CCO技术在ARDS诊断和治疗中的应用.pptVIP

PiCCOPiCCO 在在ARDSARDS诊断和治疗中的应用诊断和治疗中的应用 ( (病例分析病例分析) ) 男性，男性，6262岁，退休干部岁，退休干部 因右腹股沟不可回纳包块伴恶心呕吐四天入院因右腹股沟不可回纳包块伴恶心呕吐四天入院 6 6月月4 4日急诊全麻行剖腹探查术日急诊全麻行剖腹探查术 术中循环不稳定，心率术中循环不稳定，心率4017040170次次/ /分分 术中见小肠部分坏死，给予回肠部分切除术中见小肠部分坏死，给予回肠部分切除 大量补液（大量补液（7050ml)+ Daba7050ml)+ Daba、Dobu NEDobu NE 转转ICUICU 既往有冠心病史既往有冠心病史, , 无明确高血压病史无明确高血压病史 T 36T 36 HR 160 BP88/45mmHg HR 160 BP88/45mmHg CVP 16mmHg PAWP 22 mmHg (PEEP 10cmHCVP 16mmHg PAWP 22 mmHg (PEEP 10cmH 2 2 O) O) 球结膜水肿，两肺呼吸音粗，腹膨球结膜水肿，两肺呼吸音粗，腹膨, , 全腹压痛、反跳痛全腹压痛、反跳痛 尿少尿少 Case report: 腹痛伴恶心呕吐4天 辅助检查辅助检查 血常规： WBC 3.6109/L GRA 25% PLT 35109/L 血气： pH 7.429 PO2 86.4mmHg (FiO2 50%) Lac 6.5mmol/L 生化： ALB 15g/L CR 330umol/L 心电图： 窦性心律, ST-T异常 主要诊断：主要诊断： 右腹股沟疝右腹股沟疝 绞窄性肠梗阻绞窄性肠梗阻 回肠部分切除术后回肠部分切除术后 弥漫性腹膜炎弥漫性腹膜炎 感染性休克感染性休克 急性肾衰急性肾衰 急性呼吸衰竭急性呼吸衰竭 ( (病因病因?) ?) ARDSARDS 心源性肺水肿心源性肺水肿 急性呼吸衰竭的病因? N Engl J Med 2005;353:2788-96 ARDS ARDS 诊断标准诊断标准 急性起病急性起病 PaOPaO 2 2 /FiO/FiO 2 2 18mm Hg 18mm Hg，CI 5.3 L/min/mCI 5.3 L/min/m 2 2 ) ) Intensive Care Med, 2002,28(8):1073-7 PAWPPAWP18mmHg is common in ARDS18mmHg is common in ARDS N Engl J Med 2006,354:2213-24 n 29 pats ：PAWP 18mm Hg n 97% pats with PAWP 18mm Hg had a normal or elevated CI 1001 patients, 513 assigned to PAC, 488 to CVC Objective Criteria for ARDSObjective Criteria for ARDS PAWP18 mmHgPAWP18 mmHg不应作为不应作为ARDSARDS的诊断标准的诊断标准 肺毛细血管通透性明显增加肺毛细血管通透性明显增加 ARDSARDS区别于心源性肺水肿的特征性改变区别于心源性肺水肿的特征性改变 应在诊断标准中体现，使诊断标准更具特征性应在诊断标准中体现，使诊断标准更具特征性 Schuster DP. The search for “objective” criteria for ARDS. Intensive Care Med, 2007, 33:400-402. Ware LB,. Matthay MA. Acute Pulmonary Edema. N Engl J Med, 2005;353:2788-96. ARDSARDS高通透性肺水肿高通透性肺水肿 vs vs 急性左心衰竭高静水压性肺水肿急性左心衰竭高静水压性肺水肿 试图依据病史、临床特征、试图依据病史、临床特征、X X线胸片的特征线胸片的特征 血管外白蛋白的漏出量血管外白蛋白的漏出量 Alb in BAL/PlasmaAlb in BAL/Plasma 无创性核医学技术无创性核医学技术 热稀释技术热稀释技术 计算肺内血容量计算肺内血容量(PBV)(PBV)与血管外肺水与血管外肺水(EVLW)(EVLW) 肺血管通透性指数肺血管通透性指数(PVPI) ,(PVPI) ,可用来反映肺毛细血管通透性可用来反映肺毛细血管通透性 Objective Criteria for ARDSObjective Criteria for ARDS 20022002年年SchusterSchuster以双肺水肿、病程以双肺水肿、病程24h24h的危重患者的危重患者 为研究对象为研究对象 99mTc-Alb99mTc-Alb示踪肺血管通透性的改变示踪肺血管通透性的改变 临床诊断为临床诊断为ARDS(21ARDS(21例例) )和急性左心衰竭和急性左心衰竭(7 (7例例) ) 肺部同位素放射强度并无显著差别肺部同位素放射强度并无显著差别 高静水压性肺水肿也有少量白蛋白漏出高静水压性肺水肿也有少量白蛋白漏出 肺泡肺泡II II Objective Criteria for ARDSObjective Criteria for ARDS Schuster DP, Stark T, Stephenson J, et al. Detecting lung injury in patients with pulmonary edema. Intensive Care Med, 2002, 28: 1246-1253. PiCCOPiCCO的临床应用的临床应用 肺水指标： Extravascular Lung Water: EVLW Pulmonary Vascular Permeability Index: PVPI (EVLW/PBV) Objective Criteria for ARDSObjective Criteria for ARDS ARDSARDS与心源性肺水肿的鉴别诊断与心源性肺水肿的鉴别诊断 心源性肺水肿：心源性肺水肿： EVLWEVLW、PBVPBV均明显增加，均明显增加，PVPIPVPI降低或正常降低或正常 ARDSARDS性肺水肿：性肺水肿： EVLWEVLW明显增加、明显增加、PBVPBV不增加，不增加，PVPIPVPI明显升高明显升高 Design:Design: Retrospective review of cases Retrospective review of cases Patients:Patients: 48 critically ill pats ventilated for ARF 48 critically ill pats ventilated for ARF bilateral infiltrates on chest radiograph bilateral infiltrates on chest radiograph PaOPaO 2 2 /FiO/FiO 2 2 300 mm Hg 300 mm Hg EVLWI 12 ml/kg EVLWI 12 ml/kg Intervention:Intervention: Pulmonary permeabilityPulmonary permeability：PVPI and EVLWi/GEDVi PVPI and EVLWi/GEDVi Cause of pulmonary edema Cause of pulmonary edema：determined by 3 expertsdetermined by 3 experts EVLWi/GEDVi 3.01021.2102 1.41020.4102* Objective Criteria for ARDSObjective Criteria for ARDS PVPI can be helpful for distinguishing PVPI can be helpful for distinguishing hydrostatic pulmonary edema and ARDShydrostatic pulmonary edema and ARDS Cut-off value = 3 Se=85% Sp=100% ROC-PVPI: 0.920.04 Objective Criteria for ARDSObjective Criteria for ARDS 肺水指标可协助鉴别肺内肺水指标可协助鉴别肺内/ /外原因外原因 ARDSARDS 10 pats, 4 with 10 pats, 4 with direct and 6 with direct and 6 with indirect (sepsis indirect (sepsis induced) induced) GEDV, ITBV and GEDV, ITBV and EVLW were EVLW were measured measured PI (permeability PI (permeability index) index) ( (EVLW/ITBV EVLW/ITBV ) ) Critical Care 2006, 10(Suppl 1):P326 DirectDirectIndirectIndirectP P valuevalue ITBVIITBVI984 331.7984 331.71279 1279 312.1312.1 0.00010.0001 EVLWIEVLWI13.2 4.713.2 4.716.8 6.516.8 6.50.0140.014 PIPI0.59 0.270.59 0.270.44 0.220.44 0.220.0060.006 EVLWI 20 ml/kg: EVLWI 20 ml/kg: 肺水肿肺水肿 PVPI 3.8%: ARDSPVPI 3.8%: ARDS EVLWI/GEDI 0.31: ARDS indirectEVLWI/GEDI 0.31: ARDS indirect EKG: sepsis induced EKG: sepsis induced 心肌损害心肌损害 PiCCOPiCCO：(Dopa 5ug/kg.min(Dopa 5ug/kg.min，Dobu 10ug/kg.min)Dobu 10ug/kg.min) CO 4.1 L/min CI 2.44 L/min/m CO 4.1 L/min CI 2.44 L/min/m 2 2 SVV 30% GEDI 641 ml/m SVV 30% GEDI 641 ml/m 2 2 EVLWI 20 ml/kg PVPI 3.8 EVLWI 20 ml/kg PVPI 3.8 Objective Criteria for ARDSObjective Criteria for ARDS 下一步治疗下一步治疗 A A、去甲肾上腺素、去甲肾上腺素 B B、加肾上腺素、加肾上腺素 C C、IABPIABP D D、CRRTCRRT E E、补液、补液 PiCCOPiCCO：(Doba 5ug/kg/min(Doba 5ug/kg/min，Dobu 10ug/kg/min)Dobu 10ug/kg/min) CO CO 4.1 L/min 4.1 L/min CI CI 2.44 L/min/m2.44 L/min/m 2 2 CVP CVP 16mmHg16mmHgPAWPPAWP22mmHg22mmHg SVV SVV 30% 30% GEDI GEDI 641 ml/m641 ml/m 2 2 EVLWI EVLWI 20 ml/kg 20 ml/kg PVPI PVPI 3.8%3.8% Management of ARDS n n Prospective, nonrandomized, nonblinded interventional Prospective, nonrandomized, nonblinded interventional study.study. n n Cardiac catheterization and echocardiography Cardiac catheterization and echocardiography laboratories.laboratories. n n Normal healthy volunteersNormal healthy volunteers n n Groups: Groups: Group 1: Pulmonary catheterization and radionuclide Group 1: Pulmonary catheterization and radionuclide cineangiography n = 12 cineangiography n = 12 Group 2: volumetric echocardiography n=32Group 2: volumetric echocardiography n=32 n n Volume load: Volume load: 3 L salin iv over 3 hrs3 L salin iv over 3 hrs Crit Care Med. 2004; 32:691699. Crit Care Med 2004; 32:691699 CVP/PAWPCVP/PAWP对容量试验的反应对容量试验的反应 n择期心脏手术患者 n=20 n监测 GEDVI: PiCCO CEDVIPAC: PAC LV preload assessment: TEE nHemodynamic measurements: before (T0) and 20 min (T1) and 40 min (T2) after a volume load nVolume load: HES10 ml/kg over 20min British Journal of Anaesthesia. 2005, 94 (6): 748755. British Journal of Anaesthesia 94 (6): 74855 (2005) 容量状态评估容量状态评估 SVVSVV、PPV: predicting fluid responsivenessPPV: predicting fluid responsiveness 40 patients undergoing elective OPCABG Chest 2005, 128:848854 nSVV 、 GEDV、ITBV: Cardiac preload 感染导致的感染导致的ARDSARDS患者如何补液？患者如何补液？ 重症感染、感染性休克：需要积极液体复苏重症感染、感染性休克：需要积极液体复苏 Crit Care Med 2008, 36(1):296-327Crit Care Med 2008, 36(1):296-327 ARDSARDS：通透性增加：通透性增加 容量控制容量控制 N Engl J Med 2006, 354:2564-75N Engl J Med 2006, 354:2564-75 复苏液体种类的选择复苏液体种类的选择 胶体渗透压对肺水肿的影响胶体渗透压对肺水肿的影响 Circ Res 1959, 7: 649-57 主要处理：主要处理： 大量血浆、白蛋白输注，循环稳定下间断利尿大量血浆、白蛋白输注，循环稳定下间断利尿 ( (前前3 3日液体平衡：日液体平衡：2000ml2000ml，50ml, 50ml, 800ml )800ml ) 泰能、替考拉宁、替硝唑联合大扶康抗感染泰能、替考拉宁、替硝唑联合大扶康抗感染 呼吸机呼吸机(BiPAP(BiPAP模式，模式，PEEP 1015cmHPEEP 1015cmH 2 2 O,O, MAP 20cmH MAP 20cmH 2 2 O, VO, V T T 420ml 420ml左右左右), ),间断行间断行SISI 6-07 6-07 PiCCOPiCCO：( (多巴胺多巴胺4 4ug/kg/minug/kg/min，血压，血压120/80mmHg120/80mmHg) ) CO 6.56 L/min CI 3.62 L/min/m CO 6.56 L/min CI 3.62 L/min/m 2 2 SVV 10% GEDI 1310 ml/m SVV 10% GEDI 1310 ml/m 2 2 EVLWI 12 ml/kg PVPI 2.0 EVLWI 12 ml/kg PVPI 2.0 Management of ARDS 6