ScvO2的临床意义培训课件

1、内 容 氧供与氧耗SvO2与ScvO2ScvO2的临床应用1ScvO2的临床意义10/3/2022内 容 氧供与氧耗1ScvO2的临床意义10/2/202氧供与氧耗2ScvO2的临床意义10/3/2022氧供与氧耗2ScvO2的临床意义10/2/202215vol%=15ml/dl5vol%=5ml/dl3ScvO2的临床意义10/3/202215vol%=15ml/dl5vol%=5ml/dl3Scv4ScvO2的临床意义10/3/20224ScvO2的临床意义10/2/2022氧供DO2与氧耗VO2DO2=CaO2CO =(1.34SaO2Hb+0.0031PaO2)CO =1.34SaO

2、2HbCOVO2=(CaO2-CvO2)CO = (SaO2- SvO2) 1.34 HbCOSvO2=SaO2-VO2/(1.34HbCO) 呼吸血红蛋白循环(Fick方程)5ScvO2的临床意义10/3/2022氧供DO2与氧耗VO2DO2=CaO2CO呼吸血红蛋白循环氧摄取EO2EO2=VO2/DO2EO2=(SaO2 - SvO2)/SaO2当SaO2=100%时 ： EO2=1-SvO2全身 EO2=1 - 75% = 25%各组织EO2不同，其相应之静脉氧饱和度不同SvO2 = 1 - EO26ScvO2的临床意义10/3/2022氧摄取EO2EO2=VO2/DO26ScvO2的临

3、床意义10氧供氧耗失衡SvO2降低或增加无氧代谢组织缺氧乳酸生成7ScvO2的临床意义10/3/2022氧供氧耗失衡SvO2降低或增加无氧代谢7ScvO2的临床意义影响SvO2的因素75%-+DO2应激发热寒战躁动疼痛呼吸做功VO2CO(心衰、低容量）Hb（贫血、出血）SaO2（缺氧、呼衰）DO2CO（液体复苏、正性肌力）Hb（输血）SaO2（氧疗）VO2低体温镇静镇痛麻醉机械通气氧摄取（分流、细胞死亡）8ScvO2的临床意义10/3/2022影响SvO2的因素75%-+DO2VO2CODO2COVO2SvO2 的界值Pinsky MR, Mancebo J, Applied physiolo

4、gy in intensive care. 9ScvO2的临床意义10/3/2022SvO2 的界值Pinsky MR, Mancebo J, ScvO2与SvO210ScvO2的临床意义10/3/2022ScvO2与SvO210ScvO2的临床意义10/2/202ScvO2与SvO211ScvO2的临床意义10/3/2022ScvO2与SvO211ScvO2的临床意义10/2/202ScvO2与SvO2SvO2由肺动脉导管测得反映全身的氧耗量正常值：75%ScvO2由中心静脉（上腔静脉）导管测得反映脑及上半身的氧耗量正常值：72%12ScvO2的临床意义10/3/2022ScvO2与SvO2

5、SvO212ScvO2的临床意义10/2测定方法连续监测光纤导管或光纤中心静脉导管间断测定中心静脉血气13ScvO2的临床意义10/3/2022测定方法连续监测13ScvO2的临床意义10/2/202214ScvO2的临床意义10/3/202214ScvO2的临床意义10/2/2022正常各组织器官的静脉氧饱和度Pinsky MR, Mancebo J, Applied physiology in intensive care. 15ScvO2的临床意义10/3/2022正常各组织器官的静脉氧饱和度Pinsky MR, Mance休克时？16ScvO2的临床意义10/3/2022休克时？16S

6、cvO2的临床意义10/2/2022ScvO2与SvO2的相关性Charalambos Ladakis Pavlos Myrianthefs Andreas Karabinis et al.Central Venous and Mixed Venous Oxygen Saturation in Critically ill patients,Respairation,2001;68 279-285Linear correlation of paired ScvO2 and SvO2 measurements for 296 paired samples ScvO2 increases by 0

7、.87% for every unit increase in SvO217ScvO2的临床意义10/3/2022ScvO2与SvO2的相关性Charalambos LadaScvO2与SvO2的相关性Dueck MH et al. Anesthesiology 2005; 103:249 5718ScvO2的临床意义10/3/2022ScvO2与SvO2的相关性Dueck MH et al. Moina and Podbregar Critical Care2010,14:R42 th19ScvO2的临床意义10/3/2022Moina and Podbregar Critical Moin

8、a and Podbregar Critical Care2010,14:R4220ScvO2的临床意义10/3/2022Moina and Podbregar Critical Moina and Podbregar Critical Care2010,14:R4221ScvO2的临床意义10/3/2022Moina and Podbregar Critical Moina and Podbregar Critical Care2010,14:R4222ScvO2的临床意义10/3/2022Moina and Podbregar Critical SvO2与ScvO2的一致性绝对值相差518

9、%23ScvO2的临床意义10/3/2022SvO2与ScvO2的一致性绝对值相差518%23ScvOScvO2的临床应用24ScvO2的临床意义10/3/2022ScvO2的临床应用24ScvO2的临床意义10/2/202休克中的应用VO2DO2ScvO2/SvO2乳酸休克的本质是组织缺氧和氧代谢障碍，最终结果是MODS。液体复苏、及早纠正氧供与氧耗的失衡、降低组织缺氧程度至关重要。25ScvO2的临床意义10/3/2022休克中的应用VO2DO2ScvO2/SvO2休克的本质是组织急诊患者的复苏多数（31例/36例）存在休克的危重患者经初期复苏至正常生命体征后乳酸继续升高(2mmol/L)

10、，ScvO2仍低于正常(65%)，提示存在无氧酵解和氧债。这些患者进一步治疗后乳酸下降（4.63.8 to 2.62.5, p0.05)，ScvO2升高（5218 to 6513%, p0.05)ScvO2能作为初期复苏后指导休克治疗的指标Rady MY, Rivers EP, Novak RM: Resuscitation of the critically ill in the ED:responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am

11、J Emerg Med1996, 14:218-225.26ScvO2的临床意义10/3/2022急诊患者的复苏多数（31例/36例）存在休克的危重患者经初期重症感染与感染性休克中的应用13681377 N Engl J Med, Vol. 345, No. 19 November 8, 2001早期目标指导治疗（EGDT）27ScvO2的临床意义10/3/2022重症感染与感染性休克中的应用13681377 N En28ScvO2的临床意义10/3/202228ScvO2的临床意义10/2/2022研究结果死亡率29ScvO2的临床意义10/3/2022研究结果死亡率29ScvO2的临床意义

12、10/2/2022Rivers E, Nguyen B, Havstad S, et a1Early goal directed therapy in the treatment of severe sepsis and septic shock. N Eng J Med,2001,345:13681377.进行ScvO2监测，达到EGDT目标，可使患者病死率下降16%（46.5% vs 30.5%）。低ScvO2的预后差30ScvO2的临床意义10/3/2022Rivers E, Nguyen B, Havstad S,2012 “拯救脓毒症运动”指南早期复苏目标MAP 65mmHgCVP

13、812mmHg , 机械通气1215mmHg尿量0.5ml/kg/h ScvO2 70% or SvO2 65%31ScvO2的临床意义10/3/20222012 “拯救脓毒症运动”指南早期复苏目标MAP 感染性休克高ScvO2的预后32ScvO2的临床意义10/3/2022感染性休克高ScvO2的预后32ScvO2的临床意义10/233ScvO2的临床意义10/3/202233ScvO2的临床意义10/2/2022单因素分析结果34ScvO2的临床意义10/3/2022单因素分析结果34ScvO2的临床意义10/2/2022存活组与死亡组的ScvO235ScvO2的临床意义10/3/2022

14、存活组与死亡组的ScvO235ScvO2的临床意义10/2/该研究共纳入4家医院急诊科脓毒症患者619名，按EDGT复苏方案治疗，据ScvO2水平分为三组：低ScvO2组(70%)、正常ScvO2组(7189%)、高组(90100%)。比较住院死亡率并进行多因素分析36ScvO2的临床意义10/3/2022该研究共纳入4家医院急诊科脓毒症患者619名，按EDGT复苏23%25%31%初始ScvO2与死亡率(81/351)(56/223)(14/45)37ScvO2的临床意义10/3/202223%25%31%初始ScvO2与死亡率(81/351)(525/6296/46531/9238ScvO

15、2的临床意义10/3/202225/6296/46531/9238ScvO2的临床意义10ScvO2在ACS 中的应用该研究纳入患者43名，为收住CCU的急性冠脉综合征（ACS）并急性肺水肿或心源性休克患者，测定入室时、24h、48h的中心静脉和外周动脉血气，主要终点为致死性事件，次要终点为住院全因死亡率Acta Cardiol Sin 2008;24:1263339ScvO2的临床意义10/3/2022ScvO2在ACS 中的应用该研究纳入患者43名，为收住CC结果：存活组与死亡组ScvO2的差异有显著性Acta Cardiol Sin 2008;24:1263340ScvO2的临床意义10

16、/3/2022结果：存活组与死亡组ScvO2的差异有显著性Acta Car所有患者ScvO2、SaO2的变化存活患者ScvO2的变化Acta Cardiol Sin 2008;24:1263341ScvO2的临床意义10/3/2022所有患者ScvO2、SaO2的变化存活患者ScvO2的变化A创伤患者的评估Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prospective observational studyAlessandro

17、Di Filippo*1, Chiara Gonnelli1, Lucia Perretta1,Rosario pina1, Marco Chiostri2, Gian Franco Gensini2 and Adriano Peris1Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:2342ScvO2的临床意义10/3/2022创伤患者的评估Low central venous satuScandinavian Journal of Trauma, Resuscitation and E

18、mergency Medicine2009, 17:23ScvO265%的患者住院时间延长，死亡率明显增加43ScvO2的临床意义10/3/2022Scandinavian Journal of Trauma急诊插管对重症患者ScvO2的影响15minHernandez et al. Critical Care2009, 13:R63 44ScvO2的临床意义10/3/2022急诊插管对重症患者ScvO2的影响15minHernandeHernandez et al. Critical Care2009, 13:R63 45ScvO2的临床意义10/3/2022Hernandez et al.

19、 Critical Care插管改善ScvO2的机制插管前预充纯氧，溶解氧增加，氧供提高插管时镇静与肌松使氧摄取减少而降低氧耗初始机械通气减轻了过度通气，使pH升高而使氧离曲线右移，利于氧释放46ScvO2的临床意义10/3/2022插管改善ScvO2的机制插管前预充纯氧，溶解氧增加，氧供提高围术期ScvO2的应用47ScvO2的临床意义10/3/2022围术期ScvO2的应用47ScvO2的临床意义10/2/20患者资料48ScvO2的临床意义10/3/2022患者资料48ScvO2的临床意义10/2/2022单因素分析After multivariate analysis, mean Sc

20、vO2 value (OR 1.23 95%CI 1.01 to 1.50, p = 0.037), hospital LOS (OR 0.75 95% CI 0.59 to 0.94, p = 0.012), and SAPS II (OR 0.90 95% CI 0.82 to 0.99, p = 0.029) were independently associated with postoperative complications.多因素分析49ScvO2的临床意义10/3/2022单因素分析After multivariate analys低ScvO2与术后并发症相关P=0.004T

21、he optimal value of mean ScvO2 for discriminating between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%)50ScvO2的临床意义10/3/2022低ScvO2与术后并发症相关P=0.004The optimScvO2与乳酸在感染性休克中应用比较Jones的研究显示：在感染性休克的早期目标性治疗中，乳酸清除率达标与ScvO2达标，两组的住院死亡率无差别【25% （1730%）vs 17%（1124%）】。

22、Jones AE et al. JAMA. 2010 February 24; 303(8): 73974651ScvO2的临床意义10/3/2022ScvO2与乳酸在感染性休克中应用比较Jones的研究显示：ScvO2与容量反应性大循环指标：血压、心率、尿量、CVPCO、CIPPVSVVScvO2?52ScvO2的临床意义10/3/2022ScvO2与容量反应性大循环指标：血压、心率、尿量、CVP?ScvO2 As a Marker to Define Fluid ResponsivenessMethods:A total of 30 patients requiring VE were i

23、ncluded in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating ch

24、aracteristics curve analysis was used to test their ability to distinguish R and NRMethods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 we

25、re measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR Giraud R, et al. J Trauma.2011;70: 80280753ScvO2的临床意义10/3/2022ScvO2 As a Marker to

26、Define FlScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 80280754ScvO2的临床意义10/3/2022ScvO2 As a Marker to Define FlScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 80280755ScvO2的临床意义10/3/2022ScvO2 As a Marker to Define FlScvO2 As

27、a Marker to Define Fluid ResponsivenessResults: ScvO2 and SvO2 variations after VE (SvO2) were significantly correlated with CI changes (CI) after VE (r 0.67 and r= 0.49,p0.001, respectively). AScvO2 threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 5798%) and 81% specificity (95%CI; 5496%) Giraud R, et al. J Trauma.2011;70: 80280756ScvO2的临床意义10/3/2022Scv