周树生经胸壁心脏超声容量评估及指导快速补液试验精选文档

1、1,Series PPT of Intensive care unit,20140919,安徽省立医院重症医学科,副主任医师、副教授,安徽医科大学,硕士研究生导师,周树生,This study of 2,289 patients included prospectively from two different cohorts in a,quaternary-level provincial referral hospital in BC,Canada.(47.75,Crit Care Med,2014 Jul 22,在管理血流动力学不稳定的患者中，常见策略是提高心排血量和组织灌注，故,评估患

2、者的容量状态极其重要,对评估容量状态容量无反应的患者，增加容量负荷不但不能引起心输出量的增,加，反而会增加组织水肿及缺氧，故在进行快速补液时应首先对患者进行容量,评估,J Intensive Care Med. 2009 Sep-Oct;24(5):329-37,Techniques for assessment of intravascular volume in critically ill patients,德国生理学家,Otto Frank,英国生理学家,Starling,Frank-Starling,机制,静态前负荷参数,前负荷压力指标,CVP,及前负荷容量指标（全心舒张末期,容积,

3、GEDV,动态前负荷参数,收缩压变异率,SPV,脉压变异率,PPV,每搏变异率,SVV,及被动抬腿试验,PLR,等,Cardiovasc Ultrasound. 2008 Oct 6;6:49,World Interactive Network Focused on Critical,Ultrasound,WINFOCUS,血压,BP,失血量达,18,仍然可以通过提高血管阻力来维持相对正常的,MAP,中心静脉压,CVP,和肺动脉楔压,PAWP,通过压力代容积来反应心脏前负荷,均受到心脏顺应性，机械通气和血管张力等因素影响,超声,FATE(focus assessed transthoracic

4、 echo,草案,Research has suggested that volume responsiveness can be defined as a,15,increase in,stroke volume(SV,or,cardiac output(CO,after a 500ml,infusion,Anesth Analg.2010 Nov;111(5):1180-92,A critical review of the ability of continuous cardiac output monitors,to measure trends in cardiac output,床

5、旁超声下腔静脉直径,IVCD,测量方法,Korean J Intern Med 2014;29:241-245,一、床旁超声预测容量反应之下腔静脉直径,IVCD,J Emerg Med.2012 Apr;42(4):429-36,一、床旁超声预测容量反应之下腔静脉直径,IVCD,在容量反应时，下腔静脉直径变化与,CVP,具有相关性,P,0.001,下腔静脉直径在,1-2CM,范围具有较高的特异性和敏感性,A) Subxiphoid, transverse orientation, at end inspiration. (B) Subxiphoid, longitudinal orientat

6、ion, at end inspiration,inferior vena cava diameter(IVCD) and central venous pressure value(CVP,Pak J Med Sci. 2014 Mar;30(2):310-5,下腔静脉长轴切面,IVC= inferior vena cava; CVP= central venous pressure,Statistically relationship,between,IVC and CVP pressures,Pak J Med Sci. 2014 Mar;30(2):310-5,结论：自主呼吸患者，下腔

7、静脉直径变化可以预测容量反应,下腔静脉扩张指数,dIVC,Dmax,吸气末,Dmin,呼气末,Dmin,Intensive Care Med. 2004 Sep;30(9):1740-6,30-min volume expansion (7 ml/kg) using 4% modified fluid gelatin,二、床旁超声预测容量反应之下腔静脉扩张指数,dIVC,Baseline,After volume,expansion,Respiratory changes in inferior vena cava diameter are helpful in predicting flui

8、d,responsiveness in ventilated septic patients,Intensive Care Med. 2004 Sep;30(9):1740-6,机械通气患者,dIVC,18,预测容量反应性敏感性和特异性均在,90,以上,下腔静脉呼吸变化率,D,IVC,Dmax-Dmin)/(Dmax+Dmin,Intensive Care Med. 2004 Sep;30(9):1834-7,三、床旁超声预测容量反应之下腔静脉呼吸变化率,D,IVC,A studied 39 mechanically ventilated patients with septic shock,

9、Individual values (open circles) and mean,SD (closed circles) of the minimum D,IVC,maximum D,IVC,and,D,IVC,befor volume loading in responder (R) and non-responder (NR) patients.*P0.05 R vs NR,下腔静脉呼吸变化率,12,预测容量反应性的阳性和阴性分别为,93,和,92,Intensive Care Med. 2004 Sep;30(9):1834-7,四、床旁超声预测容量反应之下腔静脉塌陷指数,IVC,C,

10、下腔静脉塌陷指数,IVC-CI,Dmax-Dmin,Dmax,J Am Coll Surg. 2009 Jul;209(1):55-61,JACC Cardiovasc Imaging. 2011 Sep;4(9):938-45,下腔静脉,2cm,精确度,88,和下腔静脉塌陷,40,精确度,68,是确定右心房压,10mmHg,较高精,度,比组合,RAP=0,8mmHg,下腔静脉塌陷指数预测右心房压力,RAP,Intensive Care Med. 2010 Apr;36(4):692-6,IVC-CI,指导心衰患者缓慢超滤,SCUF,治疗,Hypotension,was observed on

11、ly in those patients (2/24) who reached an IVCCI,30%.In all the,other patients,a significant increase in IVC-CI was obtained without hemodynamic instability,Mean UF time was 20.3,4.6h with a mean volume of 287.6,96.2ml h-1 and a total ultrafiltrate,production of 5,780.8,1,994.6 ml,IVC-CI to guide fl

12、uid removal in slow continuous ultrafiltration: a pilot study,Intensive Care Med. 2010 Apr;36(4):692-6,IVC ultrasound is a rapid, simple, and non-invasive means for bedside monitoring of,intravascular volume during SCUF and may guide fluid removal velocity,Am J Emerg Med. 2013 Aug;31(8):1208-14,Cuto

13、ff values=ADHF were LVEF,45%, IVC-CI,20%, and 10 B,lines,LVEF,IVC-CI and B-lines,联合诊断急性呼吸困难心衰患者,锁骨下静脉和下腔静脉的塌陷指数,IVC-CI and SCV-CI,J Surg Res. 2013 Sep;184(1):561-6,SCV-CI versus IVC-CI. Linear regression demonstrates acceptable correlation between the two,measurement modalities (R,2,0.61). (Color ve

14、rsion of figure is available online.,Measurement bias plot comparing IVC-CI and SCV-CI across a broad range of collapsibility values,J Surg Res. 2013 Sep;184(1):561-6,锁骨下静脉和下腔静脉的塌陷指数,IVC-CI and SCV-CI,Crit Care Med. 2013 Mar;41(3):833-41,Point-of-care ultrasound to estimate central venous pressure:

15、a comparison of three techniques,下腔静脉直径比下腔静脉塌陷指数与,CVP,更具有相关性,R,2,0.58,R,2,0.21,R,2,0.16,Test Characteristics of Three Ultrasound Techniques in Predicting CVP10mmHg,Crit Care Med. 2013 Mar;41(3):833-41,Among spontaneously breathing patients without vasopressor support, the maximal ICVD is a more robu

16、st,estimate of CVP than the IVCCI or the IJVSR,颈内静脉的纵横比,五、床旁超声预测容量反应之舒张末期容积,LVEDA,GEDV,p Value baseline v hemorrhage;?p Value hemorrhage v hypervolemia;?p Value baseline v hypervolemia,J Cardiothorac Vasc Anesth.2007 Oct;21(5):650-4,J Crit Care. 2012 Jun;27(3):325.e7-13,全心舒张末期容积,GEDV,预测容量反应,P,0.05(B

17、L nonresponder vs BL responder,全心舒张末期容积,GEDV,预测容量反应,J Crit Care. 2012 Jun;27(3):325.e7-13,六、床旁超声预测容量反应之主动脉,AO,Peak,是用从左室流出道水平测得的吸气时主动脉内最大峰值血流速和呼气时,最小峰值血流速之差与两者平均值的比率。公式如下,Vpeakmax,和,Vpeakmin,分,别表示最大和最小峰值血流速,peak,Vpeakmax-Vpeakmin,Vpeakmax+Vpeakmin/2,100,机械通气患者主动脉峰值血流速度呼吸变异率,peak,或主动脉速度时间积分呼,吸变化率,VTI

18、,代表了容量反应性变化的幅度及前负荷,六、床旁超声预测容量反应之主动脉,AO,在心尖五腔心断面，左心室流出道可以测量主动脉瓣的速度时间积分,VTI,公式如下,VTImax,和,VTImin,分别表示主动脉瓣的速度时间积分最大和最小值,VTI,VTImax-VTImin)/(VTImax+VTImin)/2,100,机械通气患者主动脉峰值血流速度呼吸变异率,peak,或主动脉速度时间积分呼,吸变化率,VTI,代表了容量反应性变化的幅度及前负荷,机械通气患者主动脉峰值血流速度呼吸变异率,peak,能够预测容量反应,Pediatr Cardiol,2010 Nov;31(8):1166-70,主动脉

19、峰值血流速度呼吸变异率,peak,预测容量反应,Chest,2001 Mar;119(3):867-73,peak,预测机械通气脓毒症患者容量反应,The best cut,off for ?Vpeak ao was,12,with sensitivity, specificity,and positive and negative predictive,values of 81.2%, 85.7%, 93% and 66.6,PS=respiratory variations in,systolic arterial pressure(SPV,PP=respiratory variation

20、s in,pulse pressure(PPV,Chest,2001 Mar;119(3):867-73,peak,预测机械通气脓毒症患者容量反应,peak,PS=respiratory variations in,systolic arterial pressure(SPV,PP=respiratory variations in,pulse pressure(PPV,PP,PS,Pulsed Doppler before VE accurately predict the effects of VE, ?PS and ?PP are of little value in,ventilate

21、d children,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsiveness,研究方法,前瞻性研究,55,例机械通气患者,10,秒以上输液晶体溶液,50,毫升，另外,450,毫升,15,分钟输注,心输出量,CO,，每搏量,SV,，主动脉速度时间指数,VTI,，与左室射血分数,LVEF,被记录,评估内容：特征曲线下面积,AUC,Co50,co500,vti50,Wu Y,Zhou S,Liu B.et al,Critical Care,2014, 1

22、8:R108,对机械通气患者,VTI,可以评估容量反应性,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsiveness,Patient characteristics stratified by fluid responders and non-responders at baseline,Wu Y,Zhou S,Liu B.et al. Criti

23、cal Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsiveness,Hemodynamic variables were measured at baseline, during volume expansion,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthorac

24、ic echocardiography can predict,fluid responsiveness,A) Correlation between VTI50 (%) and VTI500 (%). (B) Correlation between CO50 (%) and CO500 (,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsivenes

25、s,Bland and Altman diagram between variation of cardiac output (A) and variation of velocity time index,B) after 50-ml or 500-ml volume expansion,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsiveness

26、,A 10-second fluid challenge guided by transthoracic echocardiography can predict,fluid responsiveness,Individual values of VTI50 (%) (A), SV50 (%) (B), and CO50 (%) (C) after infusion of 50ml of fluid over 10seconds,changed in patients with volume expansion-induced changes in stroke volume (SV) of

27、at least 10% (responders) and less than,10%(non-responders,Wu Y,Zhou S,Liu B.et al. Critical Care 2014, 18:R108,In critically ill patients, the variation of CO and VTI after the administration of 50-ml crystalloid,solution over 10 seconds (CO50 and VTI50) can accurately predict fluid responsiveness,

28、对机械通气血流动力学不稳定患者,VTI,可以评估容量反应性,Anesthesiology. 2011 Sep;115(3):541-7,VTI,主动脉速度时间积分呼吸变化率,Kardiol Pol. 2009 Mar;67(3):265-71,Variability of aortic blood flow predicts fluid responsiveness in spontaneously,breathing healthy volunteers,研究背景,Echo measurement of respiratory variations of aortic blood veloc

29、ity in ventilated shock patients,can accurately predict the effect of volume expansion,目的,To assess whether respiratory variability of peak aortic blood flow velocity (Vpeak) and of,aortic velocity time integral(VTI)reflects preload,dependent changes of cardiac index(CI)and,whether it predicts fluid responsiveness in healthy spontaneously breathing volunteers,结论,Vpeak,和,VTI,与前负荷改变时的,CI,密切相关，并证实在自主呼吸的患者也同样可以预,测容量反应性,Vpeak,主动脉峰值血流速度呼吸变异率,VTI,主动脉速度时间积分呼吸变化率,Crit Care.2009;13(5):R142.doi:10.1186/cc8027,机械通气患者肱动脉峰值流速变化率预测容量反应性,PP,rad,桡动脉脉搏压力变化率,Vpeak,brach,肱动脉峰值流