血流动力学监测.ppt

血流动力学监测,Hemodynamicmonitoring,主要内容,血流动力学的基本概念监测技术各种压力波形的识别及分析临床应用,血流动力学监测的基本概念,定义血流动力学血液流动的物理学血流动力学监测对影响循环系统的物理学因素的监测及解释物理概念流量（Q）压力（P）阻力（R）,物理概念,压力（P）=流量（Q）阻力（R）P：CVP、LAP/PAWP、MPAP、MAPQ：COR：SVR、PVR容量与压力的关系阻力与压力的关系阻力与管径的关系,生理概念,血压=血液流速（心输出量）循环阻力循环系统是一个连续、相对封闭的管道系统产生血液流动的压力梯度来自于心脏运动产生的压力梯度血管管径能够主动地发生变化神经内分泌活动肾素-血管紧张素-醛固酮系统,心脏内的压力梯度,心脏活动时的压力变化,常用压力监测项目,CVP/RAPLAP/PAWPABPPAP,心脏功能的影响及其调节因素,频率/节律前负荷后负荷收缩力,前负荷,定义：心肌纤维在收缩前的张力决定因素：LVEDV/LVEDPStarling定律：心肌收缩产生的能量是心肌纤维初长度的函数心肌收缩力与心肌纤维收缩的初长度呈正相关,心输出量,CO=HRSV4-8L/minSV60-80ml心输出量不等于心肌收缩力SV的影响因素：前负荷后负荷收缩力,后负荷,定义：抵抗心脏排血的压力或阻力影响因素：血管内径及血液粘滞性阻力（R=P/Q）：SVR=(MAP-RAP)/CO80PVR=(MPAP-LAP)/CO80,心肌收缩力,迄今为止，有关心肌收缩力的监测大多是间接实现的射血分数（EjectionFraction）一定程度上反映心肌收缩功能不反映心肌的舒张功能,SvO2监测,监测部位：肺动脉影响因素：CO、SaO2、Hgb、VO2意义：反映机体组织水平的氧输送及摄合平衡60%用于计算氧输送（DO2）及摄取（VO2）,氧代谢公式,氧含量：CaO2=Hb1.36SaO2+0.003PaO2CvO2=Hb1.36SvO2+0.003PvO2氧输送：DO2=COCaO2氧摄取：VO2=CO(CaO2-CvO2),影响SvO2的因素,动脉血氧饱和度（SaO2）心输出量血红蛋白组织氧摄取能力,常用公式及参考范围,常用氧代谢参数及参考范围,不同休克的变化模式,血流动力学监测技术,血流动力学监测组成,换能器将物理信号（如压力、温度、光）转换为电信号放大器汇集电信号，通过电缆传递给显示设备显示器管道及冲洗系统保持通畅压力袋肝素,动脉压监测适应症,持续血压监测需要多次抽血,动脉测压部位,桡动脉、肱动脉、股动脉Allenstest：同时压迫桡、尺动脉不断抓握动作直至手指发白放开尺动脉肢端色泽在5-7秒恢复,Allenstest,护理注意事项,波形变化与无创血压对照管道连接检查肢端循环、活动及感觉正确设定报警系统（10to20mmHg）穿刺部位固定，防止渗血、血肿,正确的动脉压波形,快速上升收缩期开始重搏切迹主动脉瓣关闭收缩结束18:889-97.,Outline,Objective:ToexaminetheassociationbetweentheuseofPACduringthefirst24hoursofcareintheintensivecareunit(ICU)andsubsequentsurvival,lengthofstay,intensityofcare,andcostofcare.Design:ObservationalstudySetting:FiveUSteachinghospitalsbetween1989and1994.Subjects:5735adultpatientsinICUs,UnadjustedOutcome,MatchedPairs,Pairs:Nodifferenceforseverityofillness,2-monthprognosisonday1,age,numberofcomorbidillnesses,functionalstatus,vitalsigns,GlasgowComaScore,WBCcount,bloodgases,creatinine,oralbumin,Conclusion,RHCwasassociatedwithincreasedmortalityandincreasedutilizationofresources.Thecauseofthisapparentlackofbenefitisunclear.ThesefindingsjustifyreconsiderationofarandomizedcontrolledtrialofRHCandmayguidepatientselectionforsuchastudy.,Debates,PatientswerenotrandomizedCasematchingbyinitialparametersmightnotcapturephysiciansjudgmentsabouttheinitialclinicalimpressionorthepatientstreatmentresponseWithoutaclearunderstandingoftheskilllevelinthesettingsofthisstudyNoprotocolsweredescribedorapparentlyexistedfortheuseofdatageneratedbythePAC,EthicalDilemma,AttempttoperformaRCTwasterminatedprematurelywithnearlyhalfofenrolledcontrolscrossingovertoPACbecausecliniciansdeemeditunethicaltowithholdPACinthefaceofclinicaldeteriorationGuyattG,OntarioIntensiveCareGroup.Arandomizedcontroltrialofright-heartcatheterizationincriticallyillpatients.JIntensiveCareMed1991;6:91-95,EffectivenessofthePulmonaryArteryCatheter?,ThePulmonaryArteryConsensusConferenceAmericanAssociationofCriticalCareNursesAmericanCollegeofChestPhysiciansAmericanThoracicSocietyEuropeanSocietyofIntensiveCareMedicineSocietyofCriticalCareMedicinePulmonaryArteryCatheterConsensusConference.Consensusstatement.CritCareMed.1997;25:910-925.,RECOMMENDATIONS(1),NobasisforanFDAmoratoriumofPACuseCarefullyweightherisksandbenefitsofthePACandpatientsorsurrogatesshouldbefullyinformedbeforeuse.Criteriainspecificclinicalsituationsshouldbedeveloped.ClinicianknowledgeaboutuseofthePACanditscomplicationsshouldbeimproved.,RECOMMENDATIONS(2),Currenttraining,credentialing,andcontinuingqualityimprovementissuesrelatedtothePACshouldbereevaluated.TheindicationsandcontraindicationsforPACusewhereclinicalequipoiseislackingshouldbedetermined.Clinicaltrialsforindicationswhereclinicalequipoiseexistsshouldbeperformed.Financialsupportfortheaboveprojectsshouldbeobtainedfromfundingagenciesandindustry.,NHLBI283:2568-2572.,Events,ArandomizedtrialcomparingmonitoringwiththePACv.s.monitoringwithacentralvenouscatheter,tobeconductedbytheNationalInstitutesofHealth,NHLBI,ARDSNetworkIssuanceofarequestforapplicationsbytheNHLBIforstudyofthePACinpatientswithrefractorycongestiveheartfailureCreationofthePulmonaryArteryCatheterEducationalProgramtobeimplementedbyvariouscriticalcareprofessionalsocietiesandgovernmentagencies,ARDSNetworkPACStudy,Prospective,Randomized,Multi-CenterTrialofPulmonaryArteryCatheter(PAC)vs.CentralVenousCatheter(CVC)forManagementofAcuteLungInjury(ALI)andAcuteRespiratoryDistressSyndrome(ARDS).CombinedwithasecondstudyevaluatingaFluidConservativevs.FluidLiberalManagementstrategyGoals:toassessthesafetyandtheefficacyofPACvs.CVCguidedmanagement1,000patientswillbeenrolled/ardsnet/,问题,ABP？CVP？PAP？,ABP？CVP？PAP？,哪一个心率更快？,i-a波，c波，v波?ii-a波，c波，v波?iii-a波，c波，v波?,心包填塞大肺动脉栓塞,哮喘二尖瓣狭窄伴充血性心衰大量胸腔积液,ABP,二尖瓣返流二尖瓣狭窄主动脉瓣狭窄肥厚性心肌病扩张性心肌病,严重左心功能衰竭急性肺栓塞低血容量二尖瓣狭窄主动脉瓣狭窄,CVP,CVP,？,57男性，发热、腹痛36小时腹部平片：膈下游离气体剖腹探查：乙状结肠憩室破裂既往史：特发性心肌病BP70/40CVP4PA17/9CO1.9SVR1800,a)去甲肾上腺素b)硝酸甘油c)多巴酚丁胺d)扩容e)限制液体摄入,2000ml/hBP80/45CVP22PA35/17CO2.1SVR1400,a)alpha激动剂b)再次给予液体负荷c)可能是感染性休克d)可能是心功能衰竭e)循环超负荷，利尿,MAP50mmHgCVP8mmHgPAOP6mmHgCO7L/min梗阻性休克心原性休克心原性休克伴低血容量分布性休克低血容量性休克,分布性休克,BP84/60/68RAP23RVP42/23PAP50/28/35PAOP28CI2.5HR128,氨力农去甲肾上腺素硝普钠硝酸甘油多巴胺,多巴胺,64岁男性，冠心病、高血压、低氧血症双侧肺底湿罗音，心动过速、S3奔马律X线：心