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Haemodynamics - putting the puzzle together.,Associate Professor Brendan E. Smith. School of Biomedical Science, Charles Sturt University, Specialist in Anaesthesia and Intensive Care, Bathurst Base Hospital, Bathurst, NSW, Australia.,HR SVR Hb,SV DO2 CVP,CO SpO2 BP,血液动力学 - 把难题集中起来,布兰登.爱德华德.史密斯 澳大利亚新南威尔士州查尔斯.斯图特大学生物医学副教授、 澳大利亚新南威尔士州巴斯罗斯特医院麻醉和重症监护专家.,HR SVR Hb,SV DO2 CVP,CO SpO2 BP,Data Acquisition. 获得数据,Haemodynamic data can be acquired in many ways 许多方法能得到血液动力学数据 Trans-Thoracic Echocardiography 经胸超声心动描记 Trans-Oesphageal Echocardiography 经食道超声心动描记 USCOM Doppler examination USCOM多普勒检查 Impedence Plethysmography 阻抗体积描记法 Pulmonary Artery Catheter 肺动脉导管 PiCCO 脉搏轮廓温度稀释连续心排量测量技术 Etc etc.等等 Each has its own benefits and drawbacks, 每种方法都有优点和缺点 BUT.但是,However we obtain the raw data we still have a big problem 但是得到原始数据后,我们仍有个大问题 What do all these figures? 这些数据意味着什么? How can we put it all together to help our patients? 如何将这些数据结合在一起帮助治疗病人?,Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,Hb SpO2,Oxygen Delivery DO2,Heart Rate,SVR,X,X,心 排 量,每搏输出,血 压,前负荷 心脏收缩 后负荷,Hb SpO2,氧运 DO2,心 率,外周阻力,X,X,To live we have to have 维持生命必须有,Blood pressure,and blood flow! 血压和血流,Blood pressure doesnt tell us anything about the hearts ability to deliver oxygen! 血压不能告诉我们关于心脏运氧能力的任何信息,Blood Pressure血压,Her blood pressure is normal. 这个女婴血压正常,Anybody NOT want to know her C.O. and DO2?! 有人会不想知道她的心排量和氧运吗?! (By permission of Dr Joe Brierley, GOSH, London.),Haemodynamics used to be a highly invasive science 血液动力学曾经是个高创伤技术,Insertion of PA Catheter was 肺动脉导管的插入是 Difficult (especially in children) 困难的(尤其在儿童) Dangerous 危险的 Time consuming 费时的 Expensive 昂贵的 Of doubtful value!数据可疑,All the data provided by PAC (and more) can be obtained non-invasively 用肺动脉导管(或其他有创方法)获得的数据可 以用无创方法得到,Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,Hb SpO2,Oxygen Delivery DO2,Heart Rate,SVR,心 排 量,每 搏 输 出,血压,前负荷 心脏收缩 后负荷,Hb SpO2,氧运 DO2,心 率,外周阻力,The Ultrasonic Cardiac Output Monitor - USCOM 连续多普勒心排量监测仪,Suprasternal CW Doppler,Parasternal CW Doppler,胸骨上连续多普勒监测,胸骨旁连续多普勒监测,What other data do we get? 还能得到其他什么数据?,Vpk = Peak Ejection Velocity峰值速度,CO / CI = Cardiac Output / Index CO/CI 心排量/心脏指数,Why Cardiac Index v Cardiac Output? 为什么心脏指数要和心排量比较?,The same applies to Stroke Volume, SVR and many other parameters in haemodynamics 同样可以应用于每搏输出、外周阻力和血液动力 学的其他参数 so we use因此可以用 Stroke Volume Index SVI 每搏输出分数 SVR index SVRI 外周阻力分数 DO2 Index DO2I 氧运分数 VO2 Index VO2I 氧耗分数 Etc等等,MD = Minute Distance = Aortic Velocity MD分钟距离=动脉速度,SV = Stroke volume每搏输出 Ejection Time + SV = Inotropy 射血时间+每搏输出=心脏收缩能力,SVR = Systemic Vascular Resistance 外周阻力,Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,Hb SpO2,Oxygen Delivery DO2,Heart Rate,SVR,Pulse Oximeters脉搏血氧计,Pulse Oximetry + Hb 脉搏血氧和血红蛋白,Central Venous Oxygen Saturation 中心静脉氧饱和度,Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,Hb SpO2,Oxygen Delivery DO2,Heart Rate,SVR,Afterload后负荷,Depends on:取决于 Degree of vasoconstriction / dilation 血管收缩/扩张的程度 Density & viscosity of blood血液密度和粘滞度 Flow rate of blood / surface tension forces 血流速率/表面张力 Elasticity of arteries动脉弹性 Stroke volume 每搏输出 等等,These are all the same factors that determine mean aortic root pressure So afterload is exactly the same as mean aortic root pressure. MAP = diastolic + (systolic diastolic) But can we use radial artery pressure?,平均动脉基础压力也是这些同样的因素确定的 所以后负荷就是和平均动脉基础压力一样的. 平均动脉压 = 舒张压+ (收缩压 舒张压) 但是可以用桡动脉压吗?,Mean Pressure = P.dt = Pressure time integral = Pti,t,t,P,Integrated Pressure,time,P2 P1,P2,P1,平均压力= P.dt = 压力时间积分= Pti,t,t,P,压力积分,time,P2 P1,P2,P1,Pti-A,Pti-R,Pti-Aortic and Pti-Radial are close enough in clinical practice to make no significant difference to haemodynamic calculations. 主动脉压力时间积分和桡动脉压力时间积分在临床上是如此相近,以致于在血液动力学计算上无明显差异。 (error typically 5%) (误差5%),Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,(Hb) SpO2,Oxygen Delivery DO2,Heart Rate,SVR,Inotropy.,Inotropy (myocardial contractility) as a concept is well known to all clinicians but not as a discrete quantity. Depressed inotropy is an important feature of many ICU presentations 1o Cardiac Conditions AMI, LVF, Cardiomyopathy,心脏收缩能力.,心肌收缩能力作为一个概念为所有临床医生所熟知,但并非只看做为一个不相关的数值 心肌收缩能力低下是许多急性疾病的一个重要特点 1o 心肌功能低下 急性心肌梗塞, 左心功能衰竭, 心肌病,2o Myocardial Depression Septicaemia, Pancreatitis, Pneumonia, DKA, Burns, Hypoxia, Crush Injury, Hypovolaemia, Anaemia, Thyroid Disorders, Hyper + Hypothermia, Poisoning, Evenomation, Iatrogenic e.g. Antihypertensives, chemotherapy, Electrolyte Disorders, Sedation, Steroids, ,2o 心肌功能低下 败血症、胰腺炎、肺炎、糖尿病酮症中毒、烧伤、低氧血症、挤压伤、低血容量症、 贫血、 甲状腺疾病、 高体温和低体温 、中毒、解毒, 治疗引起的并发症等等 、 抗高血压药物、 化疗、电解质紊乱、镇静、激素 ,Why is inotropy so important?,BP = SVR x HR x SV : SV x HR = CO.,Fluid loading,Power of the heart,Blood Pressure,Preload Inotropy Afterload,为什么心肌收缩能力如此重要,血压=外周阻力x心率x每搏量:每搏量x心率=心排量,液体负荷Fluid loading (venous return静脉回流),Power of the heart心功能,Blood Pressure血压,前负荷Preload 心脏收缩 Afterload后负荷,How do we assess inotropy?,- We use surrogates of global cardiac function - BP, HR, urine output, skin perfusion, capillary refill, skin temperature, bowel sounds, sweating, wind direction, mothers seaweed - All of these are notoriously unreliable indicators of cardiac function even in the hands of senior clinicians.,如何评估心脏收缩能力?,- 我们用下面这些指标评价心功能 - 血压,心率,尿量,皮肤灌注,毛细血管再充盈,皮肤温度,肠鸣音,出汗等等 - 即使由有经验的医生观察这些指标,这些指标也都不能真正可信地反映心功能,When should we use inotropes?,In 95% of cases this is done by clinical judgment alone! Which inotrope and how much? What are our therapeutic targets? How do we know weve reached them? If only we could measure inotropy!,什么时候应用心肌药物呢?,在95%的文献中只通过临床推断来决定 那么用什么心肌药物?用药量多少? 要达到什么样的治疗目标? 怎么知道已经到达目标了? 只要我们能评价心肌收缩能力!,How Can We Measure Inotropy? 如何评价心脏收缩能力?,Conservation of Energy,The energy produced by cardiac contraction must be converted to either Potential Energy (PE) in the form of blood pressure or Kinetic Energy (KE) in the form of blood flow. But can we measure PE & KE? Is the measurement reliable? How long does it take? Can we monitor Rx with it?,能量守恒,心肌收缩产生的能量一定要转化为以血压压差形式的势能(PE)或以血流流动形式的动能(KE) 但如何能测出势能和动能呢? 测出的数值可信吗? 测出数值需要多少时间? 我们可以用它指导治疗吗?,Potential Energy,PE developed by the heart appears in the form of the energy needed to raise the stroke volume up to arterial pressure in a given systolic time, the Flow Time. Work Done = P x V PE = MAP x SV Flow Time P = Mean Arterial Pressure - CVP SV and Flow Time are measured directly using CW Doppler.,势能,心脏产生的势能需要在一定的收缩时间内,即流动时间,把每搏输出压力提高到动脉压水平。 做功 = 压力差x 容积差 势能 = 平均动脉压 x 每搏输出 流动时间 压力差= 平均动脉压- 中心静脉压 每搏输出和流动时间可用连续多普勒直接测出,PE = BPm x SV x 10-3 7.5 x FT,Potential Energy,7.5 and 10-3 are required to convert BP in mmHg to kPa and SV in ml to m3 to conform with SI units. The unit for PE is therefore Joules/second, or Watts.,势能 = 平均动脉压 x 每搏输出 x 10-3 7.5 x 流动时间,势能(PE),7.5 和 10-3 是用来转换血压单位由 mmHg 到kPa 和每搏输出量由 ml 到 m3 以符合国际单位。 因此势能的单位是焦耳/秒,即瓦。 .,Kinetic Energy,The KE of any moving mass is given by KE = mV2 The mass of blood ejected per Stroke Volume is - SV(ml) x 10-6 x Density of blood, (1,055 kg/m3) The KE developed by the heart in a given flow time is KE = 1 x SV x 10-6 x x V2 2 x Flow Time (V is measured directly by CW Doppler),移动物体的动能公式是 动能 = mV2 每搏输出的血量质量是- 每搏输出SV(ml) x 10-6 x 血液密度 (1,055 kg/m3) 在一给定流动时间内心脏产生的动能是 KE = 1 x SV x 10-6 x x Vm2 2 x F(流动时间) (m平均速度由USCOM测量计算),动能(KE),Total Inotropy = PE + KE ( = blood pressure + blood flow) Inotropy = BPm x SV x 10-3 + 1 x SV x 10-6 x x V2 7.5 x FT 2 x FT (The Smith-Madigan Formula) The SI unit of inotropy is therefore the Watt.,总收缩力Total Inotropy = PE + KE ( = blood pressure血压 + blood flow血流) Inotropy = BPm x SV x 10-3 + 1 x SV x 10-6 x x Vm2 7.5 x FT 2 x FT (The Smith-Madigan Formula) 史密斯麦迪根公式 Annals of Emergency Medicine 51, No 4. April 2008, 480. 收缩能力的国际计量单位是瓦,Inotropy Index,But how do we judge inotropy in patients of varying size, e.g. large and small adults, children, infants? By analogy to cardiac index which is Cardiac Index = Cardiac Output Body Surface Area Smith-Madigan Inotropy Index = Inotropy BSA,The SI unit of SMII is therefore W/m2,但是如何判断体型大小不同的病人心脏收缩能力呢,比如体型大和小的成人、儿童、婴儿? 和心脏指数类似 心脏指数 = 心排量 体表面积 史密斯麦迪根心脏收缩指数= 收缩能力 体表面积,收缩力指数Inotropy Index,史密斯麦迪根心脏收缩指数的国际单位是W/m2,Smith-Madigan Inotropy Index 史密斯麦迪根心脏收缩指数,Normal Controls正常值 1.6 2.2 W/m2 Left Ventricular Failure左心衰竭 0.4 1.1 W/m2 Septicaemic Shock 0.6 1.2 W/m2,Cardiogenic Shock 心源性休克,74 year old man with STEMI74岁老年男性 BP 84/44, pulse 114, SpO2 84% on 10L/min O2 血压84/44, 心率 114, SpO2 84% on 10L/min O2 Pulmonary Oedema +严重的肺水肿 No urine output 无尿 PaO2 64mmHg, PaCO2 28mmHg Lactate 8.4乳酸盐8.4,8 12 14,2.4,60-75,90,800-1200,0.62 0.97 1.13 1.38 SMII W/m2,Dobutamine mcg/kg/min,Cardiac Output,Stroke Volume,Blood Pressure,Preload Inotropy Afterload,(Hb) SpO2,Oxygen Delivery DO2,Heart Rate,SVR,Preload,JVP / CVP - Only looking at the right side of the heart. - Tells us little about left heart preload. - Tricuspid valve integrity? Stenosis and regurgitation both lead to errors. - Arrythmias lead to error. - Even right ventricular pressure tells us little about right ventricular volume.,前负荷,JVP / CVP 颈静脉压/中心静脉压 - 只能反映右心功能。 - 很少地反映左心前负荷的情况。 - 三尖瓣是否完整? 狭窄和反流都会使数值偏差。 - 心律失常也会造成误差 - 甚至右心室压也很少能反映右心室容积的情况.,Pulmonary artery catheter What pressure should we use? PA Diastolic Pressure (PADP)? PA Wedge Pressure (PAWP)? PA mean Pressure (PAPm)? Is the catheter in the right place? What about IPPV, PEEP, pulmonary vascular patency, vasoconstriction, shunts, arrythmias, mitral valve problems.etc.,肺动脉导管 应该用哪个压力更好呢? 肺动脉舒张压 (PADP)? 肺动脉楔压(PAWP)? 肺动脉平均压(PAPm)? 导管是在正确的位置吗? 如果有间歇正压通气、呼气末正压通气、 肺血管开放,、血管收缩 、分流, 、心律失常 、二尖瓣病变 .等等情况怎么办呢?,PAC,Attempts to measure left ventricular end diastolic pressure - LVEDP Left ventricular preload is strictly the left ventricular end diastolic volume LVEDV Ventricular end di

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