administrationoflow-dosedopaminetononoliguricpatientswithsepsissyndromedoesnotraiseintramucosalgastricpHnorimprovecreatinineclearance.AmJRespirCritCareMed154:1664–16702.MarikPE,MohedinM(1994)Thecontrastingeffectsofdopamineandnorepinephrineonsystemicandsplanchnicoxygenutilizationinhyperdynamicsepsis.JAMA272:1354–135730微循環(huán)和血管活性藥NG對(duì)微循環(huán)的影響31微循環(huán)和血管活性藥NGinsepticshockafterintravascularvolumeresuscitation8septicshockpatientsMAPwasgreaterthan60mmHgandCVPgreaterthan12mmHgafterinfusionofcrystalloidsandcolloids,andthelowestpossibledoseofdopamineNG：anintravenousloadingdoseof0·5mg,thensubsequentcontinuousinfusionof2mg/hOPS：usedtoproduceimagesofsublingualmicrocirculationLancet2002;360:1395-139632微循環(huán)和血管活性藥NGinsepticshockafterintravascularvolumeresuscitation33微循環(huán)和血管活性藥OPSimages34微循環(huán)和血管活性藥70個(gè)Severesepsis和septicshock患者充分復(fù)蘇后給予硝酸甘油或安慰劑SDF評(píng)估舌下微循環(huán)主要終點(diǎn)：sublingualmicrocirculatorybloodflowofsmallvesselsCritCareMed2010;38:93-10035微循環(huán)和血管活性藥Microvascularvariablesovertime36微循環(huán)和血管活性藥TakeHomeMessage1.重視微循環(huán)檢測(cè)2.sepsis微循環(huán)功能障礙：異質(zhì)性