ScvO2的臨床意義課件

ScvO2的臨床意義1內(nèi)容氧供與氧耗SvO2與ScvO2ScvO2的臨床應(yīng)用2氧供與氧耗315vol%=15ml/dl5vol%=5ml/dl45氧供DO2與氧耗VO2DO2=CaO2×CO=(1.34×SaO2×Hb+0.0031×PaO2)×CO

=1.34×SaO2×Hb×COVO2=(CaO2-CvO2)×CO

=(SaO2-SvO2)

×1.34×Hb×COSvO2=SaO2-VO2/(1.34×Hb×CO)

呼吸血紅蛋白循環(huán)(Fick方程)6氧攝取EO2EO2=VO2/DO2EO2=(SaO2

-

SvO2)/SaO2當(dāng)SaO2=100%時：EO2=1-SvO2全身

EO2=1-75%=25%各組織EO2不同，其相應(yīng)之靜脈氧飽和度不同SvO2

=

1

-

EO27氧供氧耗失衡SvO2降低或增加無氧代謝組織缺氧乳酸生成8影響SvO2的因素75%-+DO2應(yīng)激發(fā)熱寒戰(zhàn)躁動疼痛呼吸做功VO2CO(心衰、低容量）Hb（貧血、出血）SaO2（缺氧、呼衰）DO2CO（液體復(fù)蘇、正性肌力）Hb（輸血）SaO2（氧療）VO2低體溫鎮(zhèn)靜鎮(zhèn)痛麻醉機械通氣氧攝?。ǚ至?、細胞死亡）9SvO2的界值PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.

10ScvO2與SvO211ScvO2與SvO212ScvO2與SvO2SvO2由肺動脈導(dǎo)管測得反映全身的氧耗量正常值：75%ScvO2由中心靜脈（上腔靜脈）導(dǎo)管測得反映腦及上半身的氧耗量正常值：72%13測定方法連續(xù)監(jiān)測光纖導(dǎo)管或光纖中心靜脈導(dǎo)管間斷測定中心靜脈血氣1415正常各組織器官的靜脈氧飽和度PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.

16休克時？17ScvO2與SvO2的相關(guān)性CharalambosLadakisPavlosMyrianthefsAndreasKarabinisetal.CentralVenousandMixedVenousOxygenSaturationinCriticallyillpatients,Respairation,2001;68279-285LinearcorrelationofpairedScvO2andSvO2measurementsfor296pairedsamplesScvO2increasesby0.87%foreveryunitincreaseinSvO218ScvO2與SvO2的相關(guān)性DueckMHetal.Anesthesiology2005;103:249–5719Mo?inaandPodbregarCriticalCare2010,14:R42th20Mo?inaandPodbregarCriticalCare2010,14:R4221Mo?inaandPodbregarCriticalCare2010,14:R4222Mo?inaandPodbregarCriticalCare2010,14:R4223SvO2與ScvO2的一致性絕對值相差5~18%24ScvO2的臨床應(yīng)用25休克中的應(yīng)用VO2DO2ScvO2/SvO2乳酸休克的本質(zhì)是組織缺氧和氧代謝障礙，最終結(jié)果是MODS。液體復(fù)蘇、及早糾正氧供與氧耗的失衡、降低組織缺氧程度至關(guān)重要。26急診患者的復(fù)蘇多數(shù)（31例/36例）存在休克的危重患者經(jīng)初期復(fù)蘇至正常生命體征后乳酸繼續(xù)升高(>2mmol/L)，ScvO2仍低于正常(<65%)，提示存在無氧酵解和氧債。這些患者進一步治療后乳酸下降（4.6±3.8to2.6±2.5,p<0.05)，ScvO2升高（52±18to65±13%,p<0.05)ScvO2能作為初期復(fù)蘇后指導(dǎo)休克治療的指標(biāo)RadyMY,RiversEP,NovakRM:ResuscitationofthecriticallyillintheED:responsesofbloodpressure,heartrate,shockindex,centralvenousoxygensaturation,andlactate.AmJEmergMed1996,14:218-225.27重癥感染與感染性休克中的應(yīng)用1368·1377NEnglJMed,Vol.345,No.19·November8,2001早期目標(biāo)指導(dǎo)治療（EGDT）2829研究結(jié)果——死亡率30RiversE,NguyenB,HavstadS,eta1．Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.NEngJMed,2001,345:1368—1377.進行ScvO2監(jiān)測，達到EGDT目標(biāo)，可使患者病死率下降16%（46.5%vs30.5%）。低ScvO2的預(yù)后差312012“拯救膿毒癥運動”指南

——早期復(fù)蘇目標(biāo)MAP≥65mmHgCVP8~12mmHg,機械通氣12~15mmHg尿量≥0.5ml/kg/hScvO2≥70%orSvO2≥65%32感染性休克高ScvO2的預(yù)后3334單因素分析結(jié)果35存活組與死亡組的ScvO236該研究共納入4家醫(yī)院急診科膿毒癥患者619名，按EDGT復(fù)蘇方案治療，據(jù)ScvO2水平分為三組：低ScvO2組(＜70%)、正常ScvO2組(71~89%)、高組(90~100%)。比較住院死亡率并進行多因素分析3723%25%31%初始ScvO2與死亡率(81/351)(56/223)(14/45)3825/6296/46531/9239ScvO2在ACS中的應(yīng)用該研究納入患者43名，為收住CCU的急性冠脈綜合征（ACS）并急性肺水腫或心源性休克患者，測定入室時、24h、48h的中心靜脈和外周動脈血氣，主要終點為致死性事件，次要終點為住院全因死亡率ActaCardiolSin2008;24:1263340結(jié)果：存活組與死亡組ScvO2的差異有顯著性ActaCardiolSin2008;24:1263341所有患者ScvO2、SaO2的變化存活患者ScvO2的變化ActaCardiolSin2008;24:1263342創(chuàng)傷患者的評估Lowcentralvenoussaturationpredictspooroutcomeinpatientswithbraininjuryaftermajortrauma:aprospectiveobservationalstudyAlessandroDiFilippo*1,ChiaraGonnelli1,LuciaPerretta1,Rosariopina1,MarcoChiostri2,GianFrancoGensini2andAdrianoPeris1ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:2343ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:23ScvO2≤65%的患者住院時間延長，死亡率明顯增加44急診插管對重癥患者ScvO2的影響15minHernandezetal.CriticalCare2009,13:R6345Hernandezetal.CriticalCare2009,13:R6346插管改善ScvO2的機制插管前預(yù)充純氧，溶解氧增加，氧供提高插管時鎮(zhèn)靜與肌松使氧攝取減少而降低氧耗初始機械通氣減輕了過度通氣，使pH升高而使氧離曲線右移，利于氧釋放47圍術(shù)期ScvO2的應(yīng)用48患者資料49單因素分析Aftermultivariateanalysis,meanScvO2value(OR1.23[95%CI1.01to1.50],p=0.037),hospitalLOS(OR0.75[95%CI0.59to0.94],p=0.012),andSAPSII(OR0.90[95%CI0.82to0.99],p=0.029)wereindependentlyassociatedwithpostoperativecomplications.多因素分析50低ScvO2與術(shù)后并發(fā)癥相關(guān)P=0.004TheoptimalvalueofmeanScvO2fordiscriminatingbetweenpatientswhodidordidnotdevelopcomplicationswas73%(sensitivity72%,specificity61%)51ScvO2與乳酸在感染性休克中應(yīng)用比較Jones的研究顯示：在感染性休克的早期目標(biāo)性治療中，乳酸清除率達標(biāo)與ScvO2達標(biāo)，兩組的住院死亡率無差別【25%（17~30%）vs17%（11~24%）】。JonesAEetal.JAMA.2010February24;303(8):739–74652ScvO2與容量反應(yīng)性大循環(huán)指標(biāo)：血壓、心率、尿量、CVPCO、CIPPVSVVScvO2?53ScvO2AsaMarkertoDefineFluidResponsivenessMethods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNRMethods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNRGiraudR,etal.JTrauma.2011;70:802–80754ScvO2AsaMarkertoDefineFluidResponsivenessGiraudR,etal.JTrauma.2011;70:802–80755ScvO2AsaMarkertoDefineFluidResponsivenessGiraudR,etal.JTrauma.2011;70:802–80756ScvO2AsaMarkertoDefineFluidResponsivenessResults:ScvO2andSvO2variationsafterVE(SvO2)weresignificantlycorrelatedwithCIchanges(CI)afterVE(r0.67andr=0.49,p<0.001,respectively).AScvO2thresholdvalueof4%allowedthedefinitionofRandNRpatientswith86%sensitivity(95%CI;57–98%)and81%specificity(95%CI;54–96%)GiraudR,etal.JTrauma.2011;70:802–80757ScvO2的局限性58爭論：ScvO2不能反映SvO2Biasofdifferencewas4.2%and95%limitsofagreementrangedfrom–8.1%to16.5%.Thecentralvenousoxygensaturationoverestimatedthemixedvenousoxygensaturationbyameanbias(oranabsolutedifference)of6.9%,andthe95%limitsofagreementwerelarge(-5.0%to18.8%).Thedifferencebetweencentralandmixedvenousoxygensaturationappearedtobemoresignificantwhenmixedvenousoxygensaturationwas<70%VarpulaMetal.IntensiveCareMed(2006)32:1336–1343HoKMetal.JCardiothoracVascAnesth.2010Jun;24(3):434-9.

5956.7%36%7.3%ScvO2初始值差異大(351)(223)(45)PopeJVetal.AnnEmergMed.2010January;55(1):40–46總數(shù)61960組織氧代謝指標(biāo)胃粘膜pH組織氧飽和度（StO2）微透析測組織代謝聯(lián)合指標(biāo)……？SvO2/ScvO2不能很好反應(yīng)組織氧代謝61微透析？6263ScvO2+CO2gap的意義KocsiSetal.CriticalCareResearchandPracticeVolume2013,ArticleID583598,7pages64InICUresuscitatedpatients,targetingonlyScvO2maynotbesufficienttoguidetherapy.Whenthe70%ScvO2goalvalueisreached,thepresenceofaP(cv-a)CO2largerthan6mmHgmightbeausefultooltoidentifypatientswhostillremaininadequatelyresuscitated.IntensiveCareMed(2008)34:2218-222550consecutivesepticshockpatientswithScvO2＞70%ScvO2+CO2gap的意義65SvO2ScvO2DO2VO2氧利用6667

改善氧供——改善氧耗？線粒體RampalT.CurrOpinCritCare16:244–24968總結(jié)ScvO2與SvO2相關(guān)性較好，動態(tài)監(jiān)測可反映機體的全身氧代謝狀況ScvO2可作為重癥患者病情評估、預(yù)后判斷的有效參考指標(biāo)ScvO2可用于重癥患者的治療指導(dǎo)ScvO2存在其局限性，不能替代醫(yī)師的臨床綜合判斷將來——細胞水平缺氧的判斷與治療？！69謝謝！70ScvO2與P(cv-a)CO2對外科感染性休克液體復(fù)蘇的臨床研究昆明醫(yī)科大學(xué)第二附屬醫(yī)院71研究背景本研究是針對腹部外科術(shù)后感染性休克患者，監(jiān)測入ICU最初6小時復(fù)蘇前后ScvO2、P(cv-a)CO2，探討其變化是否能更好的指導(dǎo)患者早期復(fù)蘇治療，尋找最佳的復(fù)蘇目標(biāo)，以及是否能對病情和預(yù)后作出評估和判斷。72

本研究共納入2012年1月～2013年3月期間所有收入昆明醫(yī)科大學(xué)第二附屬醫(yī)院重癥醫(yī)學(xué)科（ICU）外科術(shù)后感染性休克患者46例，其中住ICU死亡10例，28天死亡16例，住ICU病死率21.7%，28天病死率34.8%。實驗結(jié)果73檢測項目T0T6t值P值HR（次/分）113.43±22.46106.96±21.632.3730.022MAP（mmHg）75.11±17.375.11±13.320.0001.000CVP（cmH2O）14.58±5.8214.47±5.470.1710.860CO（L/min）8.15±6.866.42±3.451.0680.296P(cv-a)CO2（mmHg）7.93±6.165.87±3.101.8960.044*ScvO2（%）69.67±10.9772.28±9.42-2.0020.049*Lac（mmol/L）4.47±2.693.40±2.584.5010.000*BE（mmol/L）-6.32±4.33-4.19±4.58-2.9700.005*PaO2/FiO2（mmHg/%）207.02±74.54199.11±83.790.6820.499Cr（μmol/L）151.35±129.48140.52±105.651.1670.3086小時復(fù)蘇前后參數(shù)資料比較實驗結(jié)果P=0.044P=0.005P=0.00074實驗結(jié)果

lac丨BE丨T0時ScvO2r值-0.1690.107P值0.2610.480T6時ScvO2r值-0.342-0.299P值0.0200.044ScvO2與lac、BE相關(guān)性分析lac丨BE丨T0時P(cv-a)CO2r值0.171-0.111P值0.2570.461T6時P(cv-a)CO2r值0.652-0.495P值0.0000.000P(cv-a)CO2與lac、BE相關(guān)性分析75實驗結(jié)果ScvO2與CO相關(guān)性分析P(cv-a)CO2與CO相關(guān)性分析COT0時ScvO2r值0.391P值0.048T6時ScvO2r值0.664P值0.039COT0時P(cv-a)CO2r值-0.183P值0.040T6時P(cv-a)CO2r值-0.521P值0.00276實驗結(jié)果ScvO2與P(cv-a)CO2的相關(guān)性分析T0P(cv-a)CO2T0ScvO2T6P(cv-a)CO2T6ScvO2T0時r=-0.358，P=0.011T6時r=-0.425，P=0.003T0P(cv-a)CO2T6ScvO277實驗結(jié)果檢測項目生存組(30例）死亡組（16例）t值P值HR（次/分）103．23±21.38113.94±21.02-1.6270.111MAP（mmHg）73.97±14.3077.25±11.37-0.7930.432CO（L/min）6.33±2.126.69±2.55-0.3900.700CVP（mmHg）14.03±5.5915.28±5.30-0.7330.467Lac（mmol/L）2.09±1.005.88±2.85-5.1500.0006小時乳酸清除率0.42±0.21-0.18±0.495.7390.000ScvO2（%）74.4