周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)

周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)Thisstudyof2,289patientsincludedprospectivelyfromtwodifferentcohortsinaquaternary-levelprovincialreferralhospitalinBC,Canada.(47.75%)CritCareMed.

Jul22

周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)2/52在管理血流動力學(xué)不穩(wěn)定患者中，常見策略是提升心排血量和組織灌注，故評定患者容量狀態(tài)極其主要；對評定容量狀態(tài)容量無反應(yīng)患者，增加容量負(fù)荷不但不能引發(fā)心輸出量增加，反而會增加組織水腫及缺氧，故在進(jìn)行快速補(bǔ)液時應(yīng)首先對患者進(jìn)行容量評定。JIntensiveCareMed.Sep-Oct;24(5):329-37Techniquesforassessmentofintravascularvolumeincriticallyillpatients周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)3/52德國生理學(xué)家OttoFrank英國生理學(xué)家StarlingFrank-Starling機(jī)制周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)4/52靜態(tài)前負(fù)荷參數(shù)：前負(fù)荷壓力指標(biāo)（CVP）及前負(fù)荷容量指標(biāo)（全心舒張末期容積，GEDV）；動態(tài)前負(fù)荷參數(shù)：收縮壓變異率（SPV）、脈壓變異率（PPV）、每搏變異率（SVV）及被動抬腿試驗(yàn)（PLR）等。CardiovascUltrasound.Oct6;6:49.WorldInteractiveNetworkFocusedonCritical

Ultrasound

(WINFOCUS)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)5/52血壓（BP）：失血量達(dá)18%依然能夠經(jīng)過提升血管阻力來維持相對正常MAP;中心靜脈壓（CVP）和肺動脈楔壓(PAWP)：經(jīng)過壓力代容積來反應(yīng)心臟前負(fù)荷，均受到心臟順應(yīng)性，機(jī)械通氣和血管張力等原因影響；周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)6/52周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)7/52超聲FATE(focusassessedtransthoracicecho)草案周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)8/52Researchhassuggestedthatvolumeresponsivenesscanbedefinedasa15%increaseinstrokevolume(SV)orcardiacoutput(CO)aftera500mlinfusion.AnesthAnalg.Nov;111(5):1180-92Acriticalreviewoftheabilityofcontinuouscardiacoutputmonitorstomeasuretrendsincardiacoutput周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)9/52床旁超聲下腔靜脈直徑（IVCD）測量方法KoreanJInternMed;29:241-245一、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈直徑（IVCD）周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)10/52JEmergMed.Apr;42(4):429-36一、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈直徑（IVCD）在容量反應(yīng)時，下腔靜脈直徑改變與CVP含有相關(guān)性(P＜0.001)，下腔靜脈直徑在1-2CM范圍含有較高特異性和敏感性.(A)Subxiphoid,transverseorientation,atendinspiration.(B)Subxiphoid,longitudinalorientation,atendinspiration.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)11/52inferiorvenacavadiameter(IVCD)andcentralvenouspressurevalue(CVP)PakJMedSci.Mar;30(2):310-5.下腔靜脈長軸切面周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)12/52IVC=inferiorvenacava;CVP=centralvenouspressure.Statisticallyrelationship

betweenIVCandCVPpressuresPakJMedSci.Mar;30(2):310-5.結(jié)論：自主呼吸患者，下腔靜脈直徑改變能夠預(yù)測容量反應(yīng)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)13/52下腔靜脈擴(kuò)張指數(shù)(dIVC)＝(Dmax(吸氣末)-Dmin(呼氣末))／DminIntensiveCareMed.Sep;30(9):1740-630-minvolumeexpansion(7ml/kg)using4%modifiedfluidgelatin二、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈擴(kuò)張指數(shù)(dIVC)BaselineAftervolumeexpansion周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)14/52RespiratorychangesininferiorvenacavadiameterarehelpfulinpredictingfluidresponsivenessinventilatedsepticpatientsIntensiveCareMed.Sep;30(9):1740-6機(jī)械通氣患者，dIVC＞18％，預(yù)測容量反應(yīng)性敏感性和特異性均在90％以上.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)15/52下腔靜脈呼吸改變率（△DIVC）=（Dmax-Dmin)/(Dmax+Dmin)IntensiveCareMed.Sep;30(9):1834-7三、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈呼吸改變率（△DIVC）Astudied39mechanicallyventilatedpatientswithsepticshock.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)16/52Individualvalues(opencircles)andmean±SD(closedcircles)oftheminimumDIVC,maximumDIVCand△DIVCbeforvolumeloadinginresponder(R)andnon-responder(NR)patients.*P<0.05RvsNR下腔靜脈呼吸改變率＞12％，預(yù)測容量反應(yīng)性陽性和陰性分別為93％和92％.IntensiveCareMed.Sep;30(9):1834-7周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)17/52四、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈塌陷指數(shù)（IVCC）下腔靜脈塌陷指數(shù)(IVC-CI):（Dmax-Dmin）/DmaxJAmCollSurg.Jul;209(1):55-61周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)18/52JACCCardiovascImaging.Sep;4(9):938-45下腔靜脈≥2cm(準(zhǔn)確度88％)和下腔靜脈塌陷＜40％(準(zhǔn)確度68％)是確定右心房壓＞10mmHg較高精度比組合（RAP=0～8mmHg）下腔靜脈塌陷指數(shù)預(yù)測右心房壓力（RAP）周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)19/52IntensiveCareMed.Apr;36(4):692-6IVC-CI指導(dǎo)心衰患者遲緩超濾（SCUF）治療Hypotensionwasobservedonlyinthosepatients(2/24)whoreachedanIVCCI＞30%.Inalltheotherpatients,asignificantincreaseinIVC-CIwasobtainedwithouthemodynamicinstabilityMeanUFtimewas20.3±4.6hwithameanvolumeof287.6±96.2mlh-1andatotalultrafiltrateproductionof5,780.8±1,994.6ml.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)20/52IVC-CItoguidefluidremovalinslowcontinuousultrafiltration:apilotstudyIntensiveCareMed.Apr;36(4):692-6IVCultrasoundisarapid,simple,andnon-invasivemeansforbedsidemonitoringofintravascularvolumeduringSCUFandmayguidefluidremovalvelocity.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)21/52AmJEmergMed.Aug;31(8):1208-14Cutoffvalues=ADHFwereLVEF＜45%,IVC-CI＜20%,and≥10B-lines.LVEF、IVC-CIandB-lines聯(lián)合診療急性呼吸困難心衰患者周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)22/52鎖骨下靜脈和下腔靜脈塌陷指數(shù)（IVC-CIandSCV-CI）JSurgRes.Sep;184(1):561-6周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)23/52SCV-CIversusIVC-CI.Linearregressiondemonstratesacceptablecorrelationbetweenthetwomeasurementmodalities(R2[0.61).(Colorversionoffigureisavailableonline.)MeasurementbiasplotcomparingIVC-CIandSCV-CIacrossabroadrangeofcollapsibilityvalues.JSurgRes.Sep;184(1):561-6鎖骨下靜脈和下腔靜脈塌陷指數(shù)（IVC-CIandSCV-CI）周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)24/52CritCareMed.Mar;41(3):833-41Point-of-careultrasoundtoestimatecentralvenouspressure:acomparisonofthreetechniques下腔靜脈直徑比下腔靜脈塌陷指數(shù)與CVP更含有相關(guān)性R2=0.58R2=0.21R2=0.16周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)25/52TestCharacteristicsofThreeUltrasoundTechniquesinPredictingCVP<10mmHgCritCareMed.Mar;41(3):833-41Amongspontaneouslybreathingpatientswithoutvasopressorsupport,themaximalICVDisamorerobustestimateofCVPthantheIVCCIortheIJVSR（頸內(nèi)靜脈縱橫比）.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)26/52五、床旁超聲預(yù)測容量反應(yīng)之舒張末期容積（LVEDA、GEDV）*pValuebaselinevhemorrhage;?pValuehemorrhagevhypervolemia;?pValuebaselinevhypervolemiaJCardiothoracVascAnesth.Oct;21(5):650-4周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)27/52JCritCare.Jun;27(3):325.e7-13全心舒張末期容積（GEDV）預(yù)測容量反應(yīng)＊P＜0.05(BLnonrespondervsBLresponder)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)28/52全心舒張末期容積（GEDV）預(yù)測容量反應(yīng)JCritCare.Jun;27(3):325.e7-13周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)29/52六、床旁超聲預(yù)測容量反應(yīng)之主動脈(AO)ΔPeak是用從左室流出道水平測得吸氣時主動脈內(nèi)最大峰值血流速和呼氣時最小峰值血流速之差與二者平均值比率。公式以下(Vpeakmax和Vpeakmin分別表示最大和最小峰值血流速):

Δpeak＝(Vpeakmax-Vpeakmin)［(Vpeakmax+Vpeakmin/2]×100％。機(jī)械通氣患者主動脈峰值血流速度呼吸變異率(Δpeak)或主動脈速度時間積分呼吸改變率(ΔVTI)代表了容量反應(yīng)性改變幅度及前負(fù)荷。周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)30/52六、床旁超聲預(yù)測容量反應(yīng)之主動脈(AO)在心尖五腔心斷面，左心室流出道能夠測量主動脈瓣速度時間積分（VTI）公式以下(VTImax和VTImin分別表示主動脈瓣速度時間積分最大和最小值):

ΔVTI＝（VTImax-VTImin)/[(VTImax+VTImin)/2]×100%機(jī)械通氣患者主動脈峰值血流速度呼吸變異率(Δpeak)或主動脈速度時間積分呼吸改變率(ΔVTI)代表了容量反應(yīng)性改變幅度及前負(fù)荷。周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)31/52機(jī)械通氣患者主動脈峰值血流速度呼吸變異率(Δpeak)能夠預(yù)測容量反應(yīng)PediatrCardiol.Nov;31(8):1166-70.主動脈峰值血流速度呼吸變異率(Δpeak)預(yù)測容量反應(yīng)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)32/52Chest.Mar;119(3):867-73.Δpeak預(yù)測機(jī)械通氣膿毒癥患者容量反應(yīng)Thebestcut-offfor?Vpeakaowas12%,withsensitivity,specificity,andpositiveandnegativepredictivevaluesof81.2%,85.7%,93%and66.6%.?PS=respiratoryvariationsinsystolicarterialpressure(SPV);?PP=respiratoryvariationsinpulsepressure(PPV)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)33/52Chest.Mar;119(3):867-73.Δpeak預(yù)測機(jī)械通氣膿毒癥患者容量反應(yīng)Δpeak?PS=respiratoryvariationsinsystolicarterialpressure(SPV);?PP=respiratoryvariationsinpulsepressure(PPV)?PP?PSPulsedDopplerbeforeVEaccuratelypredicttheeffectsofVE,?PSand?PPareoflittlevalueinventilatedchildren周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)34/52A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness研究方法：前瞻性研究，55例機(jī)械通氣患者。10秒以上輸液晶體溶液50毫升，另外450毫升15分鐘輸注。心輸出量（CO），每搏量（SV），主動脈速度時間指數(shù)（VTI），與左室射血分?jǐn)?shù)（LVEF）被統(tǒng)計(jì)。評定內(nèi)容：特征曲線下面積（AUC）：ΔCo50，Δco500，Δvti50WuY,ZhouS,LiuB.etal.CriticalCare,18:R108對機(jī)械通氣患者ΔVTI能夠評定容量反應(yīng)性周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)35/52WuY,ZhouS,LiuB.etal.CriticalCare,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessPatientcharacteristicsstratifiedbyfluidrespondersandnon-respondersatbaseline周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)36/52WuY,ZhouS,LiuB.etal.CriticalCare,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessHemodynamicvariablesweremeasuredatbaseline,duringvolumeexpansion周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)37/52WuY,ZhouS,LiuB.etal.CriticalCare,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness(A)CorrelationbetweenΔVTI50(%)andΔVTI500(%).(B)CorrelationbetweenΔCO50(%)andΔCO500(%)周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)38/52WuY,ZhouS,LiuB.etal.CriticalCare,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessBlandandAltmandiagrambetweenvariationofcardiacoutput(A)andvariationofvelocitytimeindex(B)after50-mlor500-mlvolumeexpansion.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)39/52WuY,ZhouS,LiuB.etal.CriticalCare,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)40/52A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessIndividualvaluesofΔVTI50(%)(A),ΔSV50(%)(B),andΔCO50(%)(C)afterinfusionof50mloffluidover10secondschangedinpatientswithvolumeexpansion-inducedchangesinstrokevolume(SV)ofatleast10%(responders)andlessthan10%(non-responders).WuY,ZhouS,LiuB.etal.CriticalCare,18:R108Incriticallyillpatients,thevariationofCOandVTIaftertheadministrationof50-mlcrystalloidsolutionover10seconds(ΔCO50andΔVTI50)canaccuratelypredictfluidresponsiveness.周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)41/52對機(jī)械通氣血流動力學(xué)不穩(wěn)定患者ΔVTI能夠評定容量反應(yīng)性Anesthesiology.Sep;115(3):541-7.ΔVTI=主動脈速度時間積分呼吸改變率周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)42/52KardiolPol.Mar;67(3):265-71.Variabilityofaorticbloodflowpredictsfluidresponsivenessinspontaneouslybreathinghealthyvolunteers研究背景：Echomeasurementofrespiratoryvariationsofaorticbloodvelocityinventilatedshockpatientscanaccuratelypredicttheeffectofvolumeexpansion.目標(biāo)：Toassesswhetherrespiratoryvariabilityofpeakaorticbloodflowvelocity(ΔVpeak)andofaorticvelocitytimeintegral(ΔVTI)reflectspreload-dependentchangesofcardiacindex(CI)andwhetheritpredictsfluidresponsivenessinhealthyspontaneouslybreathingvolunteers.結(jié)論：ΔVpeak和ΔVTI與前負(fù)荷改變時CI親密相關(guān)，并證實(shí)在自主呼吸患者也一樣能夠預(yù)測容量反應(yīng)性.ΔVpeak=主動脈峰值血流速度呼吸變異率；ΔVTI=主動脈速度時間積分呼吸改變率周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)43/52CritCare.;13(5):R142.doi:10.1186/cc8027機(jī)械通氣患者肱動脈峰值流速改變率預(yù)測容量反應(yīng)性ΔPPrad=橈動脈脈搏壓力改變率;ΔVpeakbrach=肱動脈峰值流速呼吸改變率;ΔSVVigileo=FloTrac傳感器和Vigileo監(jiān)護(hù)系統(tǒng)七、床旁超聲預(yù)測容量反應(yīng)之外周動脈周樹生經(jīng)胸壁心臟超聲容量評估和指導(dǎo)建議建議快速補(bǔ)液試驗(yàn)44/52機(jī)械通氣患者肱動脈峰值流速改變率預(yù)測容量反應(yīng)性機(jī)械通氣患者,深吸氣時肱動脈ΔVpeakbrach>10%預(yù)測液體反應(yīng)敏感性為74%,