危重病微循环障碍

1、 Krogh A(1929)毛细血管的解剖和生理 (The Anatomy and Physiology of Capillaries) “毛细血管是血液和组织间物质交换的器 官”(an organ for interchange Of substances between the blood and the tissues：the capillaries) 贝时璋教授：贝时璋教授： 什么是生命活动什么是生命活动?根据生物物理学的观根据生物物理学的观 点，无非是自然界三个量综合运动的表现，点，无非是自然界三个量综合运动的表现， 即物质、能量和信息在生命系统中无时无即物质、能量和信息在生命系统中

2、无时无 刻地在变化，这三个量有组织、有秩序的刻地在变化，这三个量有组织、有秩序的 活动是生命的基础。活动是生命的基础。 田牛田牛.微循环学杂志，微循环学杂志，1994.1 直接参与组织、细胞的直接参与组织、细胞的物质、信息、物质、信息、 能量能量传递的血液、淋巴液、组织液的流动传递的血液、淋巴液、组织液的流动 称之为微循环。称之为微循环。 微循环的本质属性 SIRS的临床特征 心输出量的增加、全身血管阻力的降低心输出量的增加、全身血管阻力的降低 动静脉氧分压差缩小动静脉氧分压差缩小 血乳酸水平增加血乳酸水平增加 反映细胞对氧反映细胞对氧(或底物或底物)的利用障碍。用于产生细的利用障碍。用于产生

3、细 胞必需能量的氧和底物的输送或利用障碍可导致胞必需能量的氧和底物的输送或利用障碍可导致 SIRS,并形成并形成MODs 微血管构型及其微细结构 微循环障碍的监测 血乳酸 SVO2 BE DO2，VO2 near-infrared spectroscopy (NIRS), Creteur.Curr Opin Crit Care. 2008 Jun;14(3):361-6. The prognostic value of muscle StO2 in critically ill patients SUMMARY: Near-infrared spectroscopy provides a no

4、ninvasive measure of muscle oxygen metabolism and microvascular dysfunction in critically ill patients. It may be useful to guide the management of PtCO2 加热的氧电极直接置于患者胸骨旁2、3肋 间正常皮肤上来测定PtC02。 无创性、续监测组织氧合。Ptc02测定的是 传感器下面皮肤组织的P02。 组织氧张力除了受PaO2影响外，还受组织 血液灌注量的影响。组织血液灌注量正常 时，Ptc02与PaO2具有非常好的相关性。 Fife CE; S

5、mart DR; Undersea Hyperb Med. 2009V36N1:43-53 Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence. Intensive Care Med. 2009 Jun;35(6):1106-9. Epub 2009 Jan 29. Thenar oxygen saturation measured by near infrared spectroscopy as a noninvasive predi

6、ctor of low central venous oxygen saturation in septic patients. Mesquida J, Masip J, Gili G, Artigas A, Baigorri F. 2008年严重脓毒症与脓毒症休克治 疗国际指南 建议仅在成年脓毒症休克患者对容量复苏 和血管活性药物反应差时静脉给予氢化可 的松(推荐级别2C) The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with

7、 septic shock* Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 方法 N=16 cardiac output cutaneous tissue PtO2 using a Clark electrode cutaneous red blood cell flux using laser Doppler flowmetry, Sublingual microvascular flow using sidestream darkfield imaging. Shaman Jhanji, Crit Care Med 2009 Vol. 3

8、7, No. 6 Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study Arnaldo Dubin Critical

9、Care 2009, 13:R92 方法 N=20 Sublingual microcirculation was evaluated by sidestream darkfield (SDF) imaging DO2 and VO2, lactate, albumin-corrected anion gap, gastric intramucosal-arterial PCO2 difference (PCO2). Arnaldo Dubin .Critical Care 2009, 13:R92 Arnaldo Dubin. Critical Care 2009, 13:R92 Arnal

10、do Dubin .Critical Care 2009, 13:R92 Arnaldo Dubin .Critical Care 2009, 13:R92 Arnaldo Dubin. Critical Care 2009, 13:R92 2008年严重脓毒症与脓 毒症休克治疗国际指南 NE 为纠正脓毒症休克低血压首选的一线血为纠正脓毒症休克低血压首选的一线血 管升压药管升压药, 1C级级, 无在脓毒症治疗中选择何种儿茶酚胺类药无在脓毒症治疗中选择何种儿茶酚胺类药 物的最终建议物的最终建议 The effects of dobutamine on microcirculatory alter

11、ations in patients with septic shock are independent of its systemic effects Daniel De Backer,Crit Care Med 2006 Vol. 34, No. 2 方法方法 Intravenous administration of dobutamine (5 g/kgmin) for 2 hrs (n 22) followed by the addition of 102M acetylcholine (topically applied, n 10). Hemodynamic measurement

12、s sublingual microcirculation was investigated with an orthogonal polarization spectral imaging technique before and after dobutamine administration and after topical application of acetylcholine. Dobutamine Daniel De Daniel De Backer,Backer,Crit Care Med 2006 Vol. 34, No. 2Crit Care Med 2006 Vol. 3

13、4, No. 2 Daniel De Backer,Crit Care Med 2006 Vol. 34, No. 2 Daniel De Backer,Crit Care Med 2006 Vol. 34, No. 2 不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较 涂自智孙庆华Geo rge D imopou lo sSuzanaM LoboDan ielDe Figure 1Changes of arter ial lactate concentration in each group 不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休 克

14、的疗效比较克的疗效比较 涂自智孙庆华Geo rge D imopou lo sSuzanaM LoboDan ielDe Ch in Crit CareM ed, Feb. 2005,Vo l. 17,No12 Figure 2Changes of Pt aCO2gap in each group 不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休 克的疗效比较克的疗效比较 涂自智孙庆华Geo rge D imopou lo sSuzanaM LoboDan ielDe Ch in Crit CareM ed, Feb. 2005,Vo l. 17,No1

15、2 Figure 3Changes of intestinal intramucosal pH in each group Effects of hydrocortisone on microcirculatory alterations in patients with septic shock Gustavo Luiz Bu Crit Care Med 2009 Vol. 37, No. 4 Effects of hydrocortisone on microcirculatory alterations in patients with septic shock Gustavo Luiz

16、 Bu Crit Care Med 2009 Vol. 37, No. 4 orthogonal polarization spectral device was used to investigate the sublingual microcirculation the first dose (50 mg) of hydrocortisone and 1, 2, 4, and 24 hours later Global hemodynamic variables were similar at all study time points. Effects of hydrocortisone

17、 on microcirculatory alterations in patients with septic shock Gustavo Luiz Bu Crit Care Med 2009 Vol. 37, No. 4 Effects of hydrocortisone on microcirculatory alterations in patients with septic shock* Gustavo Luiz Bu cheleCrit Care Med 2009 Vol. 37, No. 4 Figure 2. Evolution of microcirculation var

18、iables during study time periods. Perfused small vessels . The effect of storage time of human red cells on intestinal icrocirculatory oxygenation in a rat isovolemic exchange model* N. J. Raat, PhD; A. J. Verhoeven, PhD; E. G. Mik, MSc; C. W. Isovolemic exchange with fresh and intermediate red bloo

19、d cells maintained PO2 whereas old cells decreased PO2 with 26%. Subsequent transfusion with red blood cells (hematocrit 60%) until reaching a hematocrit of 32.4 % (n 24) increased intestinal PO2 in all three groups to the same extent between 28% and 32%. Effects of propofol on human microcirculation M. Koch1, British Journal of Anaesthesia 101 (4): 4738 (2008) 15 patients anaesthetized by propofol for transvaginal oocyte retrieval. The sublingual microcirculatory network was studied before, during, and after propofol infusion us