經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗課件

SeriesPPTofIntensivecareunit（）經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗Thisstudyof2,289patientsincludedprospectivelyfromtwodifferentcohortsinaquaternary-levelprovincialreferralhospitalinBC,Canada.(47.75%)CritCareMed.

2014Jul22

經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗在管理血流動力學不穩(wěn)定的患者中，常見策略是提高心排血量和組織灌注，故評估患者的容量狀態(tài)極其重要；對評估容量狀態(tài)容量無反應(yīng)的患者，增加容量負荷不但不能引起心輸出量的增加，反而會增加組織水腫及缺氧，故在進行快速補液時應(yīng)首先對患者進行容量評估。JIntensiveCareMed.2009Sep-Oct;24(5):329-37Techniquesforassessmentofintravascularvolumeincriticallyillpatients經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗德國生理學家OttoFrank英國生理學家StarlingFrank-Starling機制經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗靜態(tài)前負荷參數(shù)：前負荷壓力指標（CVP）及前負荷容量指標（全心舒張末期容積，GEDV）；動態(tài)前負荷參數(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（PLR）等。CardiovascUltrasound.2008Oct6;6:49.WorldInteractiveNetworkFocusedonCritical

Ultrasound

(WINFOCUS)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗血壓（BP）：失血量達18%仍然可以通過提高血管阻力來維持相對正常的MAP;中心靜脈壓（CVP）和肺動脈楔壓(PAWP)：通過壓力代容積來反應(yīng)心臟前負荷，均受到心臟順應(yīng)性，機械通氣和血管張力等因素影響；經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗超聲FATE(focusassessedtransthoracicecho)草案經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗Researchhassuggestedthatvolumeresponsivenesscanbedefinedasa15%increaseinstrokevolume(SV)orcardiacoutput(CO)aftera500mlinfusion.AnesthAnalg.2010Nov;111(5):1180-92Acriticalreviewoftheabilityofcontinuouscardiacoutputmonitorstomeasuretrendsincardiacoutput經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗床旁超聲下腔靜脈直徑（IVCD）測量方法KoreanJInternMed2014;29:241-245一、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈直徑（IVCD）經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗JEmergMed.2012Apr;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，下腔靜脈直徑變化與CVP具有相關(guān)性(P＜0.001)，下腔靜脈直徑在1-2CM范圍具有較高的特異性和敏感性.(A)Subxiphoid,transverseorientation,atendinspiration.(B)Subxiphoid,longitudinalorientation,atendinspiration.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗inferiorvenacavadiameter(IVCD)andcentralvenouspressurevalue(CVP)PakJMedSci.2014Mar;30(2):310-5.下腔靜脈長軸切面經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗IVC=inferiorvenacava;CVP=centralvenouspressure.Statisticallyrelationship

betweenIVCandCVPpressuresPakJMedSci.2014Mar;30(2):310-5.結(jié)論：自主呼吸患者，下腔靜脈直徑變化可以預(yù)測容量反應(yīng)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗下腔靜脈擴張指數(shù)(dIVC)＝(Dmax(吸氣末)-Dmin(呼氣末))／DminIntensiveCareMed.2004Sep;30(9):1740-630-minvolumeexpansion(7ml/kg)using4%modifiedfluidgelatin二、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈擴張指數(shù)(dIVC)BaselineAftervolumeexpansion經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗RespiratorychangesininferiorvenacavadiameterarehelpfulinpredictingfluidresponsivenessinventilatedsepticpatientsIntensiveCareMed.2004Sep;30(9):1740-6機械通氣患者，dIVC＞18％，預(yù)測容量反應(yīng)性敏感性和特異性均在90％以上.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗下腔靜脈呼吸變化率（△DIVC）=（Dmax-Dmin)/(Dmax+Dmin)IntensiveCareMed.2004Sep;30(9):1834-7三、床旁超聲預(yù)測容量反應(yīng)之下腔靜脈呼吸變化率（△DIVC）Astudied39mechanicallyventilatedpatientswithsepticshock.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗Individualvalues(opencircles)andmean±SD(closedcircles)oftheminimumDIVC,maximumDIVCand△DIVCbeforvolumeloadinginresponder(R)andnon-responder(NR)patients.*P<0.05RvsNR下腔靜脈呼吸變化率＞12％，預(yù)測容量反應(yīng)性的陽性和陰性分別為93％和92％.IntensiveCareMed.2004Sep;30(9):1834-7經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗四、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.2009Jul;209(1):55-61經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗JACCCardiovascImaging.2011Sep;4(9):938-45下腔靜脈≥2cm(精確度88％)和下腔靜脈塌陷＜40％(精確度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）經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗IntensiveCareMed.2010Apr;36(4):692-6IVC-CI指導(dǎo)心衰患者緩慢超濾（SCUF）治療Hypotensionwasobservedonlyinthosepatients(2/24)whoreachedanIVCCI＞30%.Inalltheotherpatients,asignificantincreaseinIVC-CIwasobtainedwithouthemodynamicinstabilityMeanUFtimewas20.3±4.6hwithameanvolumeof287.6±96.2mlh-1andatotalultrafiltrateproductionof5,780.8±1,994.6ml.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗IVC-CItoguidefluidremovalinslowcontinuousultrafiltration:apilotstudyIntensiveCareMed.2010Apr;36(4):692-6IVCultrasoundisarapid,simple,andnon-invasivemeansforbedsidemonitoringofintravascularvolumeduringSCUFandmayguidefluidremovalvelocity.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗AmJEmergMed.2013Aug;31(8):1208-14Cutoffvalues=ADHFwereLVEF＜45%,IVC-CI＜20%,and≥10B-lines.LVEF、IVC-CIandB-lines聯(lián)合診斷急性呼吸困難心衰患者經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗鎖骨下靜脈和下腔靜脈的塌陷指數(shù)（IVC-CIandSCV-CI）JSurgRes.2013Sep;184(1):561-6經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗SCV-CIversusIVC-CI.Linearregressiondemonstratesacceptablecorrelationbetweenthetwomeasurementmodalities(R2[0.61).(Colorversionoffigureisavailableonline.)MeasurementbiasplotcomparingIVC-CIandSCV-CIacrossabroadrangeofcollapsibilityvalues.JSurgRes.2013Sep;184(1):561-6鎖骨下靜脈和下腔靜脈的塌陷指數(shù)（IVC-CIandSCV-CI）經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗CritCareMed.2013Mar;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更具有相關(guān)性R2=0.58R2=0.21R2=0.16經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗TestCharacteristicsofThreeUltrasoundTechniquesinPredictingCVP<10mmHgCritCareMed.2013Mar;41(3):833-41Amongspontaneouslybreathingpatientswithoutvasopressorsupport,themaximalICVDisamorerobustestimateofCVPthantheIVCCIortheIJVSR（頸內(nèi)靜脈的縱橫比）.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗五、床旁超聲預(yù)測容量反應(yīng)之舒張末期容積（LVEDA、GEDV）*pValuebaselinevhemorrhage;?pValuehemorrhagevhypervolemia;?pValuebaselinevhypervolemiaJCardiothoracVascAnesth.2007Oct;21(5):650-4經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗JCritCare.2012Jun;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)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗全心舒張末期容積（GEDV）預(yù)測容量反應(yīng)JCritCare.2012Jun;27(3):325.e7-13經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗六、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的吸氣時主動脈內(nèi)最大峰值血流速和呼氣時最小峰值血流速之差與兩者平均值的比率。公式如下(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變化率(ΔVTI)代表了容量反應(yīng)性變化的幅度及前負荷。經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗六、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，左心室流出道可以測量主動脈瓣的速度時間積分（VTI）公式如下(VTImax和VTImin分別表示主動脈瓣的速度時間積分最大和最小值):

ΔVTI＝（VTImax-VTImin)/[(VTImax+VTImin)/2]×100%機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變化率(ΔVTI)代表了容量反應(yīng)性變化的幅度及前負荷。經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗機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.2010Nov;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)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗Chest.2001Mar;119(3):867-73.Δpeak預(yù)測機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)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗Chest.2001Mar;119(3):867-73.Δpeak預(yù)測機械通氣膿毒癥患者容量反應(yīng)Δpeak?PS=respiratoryvariationsinsystolicarterialpressure(SPV);?PP=respiratoryvariationsinpulsepressure(PPV)?PP?PSPulsedDopplerbeforeVEaccuratelypredicttheeffectsofVE,?PSand?PPareoflittlevalueinventilatedchildren經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness研究方法：前瞻性研究，55例機械通氣患者。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），與左室射血分數(shù)（LVEF）被記錄。評估內(nèi)容：特征曲線下面積（AUC）：ΔCo50，Δco500，Δvti50WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108對機械通氣患者ΔVTI可以評估容量反應(yīng)性經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessPatientcharacteristicsstratifiedbyfluidrespondersandnon-respondersatbaseline經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessHemodynamicvariablesweremeasuredatbaseline,duringvolumeexpansion經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness(A)CorrelationbetweenΔVTI50(%)andΔVTI500(%).(B)CorrelationbetweenΔCO50(%)andΔCO500(%)經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessBlandandAltmandiagrambetweenvariationofcardiacoutput(A)andvariationofvelocitytimeindex(B)after50-mlor500-mlvolumeexpansion.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessIndividualvaluesofΔVTI50(%)(A),ΔSV50(%)(B),andΔCO50(%)(C)afterinfusionof50mloffluidover10secondschangedinpatientswithvolumeexpansion-inducedchangesinstrokevolume(SV)ofatleast10%(responders)andlessthan10%(non-responders).WuY,ZhouS,LiuB.etal.CriticalCare2014,18:R108Incriticallyillpatients,thevariationofCOandVTIaftertheadministrationof50-mlcrystalloidsolutionover10seconds(ΔCO50andΔVTI50)canaccuratelypredictfluidresponsiveness.經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗對機械通氣血流動力學不穩(wěn)定患者ΔVTI可以評估容量反應(yīng)性Anesthesiology.2011Sep;115(3):541-7.ΔVTI=主動脈速度時間積分呼吸變化率經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗KardiolPol.2009Mar;67(3):265-71.Variabilityofaorticbloodflowpredictsfluidresponsivenessinspontaneouslybreathinghealthyvolunteers研究背景：Echomeasurementofrespiratoryvariationsofaorticbloodvelocityinventilatedshockpatientscanaccuratelypredicttheeffectofvolumeexpansion.目的：Toassesswhetherrespiratoryvariabilityofpeakaorticbloodflowvelocity(ΔVpeak)andofaorticvelocitytimeintegral(ΔVTI)reflectspreload-dependentchangesofcardiacindex(CI)andwhetheritpredictsfluidresponsivenessinhealthyspontaneouslybreathingvolunteers.結(jié)論：ΔVpeak和ΔVTI與前負荷改變時的CI密切相關(guān)，并證實在自主呼吸的患者也同樣可以預(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變化率經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗CritCare.2009;13(5):R142.doi:10.1186/cc8027機械通氣患者肱動脈峰值流速變化率預(yù)測容量反應(yīng)性ΔPPrad=橈動脈脈搏壓力變化率;ΔVpeakbrach=肱動脈峰值流速呼吸變化率;ΔSVVigileo=FloTrac傳感器和Vigileo監(jiān)護系統(tǒng)七、床旁超聲預(yù)測容量反應(yīng)之外周動脈經(jīng)胸壁心臟超聲容量評估及指導(dǎo)快速補液試驗機械通氣患者肱動脈峰值流速變化率預(yù)測容量反應(yīng)性機械通氣患者,深吸氣時肱動脈ΔVpeakbrach>10%預(yù)測液體反應(yīng)的敏感性為74%,特異性為95%;ΔP