危重病患者的血流动力学监测目标.ppt

危重病患者的血流动力学治疗目标HowToMakeItSimple?,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)812mmHg*平均动脉压65mmHg尿量0.5ml/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%,DellingerRP,LevyMM,CarletJM,etal.SurvivingSepsisCampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2008.CritCareMed2008;36(1):296-327.Erratumin:CritCareMed2008;36(4):1394-1396.,中心静脉压:影响因素,NouiraS,ElatrousS,DimassiS,etal.Effectsofnorepinephrineonstaticanddynamicpreloadindicatorsinexperimentalhemorrhagicshock.CritCareMed2005;33:2339-2343,容量负荷试验:判断标准,每10分钟测定CVPCVP2mmHg继续快速补液CVP25mmHg暂停快速补液,等待10分钟后再次评估CVP5mmHg停止快速补液,每10分钟测定PAWPPAWP3mmHg继续快速补液PAWP37mmHg暂停快速补液,等待10分钟后再次评估PAWP7mmHg停止快速补液,WeilMH,HenningRJ:Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock.AnesthAnalg1979;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(50/20mmHg),病例1:入院情况,入ICU时BT37.2CHR130bpmBP84/40mmHg(DA10g/kg/min)SpO278%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)FiO2100%,PEEP10cmH2OSpO292%循环支持羟基淀粉500ml扩容无效DA13g/kg/minNE1.2g/kg/minBP110/70mmHg,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3000ml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),TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56,TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.,白蛋白vs.晶体液:SAFE研究,TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56,TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.,白蛋白vs.晶体液:SAFE研究,TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56,TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.,乳酸林格液vs.羟乙基淀粉,BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.,乳酸林格液vs.羟乙基淀粉,BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.,乳酸林格液vs.羟乙基淀粉,BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.,乳酸林格液vs.羟乙基淀粉,BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;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=MAPIAPFG=GFPPTP=MAPIAPx2,脑灌注CPP=MAPICP,健康与疾病时的自身调节,0,150,50,100,Organbloodflow(%Baseline),0,100,20,40,60,80,Organarterypressure(mmHg),Autoregulatorythreshold,Subautoregulatoryslope,疾病时的自身调节机制,0,150,50,100,Organbloodflow(%Baseline),0,100,20,40,60,80,Organarterypressure(mmHg),control,3weeks,1week,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BP160180/7090mmHg,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NG100g/min,控制BP134/56mmHg血Cr861mol/L,UO100HR1mL/kg/h乳酸2.5mmol/L或其他灌注不足表现,BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964,隐性低灌注与创伤预后,严重创伤患者两次LA2.5,输注液体或血液制品,重复LA2.5,Swan-Ganz,动脉插管,肾脏剂量多巴胺,将PCWP提高到1215将Hct提高到30%,重复LA2.5,升压药物(多巴酚丁胺)心脏超声检查,若LA仍2.5,BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964,隐性低灌注与创伤预后,BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964,感染患者的组织灌注与预后,HowellMD,DonninoM,ClardyP,etal.Occulthypoperfusionandmortalityinpatientswithsuspectedinfection.IntensiveCareMed2007;33:1892-1899,感染患者的组织灌注与预后,HowellMD,DonninoM,ClardyP,etal.Occulthypoperfusionandmortalityinpatientswithsuspectedinfection.IntensiveCareMed2007;33:1892-1899,感染性休克的EGDT,RiversE,NguyenB,HavstadS,etal:Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001;345:1368-1377,感染性休克的EGDT,RiversE,NguyenB,HavstadS,etal:Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001;345:1368-1377,感染性休克的EGDT,血流动力学目标前负荷CVP灌注压MAP组织灌注UOScvO2,RiversE,NguyenB,HavstadS,etal:Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001;345:1