休克患者血容量监测

,休克患者血容量监测,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,休克的概念,感染、创伤、烧伤等引起有效循环血量明显减少组织器官的灌注不足氧输送不能满足组织代谢需要导致组织缺氧代谢障碍和细胞受损临床综合征,休克治疗的首要任务：积极、合适补充血容量,休克发生的始动因素： 有效循环血量下降,合适的容量管理,容量管理的基本目标,保证容量合适的心脏前负荷,预防肺水肿,二者必须平衡,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,容量监测的现状,容量监测：TEE，CT，核素扫描临床表现: 血压、心率、尿量、皮肤粘膜等压力监测：漂浮导管(CVP/PAWP),心脏前负荷：VEDV,RVEDP/LVEDP的测定,压力反映容量及肺水肿的局限性,心脏顺应性瓣膜功能肺毛细血管通透性机械通气对循环的影响,PAC对容量监测的有效性和可信性受到置疑？,许多文献：CVP/PAWP不能准确反映容量状态,Principle of EVLW measurement,RAEDV,LAEDV,LVEDV,PBV,RVEDV,EVLW,Injection,PiccoThermo-dilutioncatheter,Swan-ganz catheter,呼吁容量指标的应用来反映容量状态及肺水肿,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,A physiological system model,ITTV : Intrathoracic total volume,GEDV : Global end-diastolic volume,ITBV : Intrathoracic blood volume,PTV : Pulmonary total volume,EVLW : extra-pulmonary lung water,胸內总容量,全心舒张期血容量,胸內血液容量,肺部容积,血管外肺水,容量指标的应用,胸腔内血管容量(ITBV)血管外肺水(EVLW)搏出量变异率(SVV),胸腔内血管容量(ITBV),左心舒张末期容量右心舒张末期容量肺血容量,搏出量变异率(SVV),SVV=(SVmax SVmin)/SVmeanSvmax:mean value of four SVmax/30sSVmin :mean value of four SVmin/30sSVmean,血管外肺水组成(EVLW),细胞内液间质液体肺泡内液体,内容简介,管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,ITBVvalid estimate of preload in ALI,Prospective animal study15 sheep with ALI -saline washoutMV(PEEP 0,7,14,21 respectively 60min)Measurement:LVEF,LVEDV-CT scanITBV,RVEDV-PiCCOCVP,PAWP-PAC,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,ITBV and RVEDV Provide valid estimate of preloadEven at high intrathoracic pressure,ITBV-indicator of preload in liver transplantation,60 patients undergoing Liver transplantation monitored with PiCCO and PACthe correlation between PAOP and ITBVI with respect to CI and SVIthe correlation between ITBVI and PAOP,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - more reliable indicator of preload than PAWP,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - valid indicator of preload in lung transplantation,50 patients during lung transplantationTime: 6 phase during operationCorrelation between PAWP and SVICorrelation between ITBVI and SVICorrelation between (Delta) ITBVI PAWP and Delta SVIDelta were calculated by subtracting the first from the second measurement Della RG, et al. Anesth Analg. 2002 , 95: 835-43,ITBV- superior than PAWP in preload,Della RG, et al. Anesth Analg. 2002 , 95: 835-43,Correlation of ITBV - SV in 4 phases,No correlation of PAWP - SV in any phases,Prospective, controlled, clinical study18 patients with ejection fraction 50% undergoing coronary artery bypass graft surgeryA baseline measurement :after induction of anesthesia (T1) treated by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) After 10 minutes, a second measurement (T2) was performed,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,ITBV correlated significantly with CI and SV IN CABG,ITBV has Good relationship between CI/SVI, CVP/ PCWP 与 CI/SV无相关性, ITBV 与 CI的相关性r = 0.55, ITBV 与 SV的相关性为r = 0.62,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,前瞻性临床研究40例心脏移植术后患者男34例，女6例观察术后3、6、12、24、36、48、72h ITBV/GEDV和CVP/PAWP与SV的相关性,ITBV/GEDV-good preload indicator in heart transplantation,Goedje O, et al. Chest, 2000, 118: 775-781,Goedje O, et al. Chest, 2000, 118: 775-781,Goedje O, et al. Chest, 2000, 118: 775-781,GEDV-SV: R2=0.4016ITBV-SV: R2=0.2979,Goedje O, et al. Chest, 2000, 118: 775-781,PAWP-SV: R2=0.0043CVP-SV: R2=0.0552,ITBV的改变反映肺水含量,Prospectively study16 patients with septic shock and pulmonary edema(ACCP/SCCM)SAPS II: 56Monitor: Picco,PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hIntensive Care Med, 2002,28,712-18,From intensive Care Med, 2002,28,712-18,CVP与EVLW的相关性,PAWP与EVLW的相关性,Correlation between ITBV/TEDV and EVLW,From intensive Care Med, 2002,28,712-18,ITBV 与 EVLW有良好相关性优于 CVP 与 PAWP,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,SVV可以反映机体前负荷,Prospective study20 MV patients following cardiac surgeryVolume loading(HES 20ml*BSA/10min)Measurement:CVP, PAWP-PACLVEDAI-TEEITBV, SVV-PiCCO,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,血流动力学监测,SVV may help to determine the preload condition,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,CVP/PAWP not correlated with CI,SVV may help to determine the preload condition,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,CVPnot correlated,SVV反映机体对容量治疗的反应,15例脑外科手术患者麻醉诱导后容量负荷实验： 100 mL of 6% hydroxyethylstarch given for 2 min 分组：responsive: SV5% nonresponsive: SV5%A total of 140 VLSs were performed,Anesth Analg. 2001, 92: 984-9,两组负荷试验前血流动力学状态,Response(70)nonresponse(70) PHR7675 NSSBP102116 0.001CVP9.39.3 NSSVV12.66.8 0.001,Anesth Analg. 2001, 92: 984-9,两组负荷试验后血流动力学改变,Response(70) nonresponse(70) PHR-1-1NSSBP 92 0.001 CVP9.811.9NSSVV-25.8-100.001,Anesth Analg. 2001, 92: 984-9,以上指标与SV改变的相关性,Pearsons correlationPHR0.142NSSBP-0.448 0.001SV-0.3720.001CVP0.055NSSVV0.722 0.001HR-0.089NSSBP 0.472 0.001CVP-0.084NSSVV-0.505 0.001,Anesth Analg. 2001, 92: 984-9,Responsive VLS: SVV/SV有较高的特异性和敏感性,Anesth Analg. 2001, 92: 984-9,SVV对失血性休克犬容量状态的评价,成年健康杂种犬共14只，体重12.11.1公斤,复制犬失血性休克模型稳定30分钟，改良的 Wiggers法制备失血性休克犬模型适当放血维持MAP在50 mmHg左右并稳定60分钟，模型成功,容量负荷试验2分钟内快速滴入林格氏液7ml.kg-115分钟后重复，记录容量负荷前及后5分钟的监测指标,分组 SV是否大于容量负荷试验前SV的5分为两组 反应组 (SV5) 无反应组 (SV5)直至连续两次SV均小于容量负荷试验前的5%时终止实验,监测指标HR MAP PiCCO监测仪: CO、ITBVI 、SV 、SVVSwan-Ganz导管:CO、CVP、PAWP,共进行容量负荷试验134次，每只犬平均9.61.7次，其中94次为反应组，40次为无反应组,容量负荷实验前各指标的比较,P 0.05,容量负荷试验前各指标与SV的相关性,容量负荷试验前后各指标的变化与SV的相关性,各指标对容量负荷反应(SV)的ROC曲线分析,AUC=曲线下面积, CI =可信区间,SVV大于9.5时，对容量评价的敏感性为92.6，特异性为62.5。,SVV和ITBVI可用于容量状态的评价优于HR、MAP、CVP和PAWP,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,CVP/PAWP能反映EVLW吗?,Prospectively study16 pats with septic shock and pul edema (ACCP/SCCM)SAPS II: 56Monitor: PiCCO vs PACOptimal PAWP: CI no longer increasedMonitor time: 0, 24hFrom intensive Care Med, 2002,28,712-18,Intensive Care Med, 2002,28,712-18,CVP/PAWP能反映EVLW吗?No,Intensive Care Med, 2002,28,712-18,delta与EVLW相关性, FB：fluid balance,CVP/PAWP