周树生经胸壁心脏超声容量评估及指导快速补液试验课件

SeriesPPTofIntensivecareunit〔20210919〕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Thisstudyof2,289patientsincludedprospectivelyfromtwodifferentcohortsinaquaternary-levelprovincialreferralhospitalinBC,Canada.(47.75%)CritCareMed.

2021Jul22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，故评估患者的容量状态极其重要；对评估容量状态容量无反响的患者，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。JIntensiveCareMed.2021Sep-Oct;24(5):329-37Techniquesforassessmentofintravascularvolumeincriticallyillpatients德国生理学家OttoFrank英国生理学家StarlingFrank-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，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。CardiovascUltrasound.2021Oct6;6:49.WorldInteractiveNetworkFocusedonCritical

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响心脏前负荷，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(focusassessedtransthoracicecho)草案Researchhassuggestedthatvolumeresponsivenesscanbedefinedasa15%increaseinstrokevolume(SV)orcardiacoutput(CO)aftera500mlinfusion.AnesthAnalg.2021Nov;111(5):1180-92Acriticalreviewoftheabilityofcontinuouscardiacoutputmonitorstomeasuretrendsincardiacoutput床旁超声下腔静脉直径〔IVCD〕测量方法KoreanJInternMed2021;29:241-245一、床旁超声预测容量反响之下腔静脉直径〔IVCD〕JEmergMed.2021Apr;42(4):429-36一、床旁超声预测容量反响之下腔静脉直径〔IVCD〕在容量反响时，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,transverseorientation,atendinspiration.(B)Subxiphoid,longitudinalorientation,atendinspiration.inferiorvenacavadiameter(IVCD)andcentralvenouspressurevalue(CVP)PakJMedSci.2021Mar;30(2):310-5.下腔静脉长轴切面IVC=inferiorvenacava;CVP=centralvenouspressure.Statisticallyrelationship

betweenIVCandCVPpressuresPakJMedSci.2021Mar;30(2):310-5.结论：自主呼吸患者，下腔静脉直径变化可以预测容量反响下腔静脉扩张指数(dIVC)＝(Dmax(吸气末)-Dmin(呼气末))／DminIntensiveCareMed.2004Sep;30(9):1740-630-minvolumeexpansion(7ml/kg)using4%modifiedfluidgelatin二、床旁超声预测容量反响之下腔静脉扩张指数(dIVC)BaselineAftervolumeexpansionRespiratorychangesininferiorvenacavadiameterarehelpfulinpredictingfluidresponsivenessinventilatedsepticpatientsIntensiveCareMed.2004Sep;30(9):1740-6机械通气患者，dIVC＞18％，预测容量反响性敏感性和特异性均在90％以上.下腔静脉呼吸变化率〔△DIVC〕=〔Dmax-Dmin)/(Dmax+Dmin)IntensiveCareMed.2004Sep;30(9):1834-7三、床旁超声预测容量反响之下腔静脉呼吸变化率〔△DIVC〕Astudied39mechanicallyventilatedpatientswithsepticshock.Individualvalues(opencircles)andmean±SD(closedcircles)oftheminimumDIVC,maximumDIVCand△DIVCbeforvolumeloadinginresponder(R)andnon-responder(NR)patients.*P<0.05RvsNR下腔静脉呼吸变化率＞12％，预测容量反响性的阳性和阴性分别为93％和92％.IntensiveCareMed.2004Sep;30(9):1834-7四、床旁超声预测容量反响之下腔静脉塌陷指数〔IVCC〕下腔静脉塌陷指数(IVC-CI):〔Dmax-Dmin〕/DmaxJAmCollSurg.2021Jul;209(1):55-61JACCCardiovascImaging.2021Sep;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〕IntensiveCareMed.2021Apr;36(4):692-6IVC-CI指导心衰患者缓慢超滤〔SCUF〕治疗Hypotensionwasobservedonlyinthosepatients(2/24)whoreachedanIVCCI＞30%.Inalltheotherpatients,asignificantincreaseinIVC-CIwasobtainedwithouthemodynamicinstabilityMeanUFtimewas20.3±4.6hwithameanvolumeof287.6±96.2mlh-1andatotalultrafiltrateproductionof5,780.8±1,994.6ml.IVC-CItoguidefluidremovalinslowcontinuousultrafiltration:apilotstudyIntensiveCareMed.2021Apr;36(4):692-6IVCultrasoundisarapid,simple,andnon-invasivemeansforbedsidemonitoringofintravascularvolumeduringSCUFandmayguidefluidremovalvelocity.AmJEmergMed.2021Aug;31(8):1208-14Cutoffvalues=ADHFwereLVEF＜45%,IVC-CI＜20%,and≥10B-lines.LVEF、IVC-CIandB-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-CIandSCV-CI〕JSurgRes.2021Sep;184(1):561-6SCV-CIversusIVC-CI.Linearregressiondemonstratesacceptablecorrelationbetweenthetwomeasurementmodalities(R2[0.61).(Colorversionoffigureisavailableonline.)MeasurementbiasplotcomparingIVC-CIandSCV-CIacrossabroadrangeofcollapsibilityvalues.JSurgRes.2021Sep;184(1):561-6锁骨下静脉和下腔静脉的塌陷指数〔IVC-CIandSCV-CI〕CritCareMed.2021Mar;41(3):833-41Point-of-careultrasoundtoestimatecentralvenouspressure:acomparisonofthreetechniques下腔静脉直径比下腔静脉塌陷指数与CVP更具有相关性R2=0.58R2=0.21R2=0.16TestCharacteristicsofThreeUltrasoundTechniquesinPredictingCVP<10mmHgCritCareMed.2021Mar;41(3):833-41Amongspontaneouslybreathingpatientswithoutvasopressorsupport,themaximalICVDisamorerobustestimateofCVPthantheIVCCIortheIJVSR〔颈内静脉的纵横比〕.五、床旁超声预测容量反响之舒张末期容积〔LVEDA、GEDV〕*pValuebaselinevhemorrhage;†pValuehemorrhagevhypervolemia;‡pValuebaselinevhypervolemiaJCardiothoracVascAnesth.2007Oct;21(5):650-4JCritCare.2021Jun;27(3):325.e7-13全心舒张末期容积〔GEDV〕预测容量反响＊P＜0.05(BLnonrespondervsBLresponder)全心舒张末期容积〔GEDV〕预测容量反响JCritCare.2021Jun;27(3):325.e7-13六、床旁超声预测容量反响之主动脉(AO)ΔPeak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):

Δpeak＝(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(Δpeak)或主动脉速度时间积分呼吸变化率(ΔVTI)代表了容量反响性变化的幅度及前负荷。六、床旁超声预测容量反响之主动脉(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):

ΔVTI＝〔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(Δpeak)或主动脉速度时间积分呼吸变化率(ΔVTI)代表了容量反响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(Δpeak)能够预测容量反响PediatrCardiol.2021Nov;31(8):1166-70.主动脉峰值血流速度呼吸变异率(Δpeak)预测容量反响Chest.2001Mar;119(3):867-73.Δpeak预测机械通气脓毒症患者容量反响Thebestcut-offfor∆Vpeakaowas12%,withsensitivity,specificity,andpositiveandnegativepredictivevaluesof81.2%,85.7%,93%and66.6%.∆PS=respiratoryvariationsinsystolicarterialpressure(SPV);∆PP=respiratoryvariationsinpulsepressure(PPV)Chest.2001Mar;119(3):867-73.Δpeak预测机械通气脓毒症患者容量反响Δpeak∆PS=respiratoryvariationsinsystolicarterialpressure(SPV);∆PP=respiratoryvariationsinpulsepressure(PPV)∆PP∆PSPulsedDopplerbeforeVEaccuratelypredicttheeffectsofVE,∆PSand∆PPareoflittlevalueinventilatedchildrenA10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness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〕：ΔCo50，Δco500，Δvti50WuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108对机械通气患者ΔVTI可以评估容量反响性WuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessPatientcharacteristicsstratifiedbyfluidrespondersandnon-respondersatbaselineWuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessHemodynamicvariablesweremeasuredatbaseline,duringvolumeexpansionWuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsiveness(A)CorrelationbetweenΔVTI50(%)andΔVTI500(%).(B)CorrelationbetweenΔCO50(%)andΔCO500(%)WuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessBlandandAltmandiagrambetweenvariationofcardiacoutput(A)andvariationofvelocitytimeindex(B)after50-mlor500-mlvolumeexpansion.WuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108A10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessA10-secondfluidchallengeguidedbytransthoracicechocardiographycanpredictfluidresponsivenessIndividualvaluesofΔVTI50(%)(A),ΔSV50(%)(B),andΔCO50(%)(C)afterinfusionof50mloffluidover10secondschangedinpatientswithvolumeexpansion-inducedchangesinstrokevolume(SV)ofatleast10%(responders)andlessthan10%(non-responders).WuY,ZhouS,LiuB.etal.CriticalCare2021,18:R108Incriticallyillpatients,thevariationofCOandVTIaftertheadministrationof50-mlcrystalloidsolutionover10seconds(ΔCO50andΔVTI50)canaccuratelypredictfluidresponsiveness.对机械通气血流动力学不稳定患者ΔVTI可以评估容量反响性Anesthesiology.2021Sep;115(3):541-7.ΔVTI=主动脉速度时间积分呼吸变化率KardiolPol.2021Mar;67(3):265-71.Variabilityofaorticbloodflowpredictsfluidresponsivenessinspontaneouslybreathinghealthyvolunteers研究背景：Echomeasurementofrespiratoryvariationsofaorticbloodvelocityinventilatedshockpatientscanaccuratelypredicttheeffectofvolumeexpansion.目的：Toassesswhetherrespiratoryvariabilityofpeakaorticbloodflowvelocity(ΔVpeak)andofaorticvelocitytimeintegral(ΔVTI)reflectspreload-dependentchangesofcardiacindex(CI)andwhetheritpredictsfluidresponsivenessinhealthyspontaneouslybreathingvolunteers.结论：ΔVpeak和ΔVTI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响性.ΔVpeak=主动脉峰值血流速度呼吸变异率；ΔVTI=主动脉速度时间积分呼吸变化率CritCare.2021;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响性ΔPPrad=桡动脉脉搏压力变化率;ΔVpeakbrach=肱动脉峰值流速呼吸变化率;ΔSVVigileo=FloTrac传感器和