血流动力学监测与心脏超声.ppt

指南解读：血流动力学监测与心脏超声（CUS）,SLAX:肋下长轴切面SIVC:肋下下腔静脉切面PLAX：胸骨旁长轴切面PSAX:胸骨旁短轴切面A4CH:心尖四腔心切面,CUS最常用的五个切面,AntonelliM,etal.IntensiveCareMed.2007;33(4):575-90.CecconiM,etal.IntensiveCareMed.2014;40(12):1795-815.,25位专家组成的团队,12位专家组成的团队,FiveSpecificQuestions,(1)Whataretheepidemiologicandpathophysiologicfeaturesofshockintheintensivecareunit?(2)Shouldwemonitorpreloadandfluidresponsivenessinshock?(3)Howandwhenshouldwemonitorstrokevolumeorcardiacoutputinshock?(4)Whatmarkersoftheregionalandmicrocirculationcanbemonitored,andhowcancellularfunctionbeassessedinshock?(5)Whatistheevidenceforusinghemodynamicmonitoringtodirecttherapyinshock?,2014Consensus,Recommendedagainst常规使用:(1)thepulmonaryarterycatheterinshock休克患者使用肺动脉导管(2)staticpreloadmeasurementsusedalonetopredictfluidresponsiveness仅仅使用静态的前负荷测量方法来预测液体反应性,Maindifferences,Bloodpressurestatements,ICM2007,ICM2014,Fluidresponsivenessstatements,ICM2007,ICM2014,ICM2007,Hemodynamicmonitoring,ICM2014,CecconiM,etal.IntensiveCareMed.2014;40(12):1795-815.,Mainnewstatements,(1)Statementsonindividualizingbloodpressuretargets;(2)Statementsontheassessmentandpredictionoffluidresponsiveness;(3)Statementsontheuseofechocardiographyandhemodynamicmonitoring.,2014Consensus,IdentificationofthetypeofshockWerecommendfurtherhemodynamicassessment(suchasassessingcardiacfunction)todeterminethetypeofshockiftheclinicalexaminationdoesnotleadtoacleardiagnosis.BestpracticeWesuggestthat,whenhemodynamicassessmentisneeded,echocardiographyisthepreferredmodalitytoinitiallyevaluatethetypeofshockasopposedtomoreinvasivetechnologies.Recommendation.Level2;QoE(B),Rationale:Contextanalysis(trauma,infection,chestpain,etc.)andclinicalevaluationwhichfocusesonskinperfusionandjugularveindistensionusuallyorientdiagnosistothetypeofshock,butcomplexsituationsmayexist(e.g.cardiactamponadeinapatientwithtraumaorsepticshockinapatientwithchronicheartfailure)inwhichadiagnosisismoredifficult.,VincentJL,etal.NEnglJMed.2013;369(18):1726-34.,ManifestationonEcho,梗阻性,心包填塞,FOCUS的测量很迅速，即使是初学者，一般时间也小于3min；FOCUS应当被列入重症培训的项目中去。,BeraudAS,etal.CritCareMed.2013;41(8):e179-81.,IC-FoCUS国际聚焦心脏超声循证建议,ViaG,etal.JournaloftheAmericanSocietyofEchocardiography.2014;27(7):683e1-e33.,名称确认：聚焦心脏超声（FoCUS）重点用于生命支持的评估、复苏的评估等。,FoCUSstatement,ShockandHemodynamicInstability43.Inthesettingofshock,FoCUSaccuratelyassessesglobalLVsystolicfunction,whencomparedwithcomprehensivestandardechocardiography.1A:StrongRecommendation,withVeryGoodAgreement;LevelAEvidence44.Inthesettingofshock,FoCUSnarrowsthedifferentialdiagnosis.1A:StrongRecommendation,withVeryGoodAgreement;LevelAEvidence,2014Consensus,MonitoringcardiacfunctionandcardiacoutputEchocardiographycanbeusedforthesequentialevaluationofcardiacfunctioninshock.StatementoffactWerecommendthatlessinvasivedevicesareused,insteadofmoreinvasivedevices,onlywhentheyhavebeenvalidatedinthecontextofpatientswithshock.Bestpractice,Rationale:EchocardiographycanhelptheICUphysicianinthreeways:(1)bettercharacterizationofthehemodynamicdisorders;(2)selectionofthebesttherapeuticoptions(intravenousfluids,inotropesandultrafiltration);(3)assessmentoftheresponseofthehemodynamicdisorderstotherapy.VTI,LVEF,LVEDA,RVEDA,E/Aratio,LheritierG,etal.IntensiveCareMed.2013;39(10):1734-42.,急性肺心病ACP:RVEDA/LVEDA0.6,左室短轴可见室间隔矛盾运动卵圆孔未闭PFO：左右心房之间可见右向左分流结果：22.5%的机械通气患者患ACP，15.5%的患者患PFO，4.5%的患者同时患ACP和PFO。,FoCUSstatement,ShockandHemodynamicInstability,FoCUSstatement,EstimatingCVP,DiagnosingHypovolemia,andPredictingFluidResponsiveness,shocksubject,controlsubject,YanagawaY,etal.JTrauma.2005;58(4):825-9.,IVC的直径与创伤患者的低血容量相关,FoCUSstatement,在怀疑血容量不足的自主呼吸患者中，在PLR前后使用FoCUS测量心输出量可以准确地识别出患者是否存在血容量不足以及能否获益于补液,MaizelJ,etal.IntensiveCareMed.2007;33(7):1133-8.,PreauS,etal.CritCareMed.2010;38(3):819-25.,Change(%)=100%*(post-VEvaluebaseline2value)/baseline2value.Respond:change15%,PLR,passivelegraising;VE,volumeexpansion,PP,radialpulsepressure;SV,strokevolume;VF,pe