危重病患者的血流动力学监测与治疗协和杜斌

危重病患者的血流动力学监测与治疗How To Make It Simple?,北京协和医院杜斌,血流动力学监测与治疗,CO,MAP,SVR,=,x,SV,HR,x,后负荷,前负荷,心肌收缩力,血流动力学监测,血流动力学监测: 基本内容,1,前负荷Preload,2,灌注压MAP,危重病患者的容量缺乏,为何需要扩容治疗?,CVP (mmHg),CO (L/min),根据临床表现判断容量状态,低容量表现心动过速低血压(严重者)高乳酸(严重者)肢端温度降低,脱水表现皮肤充盈下降口渴口干腋窝干燥高血钠高蛋白血症高血红蛋白高血球压积,体位性低血压动脉血压或每搏输出量的呼吸波动下肢被动抬高容量负荷试验结果阳性,肾脏灌注减少浓缩尿(低尿钠,高尿渗)BUN升高(与肌酐升高不成比例)持续性代谢性酸中毒,动态指标,静态指标,容量状态评价,低血容量: 临床表现,脱水: 临床表现,前负荷的维持: 指南建议,复苏目标 (1C)中心静脉压(CVP) 8 12 mmHg*平均动脉压 65 mmHg尿量 0.5 ml/kg/hr中心静脉(上腔静脉)血氧饱和度 70%，或混合静脉血氧饱和度 65%,Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,中心静脉压: 影响因素,Nouira S, Elatrous S, Dimassi S, et al. Effects of norepinephrine on static and dynamic preload indicators in experimental hemorrhagic shock. Crit Care Med 2005; 33: 2339-2343,容量负荷试验: 判断标准,每10分钟测定CVPCVP 2 mmHg继续快速补液CVP 2 5 mmHg暂停快速补液, 等待10分钟后再次评估CVP 5 mmHg停止快速补液,每10分钟测定PAWPPAWP 3 mmHg继续快速补液PAWP 3 7 mmHg暂停快速补液, 等待10分钟后再次评估PAWP 7 mmHg停止快速补液,Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132,病例1: 现病史,男性, 70岁, 2001年1月9日入院咳嗽, 咳痰12天, 发热4天, 呼吸困难1天12天前咳嗽, 咳黄粘痰, 伴全身乏力4天前寒战高热, 体温39.5CCXR：肺部感染, 右上肺膨胀不全头孢呋肟治疗无效1天前呼吸困难, 紫绀, 伴血压下降(50/20 mmHg),病例1: 入院情况,入ICU时BT 37.2CHR 130 bpmBP 84/40 mmHg (DA 10 g/kg/min)SpO2 78%双肺散在湿罗音,病例1: 入院诊断,诊断重度社区获得性肺炎急性呼吸功能衰竭感染性休克,病例1: 支持治疗,呼吸功能支持(SIMV + PSV)FiO2 100%, PEEP 10 cmH2OSpO2 92%循环支持羟基淀粉500 ml扩容无效DA 13 g/kg/min NE 1.2 g/kg/minBP 110/70 mmHg,病例1: 血流动力学监测,放置肺动脉漂浮导管HR130MAP71CVP9PAWP9CI1.96SVRI2524PVRI529NE1.0,病例1: 血流动力学监测,扩容3000 ml后HR103MAP118CVP12PAWP18CI3.63SVRI2182PVRI331NE1.0,白蛋白 vs. 晶体液: SAFE研究,多中心, 随机, 双盲, 对照试验澳大利亚和新西兰16个ICU的7000名患者2001/11至2003/6入选标准: 需要输液治疗 + 1项低血容量的客观指标排除标准: 肝脏移植, 心脏手术, 烧伤4%白蛋白(n = 3499) vs. 生理盐水(n = 3501),The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,白蛋白 vs. 晶体液: SAFE研究,The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,白蛋白 vs. 晶体液: SAFE研究,The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,乳酸林格液 vs 羟乙基淀粉: VISEP,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,血流动力学监测: 前负荷,前负荷不足危重病人中非常普遍临床表现缺乏特异性可能需要试验性治疗不同种类液体有差异,血流动力学监测: 基本内容,1,前负荷Preload,2,灌注压MAP,血流动力学中的欧姆定律,R = P / flow,Pin,Pout,flow,R,器官灌注压,肾脏灌注RPP = MAP IAPFG = GFP PTP = MAP IAP x 2,脑灌注CPP = MAP ICP,健康与疾病时的自身调节,0,150,50,100,Organ blood flow(% Baseline),0,100,20,40,60,80,Organ artery pressure (mmHg),Autoregulatory threshold,Subautoregulatory slope,疾病时的自身调节机制,0,150,50,100,Organ blood flow(% Baseline),0,100,20,40,60,80,Organ artery pressure (mmHg),control,3 weeks,1 week,升压药物: 指南建议,维持MAP 65 mmHg (1C)首选升压药物应为去甲肾上腺素或多巴胺, 并经中心静脉输注(1C)肾上腺素, 苯肾上腺素或血管加压素不应作为感染性休克的一线用药(2C)在去甲肾上腺素基础上加用血管加压素0.03 U/min, 可能与单纯应用去甲肾上腺素效果相等感染性休克时如血压对去甲肾上腺素反应不佳, 可首选肾上腺素或多巴胺(2B)不应使用小剂量多巴胺进行肾脏保护(1A)需要升压药的患者应留置动脉导管(1D),Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,平均动脉压应当多少?,无创血压不准确高血压时读数低低血压时读数高有创血压与无创血压经常不一致,血流动力学监测: 技巧,确认患者的平均动脉压家属病历记录检查患者平均动脉压的测定方法无创 vs. 有创确定无创血压与有创血压的差值,病例2: 基本情况,男性, 74岁, 病历号既往史I型糖尿病18年糖尿病肾病高血压病史5年口服络活喜, 倍他乐克等药物平素BP 160 180 / 70 90 mmHg,病例2: 现病史,2007年7月25日入院主因发现恶心, 呕吐1周, 伴心前区疼痛及少尿3天1周前出现恶心, 呕吐, 予对症治疗3天前出现心前区疼痛, 憋闷, 尿量减少静脉泵入NG 100 g/min, 控制BP 134/56 mmHg血Cr 861 mol/L, UO 500 ml/d (速尿400 mg/d)血液透析, 透析过程中出现心绞痛, 持续不缓解,病例2: 体格检查,GCSE4V5M6BT36.2CHR70 bpmRR20 bpmBP103/45 mmHgSpO298 100% (鼻导管吸氧5 lpm),病例2: 实验室检查,CBC: WCC 14.79, Hb 102, plt 215Chemistry (8 2):Na140mmol/LCl 97mmol/LK 4.2mmol/LCr745mol/LBUN 31.14mmol/LCK-MB 6.8u/LcTnI 11.56g/LGLU 21.5mmol/L,病例2: MAP与组织灌注,心绞痛*,*发作时EKG: V3-6导联ST段压低0.1 0.2 mv,病例2: MAP与组织灌注,心绞痛*,*发作时EKG: V3-6导联ST段压低0.1 0.2 mv,病例2: MAP与组织灌注,心绞痛*,*发作时EKG: V3-6导联ST段压低0.1 0.2 mv,感染性休克: NE + DB vs. Epi,满足以下标准 7 d感染证据SIRS标准 2/4组织低灌注或器官功能不全( 2)PaO2/FiO2 280UO 2 mmol/LPlt 100 x 109/L,满足以下标准 24 hSBP 90 mmHg或MAP 1000 ml或PCWP 12 18 mmHg血管活性药物多巴胺 15 g/kg/minEpi或NE: 任何剂量,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克需要血管活性药物(NE 5 g/min) (n = 779),起始剂量0.01 U/min增加剂量0.005 U/min最大剂量0.03 U/min (n = 397),起始剂量5 g/min增加剂量2.5 g/min最大剂量15 g/min) (n = 382),血管加压素(VP)(0.12 U/ml) (n = 397),去甲肾上腺素(NE)(60 g/ml) (n = 382),感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,Parrillo JE. Septic shock vasopressin, norepinephrine, and urgency. N Engl J Med 2008; 358: 954-956,血流动力学监测: 灌注压,灌注压不足灌注压没有固定数值注意有创及无创血压的差异根据患者情况确定目标血压排除低血容量时应用升压药具有受体激动作用的药物(多巴胺, 去甲肾上腺素等),血流动力学监测: 基本内容,1,前负荷Preload,2,灌注压MAP,病例3,一名25岁体重70 kg肺炎患者, BP 100/50 (65) mmHg, CVP 0 mmHg, 尿量50 ml/hr, pH 7.4. 患者神志清楚, 四肢温暖. 最适宜的血流动力学处理措施为:IV输注胶体液250 ml无需任何处理IV输注5%葡萄糖250 ml小剂量多巴胺输注多巴酚丁胺输注,组织灌注不足的表现,皮肤花斑四肢冰冷毛细血管再充盈时间延长尿量减少意识障碍代谢性酸中毒乳酸酸中毒ScvO2 4.5 L/min/m2DO2I 600 ml/min/m2VO2I 170 ml/min/m2,Velmahos GC, Demetriades D, Shoemaker WC, et al.: Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial. Ann Surg 2000, 232: 409-418.,Boyd O, Hayes M. The oxygen trial: the goal. Br Med Bull 1999; 55(1): 125-139,超正常值与患者预后,循环支持治疗: 指南建议,正性肌力药物治疗心肌功能障碍(心脏充盈压力升高及心输出量降低)时使用多巴酚丁胺(1C)不应使心脏指数增加到预先确定的超正常水平(1B),Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,隐性低灌注与创伤预后,The Golden Hour and the Silver Day入选标准:成年创伤患者存活时间 24小时ISS 20血流动力学稳定SBP 100HR 1 mL/kg/h乳酸 2.5 mmol/L或其他灌注不足表现,Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后,严重创伤患者两次LA 2.5,输注液体或血液制品,重复LA 2.5,Swan-Ganz, 动脉插管, 肾脏剂量多巴胺,将PCWP提高到12 15将Hct提高到30%,重复LA 2.5,升压药物(多巴酚丁胺)心脏超声检查,若LA仍 2.5,Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后,Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,感染患者的组织灌注与预后,Howell MD, Donnino M, Clardy P, et al. Occult hypoperfusion and mortality in patie