周树生---经胸壁心脏超声容量评估及指导快速补液试验.ppt

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,1,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

2、估患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，GE

3、DV）； 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 CriticalUltrasound(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 transtho

4、racic 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

5、 output,床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(P0.001)，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

6、 orientation, 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

7、.,结论：自主呼吸患者，下腔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 i

8、n predicting fluid responsiveness in ventilated septic patients,Intensive Care Med. 2004 Sep;30(9):1740-6,机械通气患者，dIVC18，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（DIVC）=（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（DIVC）,A studied 39 mechanically ventilated patients w

9、ith septic shock.,Individual values (open circles) and mean SD (closed circles) of the minimum DIVC, maximum DIVC and DIVC 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

10、静脉塌陷指数（IVCC）,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=08mmHg）,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 ob

11、served only in those patients (2/24) who reached an IVCCI30%.In all the other patients,a significant increase in IVC-CI was obtained without hemodynamic instability,Mean UF time was 20.34.6h with a mean volume of 287.696.2ml h-1 and a total ultrafiltrate production of 5,780.8 1,994.6 ml.,IVC-CI to g

12、uide fluid 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

13、-14,Cutoff values=ADHF were LVEF45%, 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 (R2 0.61). (C

14、olor version 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

15、pressure: 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,R2 = 0.58,R2 = 0.21,R2 = 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

16、a more robust 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

17、容量反应,P0.05(BL 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/2100。,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

18、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。,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)/2100%,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;3

19、1(8):1166-70.,主动脉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

20、=respiratory variations 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 l

21、ittle value in ventilated 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.

22、 Critical Care 2014, 18: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

23、S,Liu B.et al. Critical 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 g

24、uided by transthoracic 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 pred

25、ict fluid responsiveness,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 pre

26、dict fluid responsiveness,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

27、in stroke volume (SV) of 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 pr

28、edict fluid responsiveness.,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 var

29、iations of aortic blood velocity 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,PPrad=桡动脉脉搏压力变化率;Vpeakbrach=肱动脉峰值流速呼吸变