休克患者血容量的監(jiān)測進展課件

ICU休克患者血容量的監(jiān)測進展內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)休克的概念感染、創(chuàng)傷、燒傷等引起有效循環(huán)血量明顯減少組織器官的灌注不足氧輸送不能滿足組織代謝需要導(dǎo)致組織缺氧代謝障礙和細胞受損臨床綜合征容量管理的基本目標(biāo)保證容量－合適的心臟前負荷預(yù)防肺水腫二者必須平衡內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)容量監(jiān)測的現(xiàn)狀容量監(jiān)測：TEE，CT，核素掃描臨床表現(xiàn):血壓、心率、尿量、皮膚粘膜等壓力監(jiān)測：漂浮導(dǎo)管(CVP/PAWP)心臟前負荷：VEDVRVEDP/LVEDP的測定壓力反映容量及肺水腫的局限性心臟順應(yīng)性瓣膜功能肺毛細血管通透性機械通氣對循環(huán)的影響PAC對容量監(jiān)測的有效性和可信性受到置疑？？許多文獻：CVP/PAWP不能準確反映容量狀態(tài)內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)AphysiologicalsystemmodelITTV:IntrathoracictotalvolumeGEDV:

Globalend-diastolicvolume

ITBV:Intrathoracicbloodvolume

PTV:PulmonarytotalvolumeEVLW:extra-pulmonarylungwater

胸內(nèi)總?cè)萘咳氖鎻埰谘萘啃貎?nèi)血液容量肺部容積血管外肺水容量指標(biāo)的應(yīng)用胸腔內(nèi)血管容量(ITBV)血管外肺水(EVLW)搏出量變異率(SVV)搏出量變異率(SVV)SVV=(SVmax–SVmin)/SVmeanSvmax:meanvalueoffourSVmax/30sSVmin:meanvalueoffourSVmin/30sSVmean血管外肺水組成(EVLW)細胞內(nèi)液間質(zhì)液體肺泡內(nèi)液體內(nèi)容簡介管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)LueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressureITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.Anesth

Analg.2002,95:835-43ITBV---superiorthanPAWPinpreloadDellaRG,etal.Anesth

Analg.2002,95:835-43CorrelationofITBV-SVin4phasesNocorrelationofPAWP-SVinanyphases前瞻性臨床研究40例心臟移植術(shù)后患者男34例，女6例觀察術(shù)后3、6、12、24、36、48、72hITBV/GEDV和CVP/PAWP與SV的相關(guān)性ITBV/GEDV---goodpreloadindicatorinhearttransplantationGoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781^GEDV-^SV:R2=0.4016^ITBV-^SV:R2=0.2979GoedjeO,etal.Chest,2000,118:775-781^PAWP-^SV:R2=0.0043^CVP-^SV:R2=0.0552ITBV的改變反映肺水含量Prospectivelystudy16patientswithsepticshockandpulmonaryedema(ACCP/SCCM)SAPSII:56Monitor:Picco,PACOptimalPAWP:CInolongerincreasedMonitortime:0,24hIntensiveCareMed,2002,28,712-18FromintensiveCareMed,2002,28,712-18CVP與EVLW的相關(guān)性PAWP與EVLW的相關(guān)性CorrelationbetweenITBV/TEDVandEVLWFromintensiveCareMed,2002,28,712-18ITBV

與EVLW有良好相關(guān)性優(yōu)于

CVP

與PAWP內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)SVV可以反映機體前負荷Prospectivestudy20MVpatientsfollowingcardiacsurgeryVolumeloading(HES20ml*BSA/10min)Measurement:CVP,PAWP---PACLVEDAI----TEEITBV,SVV----PiCCOReuterDA,etal.IntensiveCareMed.2002,28:392-8.血流動力學(xué)監(jiān)測SVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVP/PAWPnotcorrelatedwithCISVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVPnotcorrelatedSVV反映機體對容量治療的反應(yīng)15例腦外科手術(shù)患者麻醉誘導(dǎo)后容量負荷實驗：100mLof6%hydroxyethylstarchgivenfor2min分組：responsive:SV>5%

nonresponsive:SV<5%Atotalof140VLSswereperformedAnesth

Analg.2001,92:984-9兩組負荷試驗前血流動力學(xué)狀態(tài) Response(70) nonresponse(70)PHR 76 75 NSSBP 102 116 0.001CVP 9.3 9.3 NSSVV 12.6 6.8 <0.001Anesth

Analg.2001,92:984-9兩組負荷試驗后血流動力學(xué)改變Response(70)nonresponse(70)PHR -1 -1 NSSBP 9 2 <0.001CVP 9.8 11.9 NS SVV -25.8 -10 <0.001Anesth

Analg.2001,92:984-9以上指標(biāo)與SV改變的相關(guān)性Pearson’scorrelation PHR 0.142 NSSBP -0.448 <0.001SV -0.372 <0.001CVP 0.055 NSSVV 0.722 <0.001HR -0.089 NSSBP 0.472 <0.001CVP -0.084 NSSVV -0.505 <0.001Anesth

Analg.2001,92:984-9ResponsiveVLS:SVV/SV有較高的特異性和敏感性Anesth

Analg.2001,92:984-9SVV對失血性休克犬容量狀態(tài)的評價成年健康雜種犬共14只，體重12.1±1.1公斤復(fù)制犬失血性休克模型穩(wěn)定30分鐘，改良的Wiggers’法制備失血性休克犬模型適當(dāng)放血維持MAP在50mmHg左右并穩(wěn)定60分鐘，模型成功容量負荷試驗2分鐘內(nèi)快速滴入林格氏液7ml.kg-115分鐘后重復(fù)，記錄容量負荷前及后5分鐘的監(jiān)測指標(biāo)分組△SV是否大于容量負荷試驗前SV的5％分為兩組反應(yīng)組(△SV＞5％)無反應(yīng)組(△SV＜5％)直至連續(xù)兩次△SV均小于容量負荷試驗前的5%時終止實驗監(jiān)測指標(biāo)HRMAPPiCCO監(jiān)測儀:CO、ITBVI、SV、SVVSwan-Ganz導(dǎo)管:CO、CVP、PAWP共進行容量負荷試驗134次，每只犬平均9.6±1.7次，其中94次為反應(yīng)組，40次為無反應(yīng)組容量負荷實驗前各指標(biāo)的比較

反應(yīng)組

無反應(yīng)組

HR111.3±33.6115.6±44.1CVP5.4±2.46.2±2.5PAWP7.9±2.98.6±2.9P<0.05

容量負荷試驗前各指標(biāo)與△SV的相關(guān)性

rP值HR(bpm)-0.1480.089MAP(mmHg)-0.0910.296CVP(mmHg)-0.0920.292PAWP(mmHg)-0.0910.297ITBVI(ml/m2)0.3560.000SVV(%)0.5310.001容量負荷試驗前后各指標(biāo)的變化與△SV的相關(guān)性

rP值△HR(bpm)-0.0810.353△MAP(mmHg)0.0200.820△CVP(mmHg)-0.3710.000△PAWP(mmHg)-0.4480.000△ITBVI(ml/m2)0.4380.000△SVV(%)–0.3760.000各指標(biāo)對容量負荷反應(yīng)(△SV)的ROC曲線分析

AUC95％CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.434－0.6510.207－0.3810.313－0.5170.336－0.5390.583－0.7910.805－0.939AUC=曲線下面積,CI=可信區(qū)間

SVV大于9.5％時，對容量評價的敏感性為92.6％，特異性為62.5％。

SVV和ITBVI可用于容量狀態(tài)的評價優(yōu)于HR、MAP、CVP和PAWP內(nèi)容簡介容量管理的基本目標(biāo)容量監(jiān)測的現(xiàn)狀及局限性容量監(jiān)測的進展ITBV的應(yīng)用SVV的應(yīng)用EVLW的應(yīng)用小結(jié)CVP/PAWP能反映EVLW嗎?Prospectivelystudy16patswithsepticshockandpuledema(ACCP/SCCM)SAPSII:56Monitor:PiCCOvsPACOptimalPAWP:CInolongerincreasedMonitortime:0,24hFromintensiveCareMed,2002,28,712-18IntensiveCareMed,2002,28,712-18CVP/PAWP能反映EVLW嗎?

NoIntensiveCareMed,2002,28,712-18delta與EVLW相關(guān)性,FB：fluidbalanceCVP/PAWP能反映EVLW嗎?

No肺水含量是ARDS的預(yù)后指標(biāo)Retrospectiveanalysis373ICUpatsinu