休克基础监护及治疗进展

休克基础监护及治疗进展,北京协和医院加强医疗科王小亭,2017/11/28,2,PUMCH,休克基础,概念休克的历史与发展分类 按病因分类 按血流动力学分类机制,2017/11/28,3,PUMCH,概念,基本概念休克是不同原因造成急性循环衰竭致使组织血液灌流不足造成细胞水平的一种急性氧代谢障碍，导致细胞及组织器官功能受损的病理过程的综合征。,2017/11/28,4,PUMCH,概念,进展概念氧输送与氧耗氧摄取与氧利用,2017/11/28,5,PUMCH,概念,更深层理解点与线的关系意义:Occult shock的早期发现,2017/11/28,6,PUMCH,休克的新认识 共同的连续发展过程,初始因素 失血、创伤、 感染、心脏,休克,机体的炎症反应,组织氧需求与氧输送的矛盾,分布性休克,2017/11/28,7,PUMCH,休克历史与发展,80年前:初步认识阶段8090年: 发展阶段90年-:进一步发展阶段,2017/11/28,8,PUMCH,80年前,总与战争有关1773年,法国医生LeDranSHOCK 枪伤与战伤：失血二战（年代）沼泽与溪流朝鲜战争（年代）创伤性肾衰越南战争（年代）休克肺,2017/11/28,9,PUMCH,年代,血流动力学监测应用于临床循环监测指标逐步丰富连续定量可反馈指标滴定式治疗休克的血流动力学分类血压下降为休克晚期指标,2017/11/28,10,PUMCH,年,整体性与器官关系临床应用upranormal-optimal()与Scvo2组织细胞缺氧与i分子水平,2017/11/28,11,PUMCH,休克分类,病因分类血流动力学分类低血容量性休克心源性休克分布性休克梗阻性休克,2017/11/28,12,PUMCH,低血容量性休克,特点：低排高阻2025%以上的循环容量急性丢失病因：失血性、非失血性（呕吐、腹泻、高热及利尿）,2017/11/28,13,PUMCH,心源性休克,特点：低排高阻心脏不能产生足够的CO病因：AMI、心肌炎、心律失常、心功能不全,2017/11/28,14,PUMCH,分布性休克,特点：高排低阻血管舒缩功能异常引起的循环衰竭容量血管扩张（神经性休克、过敏性休克）阻力血管扩张及动静脉分流增加（感染性休克）,2017/11/28,15,PUMCH,梗阻性休克,机械因素所致：监测困难静脉回流：张力性气胸、PEEP、正压通气流出道受阻：肺栓塞、主动脉夹层、肺动脉高压,2017/11/28,16,PUMCH,发病机制,以感染性休克为代表,病原体（初始免疫细胞）,促炎症因子,大量炎症细胞激活,组织细胞功能受损,循环受累,大量炎性因子释放,休克血流动力学监测,2017/11/28,18,PUMCH,基础理论,定律及曲线理论氧输送理论,2017/11/28,19,PUMCH,O,前负荷 STARLING 定律,2017/11/28,20,PUMCH,ABC理论,PAWP,CI,A,B,C,D,2017/11/28,21,PUMCH,氧输送监测,氧输送（DO2） DO2 =CI*1.34*Hb*SaO2氧耗（ VO2 ） VO2 =CI*（CaO2-CvO2）,2017/11/28,22,PUMCH,血流动力学监测目的,维持组织器官灌注和血流动力学稳定 -危重病人全身稳定的核心/基石 -血流动力学无处不在血流动力学不稳定的评估 -及时发现异常环节指导血流动力学支持治疗 -实现滴定式治疗 -监测与治疗策略结合,2017/11/28,23,PUMCH,血流动力学监测的重点,前负荷心输出量心肌收缩力后负荷心肌顺应性微循环及组织氧合监测 心率等基础监测,2017/11/28,24,PUMCH,血流动力学监测方法与进展,“重中之重”代表前负荷与评估容量反应性的指标CO的测量及进展微循环及组织氧合的监测,2017/11/28,25,PUMCH,前负荷及评估容量反应性,ICU永恒的命题压力指标及容量指标静态指标及动态指标容量反应性的评估方法,2017/11/28,26,PUMCH,Current Opinion in Critical Care 2005, 11:264270,2017/11/28,27,PUMCH,前负荷及评估容量反应性,压力指标及可获得CVPPAWP研究结果各异，不佳似乎大于理想,Magder S, Bafaqeeh F. The clinical role of central venous pressure measurements.J intensive care Med 2007;22:44-51Osman D, Ridel C, Ray P, et al: Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007;35:295296,2017/11/28,28,PUMCH,Elastic band demonstrating the concept of unstressed volume. There is no tension in the wall of the elastic until it isstretched beyond the resting volume,Crit Care Med 1998; 26:1061-1064,深入认识：CVP与静脉回流,2017/11/28,29,PUMCH,前负荷及评估容量反应性,容量指标20世纪80年代后床旁测定 经食道心超左心室舒张末容积等RVEDVI或CEDVI（容积测量肺动脉导管） 研究结果欠理想2000年后PiCCO GEDV/ITBV研究结果较理想,British Journal of Anaesthesia 94 (6): 74855 (2005),2017/11/28,30,PUMCH,右室舒张末容积(RVEDV/CEDV)(pulmonary artery thermodilution)肺动脉漂浮导管,左室舒张末面积(LVEDA)(echocardiography)超声心动图,Global end-diastolic volume (GEDV)全心舒张末容积(transpulmonary thermodilution),胸腔内血液容积(ITBV)(thermo-dye transpulmonary dilution)热染料双指示剂法,容量指标,前负荷及评估容量反应性,2017/11/28,31,PUMCH,GEDVI PiCCO system better reflects leftventricular preload than CEDVI pulmonary artery catheter,前负荷及评估容量反应性,容量指标,2017/11/28,32,PUMCH,思 考,应用压力指标的原因无奈需要容量指标好于压力指标 理想？现实？ 两者结合 112 ?,2017/11/28,33,PUMCH,思 考,压力指标受到越来越多的质疑 以压力指标为指导的治疗策略获得极大成功 EGDT ARDS.net-自由与保守的液体策略,矛盾!?,2017/11/28,34,PUMCH,前负荷及评估容量反应性,静态指标 CVP PAOP 回顾性动态指标 SVV SPV PPV delta-DOWN 等 广义性及前瞻性 动态指标可能有比静态指标更好的反应性 应用范围局限,Homodynamic Evaluation and Monitoring in the ICU CHEST, 2007,132,2020-2029,2017/11/28,35,PUMCH,2017/11/28,36,PUMCH,2017/11/28,37,PUMCH,2017/11/28,38,PUMCH,容量反应性的方法,Fluid challenge (2种方法4点要求)Immediate administration crystalloid or colloid equivalent (eventually repeatable, if indicated） A straight-leg raise（passive leg raising）A goal of obtaining a rise in CVP at least 2 mmHg(CVP2mmHg)A positive response improved cardiac output tissue perfusion,Intensive Care Med (2007) 33:575590,Vincent JL, Weil MH (2006) Fluid challenge revisited. Crit Care Med 34:13331337,2017/11/28,39,PUMCH,容量反应性的方法,Crit Care Med 2006 Vol. 34, No. 5,PLR as a “reversible volume challenge”,2017/11/28,40,PUMCH,容量反应性的方法,呼气末暂停15秒法 最后5秒测量SV或CI等,2017/11/28,41,PUMCH,前负荷/容量反应性和治疗策略,目前： CVP为液体复苏目标的EGDT已有： 以SVV结合SV为液体复苏目标的针对ICU 低血压和少尿的病人尚没有：容量指标相关的治疗策略下一步：设计以不同容量反应性评估方法为指导 液体复苏的临床研究,2017/11/28,42,PUMCH,CO的测量及进展,血流动力学监测的关键环节CO测量方法：有创微创无创,2017/11/28,43,PUMCH,NiCO,CCO,LiDCO,PiCCO,Monitor,PAC,2017/11/28,44,PUMCH,CO的测量方法有创,临床应用成熟CO-TDs Thermodilution CO PAC-CO温度(热)稀释法 CO-染料稀释法,New England Journal of Medicine (1970),2017/11/28,45,PUMCH,血流动力学监测革命的第一步,1970年，. wan和William Ganz发明了带套囊的肺动脉漂浮导管 wan-Ganz导管 New England Journal of Medicine (1970),2017/11/28,46,PUMCH,2017/11/28,47,PUMCH,Swan-Ganz导管,2017/11/28,48,PUMCH,进 步,持续监测1992连续温度稀释法,2017/11/28,49,PUMCH,PAC的作用,higher 30-day mortality higher mean cost of hospital stay longer length of stay in the ICUsignificant increase in cardiac complications 1.Connors AF Jr, Speroff T, Dawson NV,et al. (1996) The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 276:889897 2 .Mackirdy FL, Howie JC (1997) The relationship between the presence of pulmonary artery catheters and the case mixed adjusted outcome of patients admitted to Scottish ICUs. Clin Intensive Care 8:9133 3.Polanczyk CA, Rohde LE, Goldman L,Cook EF,et al(2001) Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 286:309314,2000年前后几乎被打倒,2017/11/28,50,PUMCH,没有坏处 可能有益处1.在休克或ARDS病人PAC的应用不影响 28-day mortality duration of stay in the ICU or hospital2.应用于创伤引起的ARDS病人-目前唯一的好结果 Trauma patients managed with a PAC are more severely injured and have a higher mortality Survival benefit when managed with a PAC Injury Severity Score of 2575 BE of less than 11 age of 6190 yrs,Critical Care Medicine. 34(6):1597-1601, June 2006.,PAC的作用,2017/11/28,51,PUMCH,PAC的作用,1.危重病人A meta-analysis of the efficacy and safety of the PAC (13 RCTs； 5,051 patients)neither increased overall mortality or days in hospital nor conferred benefit2.急性肺损伤：ARDS.NETNo difference in mortalityNo differences in time on ventilator, or time in the ICU,最近：不好也不坏,2017/11/28,52,PUMCH,2017/11/28,53,PUMCH,PAC何时用？,更公正评价借专家一句话！,2017/11/28,54,PUMCH,基本原理：血管系统与心脏每搏量的相互作用,心脏每搏输出量SV,CO测量微创,不同的专有计算公式,2017/11/28,55,PUMCH,CO测量微创,经肺热稀释方法脉搏波形分析,PiCCO,最经典内容最丰富全面,2017/11/28,56,PUMCH,PiCCO,中心静脉注射,右心,左心,肺,PiCCO导管插在股动脉内,2017/11/28,57,PUMCH,PiCCO与Swan-Ganz热稀释导管测量心输出量的异同,Swan-Ganz热稀释 测量位置,PiCCO动脉热稀释测量位置,2017/11/28,58,PUMCH,PiCCO的专有公式,“Beat to beat” 连续测量CO,曲线下面积,曲线形态,主动脉顺应性,心率,校正系数（经肺热稀释方法得到）,CO测量微创,2017/11/28,59,PUMCH,CO测量微创,FLO-Trac/Vigileosystem,简单但指标少,LiDCO,需要特殊物质,2017/11/28,60,PUMCH,CO测量微创,微创而连续简便易行减少并发症时，是否改善预后？急需大规模临床研究应该相当有前途,2017/11/28,61,PUMCH,CO的测量方法无创,不易推广：昂贵；技术复杂UCG-USCOMTEE,2017/11/28,62,PUMCH,USCOM,2017/11/28,63,PUMCH,TEE,2017/11/28,64,PUMCH,2017/11/28,65,PUMCH,CO的测量方法无创,ICG-CO阻抗法-NICOMFICK METHODNICO System,尚不成熟,2017/11/28,66,PUMCH,2017/11/28,67,PUMCH,CO监测应用临床现状,PAC的局限性相对的金指标微创方法的春天 以PiCCO为代表无创方法在期待未来,2017/11/28,68,PUMCH,CO测量方法的选择,相关技术知识方便/安全准确性可以获得其他血流动力学指标目前微创化无创化全面化趋势明显,2017/11/28,69,PUMCH,2017/11/28,70,PUMCH,CO监测何时用？,何时应用CO监测现有的推荐意见 不常规推荐应用CO测量或监测 在临床有明显心衰证据同时有诊断需要时应用 尽管充足液体复苏后依然持续休克时,2017/11/28,71,PUMCH,CO监测的未来研究方向,哪种CO测量方法最佳影响预后 PiCCO为代表的微创方法是否能带来良好预后？以CO为血流动力学治疗目标可以改善预后吗？CO的监测治疗对不同种类的血流动力学不稳定的影响？,2017/11/28,72,PUMCH,组织氧合及微循环水平监测微观代谢水平,PH和BELAC（乳酸）及LAC清除率SVO2/SCVO2（混合或中心静脉血氧饱和度） -持续监测 -定义整体心血管功能充足性的金标准,2017/11/28,73,PUMCH,LAC清除率,There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance.Patients with a lactate clearance 10% had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p .007).,2017/11/28,74,PUMCH,SVO2SCVO2,Arterial and venous oxygen saturations in various vascular regions,2017/11/28,75,PUMCH,a low SvO2 must incite clinicians to increase DO2 (mainly through CO increase),2017/11/28,76,PUMCH,Percentage error = 2 SD/mean reference value = 11%,r = 0.88,2017/11/28,77,PUMCH,2017/11/28,78,PUMCH,2017/11/28,79,PUMCH,SVO2/SCVO2监测相关的治疗策略,SVO2相关的治疗策略,2017/11/28,80,PUMCH,N Engl J Med 2001;345:1368-77,2017/11/28,81,PUMCH,Rivers et al NEJM 2001,2017/11/28,82,PUMCH,In-hospital mortality (%),46.5,30.5,49.2,33.3,56.9,44.3,28-day mortality (%),60-day mortality (%),0.009,0.03,0.01,p value,N Engl J Med 2001;345:1368-77,EGDT,CONTROL,2017/11/28,83,PUMCH,Early and aggressive treatment of circulatory failure based on a physiologic protocol targeting ScvO2 results in a better outcome,N Engl J Med 2001;345:1368-77,2017/11/28,84,PUMCH,2017/11/28,85,PUMCH,SVO2/SCVO2监测相关的治疗策略,ScVO2-EGDT治疗策略树,2017/11/28,86,PUMCH,组织氧合及微循环水平监测 Macroscopic level,From Toe temperature to OPSGastric tonometry Sublingual capnometry Laser Doppler flowmetry (mucosal perfusion)Indocyanine green clearance Near-infrared spectroscopy (NIRS).OPS（orthogonal polarization spectral imaging） 正交极化光谱图像 光源转换为550nm 血红蛋白为吸光点天然造影剂,2017/11/28,87,PUMCH,OPS,2017/11/28,88,PUMCH,OPS图像,正 常,Septic ShockMale 47 YOMAP 68 mmHg, lactate 3.6 mEq/Ldopa 20 , norepi 0.13,2017/11/28,89,PUMCH,血流动力学监测其他重要内容,心肌收缩性 -来源于PiCCO/心脏超声后负荷血管外肺水/肺血管通透性指数 -EVLW/PVPI,2017/11/28,90,PUMCH,Contractility is a measure for the performance of the heart muscle 心肌收缩性是流量监测CO的必须补充,Contractility parameters of PiCCO technology: dPmx (maximum rate of the increase in pressure) GEF (Global Ejection Fraction) CFI (Cardiac Function Index),心肌收缩性,kg,kg,2017/11/28,91,PUMCH,来源于脉搏轮廓分析的心肌收缩性参数,dPmx = maximum velocity of pressure increase,dPmx代表了左心室压力上升的最大速度,心肌收缩性,2017/11/28,92,PUMCH,参数可靠性研究,femoral dP/max mmHg/s,LV dP/dtmax mmHg/s,dPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients,de Hert et al., J CardioThor&VascAnes 2006,n = 220y = -120 + (0,8* x)r = 0,82p 0,001,0,500,1000,1500,0,1000,1500,2000,2000,500,心肌收缩性,2017/11/28,93,PUMCH,is calculated as 4 times the stroke volume divided by the global end-diastolic volume reflects both left and right ventricular contractility,GEF = Global Ejection Fraction,来源于热稀释法的心肌收缩性参数,4 x SV,GEF =,GEDV,LA,LV,RA,RV,心肌收缩性,2017/11/28,94,PUMCH,Combes et al, Intensive Care Med 30, 2004,GEF = Global Ejection Fraction,Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1 specifity,22,20,19,18,16,12,8,D FAC, %,D GEF, %,5,10,-5,-20,-10,10,20,15,-15,-10,r=076, p0,0001n=47,心肌收缩性,来源于经肺热稀释法的心肌收缩性参数,2017/11/28,95,PUMCH,is - similar to the GEF a parameter of both left and right ventricular contractility,CFI = Cardiac Function Index心脏功能指数,CI,CFI =,GEDVI,心肌收缩性,来源于经肺热稀释法的心肌收缩性参数,2017/11/28,96,PUMCH,心血管状态信息的重要 控制容量和血管活性药物应用的重要决定因素,(MAP CVP) x 80,SVR =,CO,后负荷,SVR = Systemic Vascular Resistance,MAP = Mean Arterial PressureCVP = Central Venous PressureCO = Cardiac Output80 = Factor for correction of units,2017/11/28,97,PUMCH,dPmx 左室功能 GEF and CFI 全心功能 SVR 心血管状态信息的重要,小结,2017/11/28,98,PUMCH,血流动力学监测的别样选择,-来源于 PiCCO 技术的EVLW和PVPI,Extravascular Lung Water（EVLW）Pulmonary Permeability (PVPI),2017/11/28,99,PUMCH,ITTV ITBV= EVLW,Extravascular Lung Water (EVLW)的计算,2017/11/28,100,PUMCH,Katzenelson et al,Crit Care Med 32 (7), 2004,Sakka et al, Intensive Care Med 26: 180-187, 2000,Gravimetry,Dye dilution,EVLW from the PiCCO technology has been shown to have a good correlation with the measurement of extravascular lung water via the gravimetry and dye dilution reference methods,Validation of EVLW,n = 209r = 0.96,ELWI by gravimetry,ELWI by PiCCO,R = 0,97P 0.05,0,20,80,15,-10,-15,10,60,D radiographic score,-80,-60,-40,-20,D ELWI,EVLW as a quantifier of lung oedema,2017/11/28,103,PUMCH,ELWI (ml/kg), 21 n = 54,14 - 21 n = 100,7 - 14 n = 174,3),Classification of Lung Oedema with the PVPI,Lung oedema,hydrostatic,PBV,EVLW,PBV,EVLW,PBV,EVLW,PBV,EVLW,2017/11/28,107,PUMCH,EVLWI answers the question:,PVPI answers the question:,有益于指导治疗!,How much water is in the lungs?,Why is it there?,2017/11/28,108,PUMCH,小结,EVLW 目前床旁可用的唯一评价血管外肺水指标 胸片不能可靠发现和评价肺水肿 EVLW 提示重症病人预后 PVPI有助于区分肺水肿类型,2017/11/28,109,PUMCH,治疗及进展,支持治疗提高氧输送循环支持血流动力学呼吸支持及b脏器功能支持肾；肝营养支持辅助治疗：激素；严格控制血糖；等病因治疗,2017/11/28,110,PUMCH,血流动力学支持,容量低血容量休克刻不容缓感染性休克刻不容缓容量复苏心源性休克容量调节,2017/11/28,111,PUMCH,血流动力学管理流程,基础监测组织氧合微循环监测,基础监测组织氧合微循环监测,心输出量监测,心肌收缩力,最佳前负荷容量反应性,最佳后负荷,不能忽视的内容：EVLW/PVPI等,2017/11/28,112,PUMCH,血流动力学管理流程没有CO监测时,基础监测组织氧