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 Identificationofthetypeofshock Werecommendfurtherhemodynamicassessment 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 LevelAEvidence 44 Inthesettingofshock FoCUSnarrowsthedifferentialdiagnosis 1A StrongRecommendation withVeryGoodAgreement LevelAEvidence 2014Consensus MonitoringcardiacfunctionandcardiacoutputEchocardiographycanbeusedforthesequentialevaluationofcardiacfunctioninshock Statementoffact Werecommendthatlessinvasivedevicesareused 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 LVEDA 0 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 change 15 PLR passivelegraising VE volumeexpansion PP radialpulsepressure SV strokevolume VF peakvelocityoffemoralarteryflow FoCUSstatemen