急危重症患者的血流动力学监测

1、NiCOCCOLiDCOPiCCOMonitorPACPAWPCIABCDn女,28岁,“腹痛、发热3天 诊所静脉输入诺氟沙星 腹痛、皮疹3天”n急诊尿常规提示尿路感染 停用原药，改为西力欣 病情迅速恶化 MODS nMAP40mmHg HR130bpm, 频频发室早发室早 n呼吸呼吸 (SpO290%; 窒息窒息) n恶心呕吐恶心呕吐n昏迷昏迷(GCS评分评分5分）分）n拟诊：拟诊： 过敏性休克过敏性休克n肾上腺素泵入 、地塞米松静脉注射PUMCH_ICUnBP 100/70 mmHg (E1.1ug/kg/min NE 0.5ug/kg/min)Rivers E, Nguyen B, Ha

2、vstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368-1377入室入室 入入 ICU时情况时情况nBP 100/70 mmHg (E1.1ug/kg.min NE 0.5ug/kg.min)nCVP14mmHg nVT400ml; f16bpm PEEP8cmH2O FiO2100% SpO2 95%n心肌酶心肌酶 CK384U/L CKMB25.7ug/L cTnI 21.24ug/LnPH7.18;

3、 PCO2 29.8 mmHg PO2 104mmHg; cLac18mmol/L; BE-13.7mmol/L; ScVO261%入室入室急诊nCVP14mmHgnPEEP8cmH2O FiO2100% SpO2 95% n心肌酶心肌酶 CK384U/L CKMB25.7ug/L cTnI 21.24ug/La. 经肺热稀释技术经肺热稀释技术b. 动脉脉搏轮廓分析技术动脉脉搏轮廓分析技术弹丸注弹丸注射射 肺肺PiCCO 导管导管 如：股动脉 经肺热稀释技术需要在中心静经肺热稀释技术需要在中心静脉注射冷盐水脉注射冷盐水( 8C)或室温盐或室温盐水水(3.07008507007008507008

4、50ELWI (ml/kg)GEDI (ml/m2)or ITBI (ml/m2)CFI (1/min)or GEF (%)101010101010V+V+!V+!V+CatCatOK!V-700850700-800850-10004.5255.5304.525 700-800 850-1000Cat5.530700850 700-800 850-1000 700-800 850-1000 10 10 10 10V-V+ = 增加容量增加容量 (! = 慎重慎重)V- = 减少容量减少容量Cat = 儿茶酚胺心血管药物儿茶酚胺心血管药物* SVV 只能用于没有心律失常的完全机械通气病人只能用于

5、没有心律失常的完全机械通气病人700850 10Optimise to SVV* (%) 101010测测量量结结果果目目标标治治疗疗1.2.不承诺完全合乎您的临床实践不承诺完全合乎您的临床实践10101010注射液温度电缆注射液温度电缆 中心静脉导管中心静脉导管动脉热稀释导管动脉热稀释导管 注射液温度电缆注射液温度电缆 PULSION 一次性压力传感器一次性压力传感器 PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP) 5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI) 625 温度测量电缆温度测量电缆 压力

6、电缆压力电缆2022-4-5治疗：4. 准备行CVVH1. 尝试扩容-胶体约200ml2. 调整血管活性药PUMCH_ICU3. 给予激素-氢化可的松100mg2022-4-5利尿利尿强心强心PUMCH_ICU2022-4-5PUMCH_ICU41岁，男性 栓下肢间隙综合征T 39HR 102/min;BP 65/50 mmHg入院第一天15 L 液体复苏Saugel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:38Jabot,J.et.al.Crit Care Med

7、 2009; 37:29132918Jabot,J.et.al.Crit Care Med 2009; 37:29132918passive leg raising (PLR) and volume expansionnTo find the relationship between macrocirculation and microcirculationPatients nsevere sepsis or septic shockn25 mechanically ventilated neligible for VE nin the first 24 h of their admissio

8、nPottecher.J, Deruddre.S，Teboul Jean-Louis.Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients. Intensive Care MednIn preload-responsive patients with severe sepsis and septic shock patients during the f

9、irst 24 h of their ICU stay, both PLR and VE improved sublingual microcirculatory perfusion.nAt the level of VE used in the study, changes in microcirculation were not explained by changes in rheologic factors or changes in MAP.nDifferent mechanisms were implicated in the regulation of microvascular

10、 perfusion and in the changes in CO.Assessment of RBF responsiveness to fluid or vasopressor challengesDeruddre S. Renal arterial resistance in septic shock. Intensive Care Med 2007; 33:15571562.Effects of increasing MAP with NE on the renal RInUniversity teaching hospitaln11 patients with septic sh

11、ock nMAP at successively 65, 75, and 85 mmHg (NE titrated)nHemodynamic parameters and renal function variables nDoppler ultrasonography to assess the renal resistive indexDeruddre S. Renal arterial resistance in septic shock. Intensive Care Med 2007; 33:15571562.Deruddre S. Renal arterial resistance

12、 in septic shock. Intensive Care Med 2007; 33:15571562.Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.Mullens, W. et al. J Am Coll Cardiol 2009;53:589-596Relative Contributions of CVP and CI to GFR at Time of PAC RemovalCopyright 2009 American College of Cardiology Foundation. Restrictions may apply.Mullens, W. et al. J Am Coll Cardiol 2009;53:589-596ROC Curves for CVP and CI on Admission for the Development of WRFCopyright 2009 American College of Cardiology Foundati