休克患者血容量的监测进展课件.ppt

1、杨 毅东南大学医学院附属中大医院ICU东南大学急诊与危重病医学研究所休克患者血容量的监测进展内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结休克的概念休克的概念感染、创伤、烧伤等感染、创伤、烧伤等引起有效循环血量明显减少引起有效循环血量明显减少组织器官的灌注不足组织器官的灌注不足氧输送不能满足组织代谢需要氧输送不能满足组织代谢需要导致组织缺氧导致组织缺氧代谢障碍和细胞受损代谢障碍和细胞受损临床综合征临床综合征休克治疗的首要任务：休克治疗的首

2、要任务：积极、合适补充血容量积极、合适补充血容量休克发生的始动因素：休克发生的始动因素：有效循环血量下降有效循环血量下降合适的容量管理合适的容量管理容量管理的基本目标容量管理的基本目标保证容量合适的心脏前负荷保证容量合适的心脏前负荷预防肺水肿预防肺水肿二者必须平衡二者必须平衡内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结容量监测的现状容量监测的现状n容量监测：容量监测：TEE，CT，核素扫描核素扫描n临床表现临床表现:血压、心率、尿量、皮

3、肤粘膜等血压、心率、尿量、皮肤粘膜等n压力监测：漂浮导管压力监测：漂浮导管(CVP/PAWP)心脏前负荷：心脏前负荷：VEDVRVEDP/LVEDP的测定的测定压力反映容量及肺水肿的局限性压力反映容量及肺水肿的局限性n心脏顺应性心脏顺应性n瓣膜功能瓣膜功能n肺毛细血管通透性肺毛细血管通透性n机械通气对循环的影响机械通气对循环的影响PACPAC对容量监测的对容量监测的有效性和可信性受到置疑？有效性和可信性受到置疑？许多文献：许多文献：CVP/PAWP不能准确反映容量状态不能准确反映容量状态Principle of EVLW measurementRAEDVLAEDVLVEDVPBVRVEDVEV

4、LWInjectionPiccoThermo-dilutioncatheterSwan-ganz catheter呼吁容量指标的应用呼吁容量指标的应用来反映容量状态及肺水肿来反映容量状态及肺水肿内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结A physiological system modelITTV:Intrathoracic total volumeGEDV:Global end-diastolic volume ITBV:Intr

5、athoracic blood volume PTV :Pulmonary total volumeEVLW:extra-pulmonary lung water 胸內总容量全心舒张期血容量胸內血液容量肺部容积血管外肺水容量指标的应用容量指标的应用胸腔内血管容量胸腔内血管容量(ITBV)血管外肺水血管外肺水(EVLW)搏出量变异率搏出量变异率(SVV)胸腔内血管容量胸腔内血管容量(ITBV)左心舒张末期容量左心舒张末期容量右心舒张末期容量右心舒张末期容量肺血容量肺血容量nSVV=(SVmax SVmin)/SVmeannSvmax:mean value of four SVmax/30snSV

6、min:mean value of four SVmin/30snSVmean内容简介内容简介n管理的基本目标管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结ITBVvalid estimate of preload in ALIoProspective animal studyo15 sheep with ALI-saline washoutoMV(PEEP 0,7,14,21 respectively 60min)oMeasurement:oLVEF,LVEDV-CT sca

7、noITBV,RVEDV-PiCCOoCVP,PAWP-PACnLuecke T,et al.Intensive Care Med,2004,30:119-126Luecke T,et al.Intensive Care Med,2004,30:119-126nLuecke T,et al.Intensive Care Med,2004,30:119-126ITBV and RVEDV Provide valid estimate of preloadEven at high intrathoracic pressureITBV-indicator of preload in liver tr

8、ansplantation60 patients undergoing Liver transplantation monitored with PiCCO and PACthe correlation between PAOP and ITBVI with respect to CI and SVIthe correlation between ITBVI and PAOP Della Rocca G,et al.Eur J Anaesthesiol.2002,19:868-750.470.470.550.550.020.020.0150.0150.0020.0020 00.10.10.20

9、.20.30.30.40.40.50.50.60.6相关系数r相关系数rITBV-ITBV-CICIITBV-ITBV-SVISVIPAWP-PAWP-CICIPAWP-PAWP-SVISVIPAWP-PAWP-ITBVITBVITBVI-more reliable indicator of preload than PAWP Della Rocca G,et al.Eur J Anaesthesiol.2002,19:868-75ITBVI-valid indicator of preload in lung transplantationv50 patients during lung t

10、ransplantationvTime:6 phase during operationvCorrelation between PAWP and SVIvCorrelation between ITBVI and SVIvCorrelation between(Delta)ITBVI PAWP and Delta SVInDelta were calculated by subtracting the first from the second measurement n Della RG,et al.Anesth Analg.2002,95:835-430.410.410.020.020

11、00.050.050.10.10.150.150.20.20.250.250.30.30.350.350.40.40.450.45r rITBV-SVIITBV-SVIPAWP-SVIPAWP-SVIn Della RG,et al.Anesth Analg.2002,95:835-430.30.30.570.570.260.260.670.670 00.10.10.20.20.30.30.40.40.50.50.60.60.70.7r r1 12 24 45 5timetimeqProspective,controlled,clinical studyq18 patients with ej

12、ection fraction 50%undergoing coronary artery bypass graft surgeryqA baseline measurement:after induction of anesthesia(T1)qtreated by infusion of 6%hydroxyethyl starch 200/0.5(7 mL/kg)qAfter 10 minutes,a second measurement(T2)was performedWiesenack C,et al.Cardiothorac Vasc Anesth.2001,15:584-8ITBV

13、 correlated significantly with CI and SV IN CABG CVP/PCWP 与与 CI/SV无相关性无相关性 ITBV 与与 CI的相关性的相关性r=0.55 ITBV 与与 SV的相关性为的相关性为r=0.62Wiesenack C,et al.Cardiothorac Vasc Anesth.2001,15:584-8n前瞻性临床研究前瞻性临床研究n40例心脏移植术后患者例心脏移植术后患者n男男34例，女例，女6例例n观察术后观察术后3、6、12、24、36、48、72h ITBV/GEDV和和CVP/PAWP与与SV的相关性的相关性ITBV/GED

14、V-good preload indicator in heart transplantation Goedje O,et al.Chest,2000,118:775-781Goedje O,et al.Chest,2000,118:775-781Goedje O,et al.Chest,2000,118:775-781nGEDV-SV:R2=0.4016nITBV-SV:R2=0.2979Goedje O,et al.Chest,2000,118:775-781nPAWP-SV:R2=0.0043nCVP-SV:R2=0.0552ITBV的改变反映肺水含量的改变反映肺水含量vProspect

15、ively studyv16 patients with septic shock and pulmonary edema(ACCP/SCCM)vSAPS II:56vMonitor:Picco,PACvOptimal PAWP:CI no longer increasedvMonitor time:0,24hIntensive Care Med,2002,28,712-18From intensive Care Med,2002,28,712-18051015202530354045051015202530CVP(mmHg)CVP(mmHg)EVLW(ml/kg)EVLW(ml/kg)CVP

16、与与EVLW的相关性的相关性05101520253035404505101520253035PAWP(mmHg)PAWP(mmHg)EVLW(ml/kg)EVLW(ml/kg)PAWP与与EVLW的相关性的相关性0.560.560.640.640.520.520.540.540.560.560.580.580.60.60.620.620.640.64r rITBV-EVLWITBV-EVLWTEDV-EVLWTEDV-EVLWCorrelation between ITBV/TEDV and EVLWnFrom intensive Care Med,2002,28,712-180.220.22

17、0.10.10.60.60.680.680.30.30 00.10.10.20.20.30.30.40.40.50.50.60.60.70.7r rCVPCVPPAWPPAWPITBVITBVTEDVTEDVFBFB内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结SVV可以反映机体前负荷可以反映机体前负荷Prospective study20 MV patients following cardiac surgeryVolume loadi

18、ng(HES 20ml*BSA/10min)Measurement:CVP,PAWP-PACLVEDAI-TEEITBV,SVV-PiCCOReuter DA,et al.Intensive Care Med.2002,28:392-8.血流动力学监测血流动力学监测SVV may help to determine the preload condition nReuter DA,et al.Intensive Care Med.2002,28:392-8.0.550.550.680.680 00.10.10.20.20.30.30.40.40.50.50.60.60.70.7相关系数r相关系

19、数rSVV(base)-CISVV(base)-CILVEDAI(base)-CILVEDAI(base)-CICVP/PAWP not correlated with SVV may help to determine the preload condition nReuter DA,et al.Intensive Care Med.2002,28:392-8.0.590.590.790.790.330.330 00.10.10.20.20.30.30.40.40.50.50.60.60.70.70.80.8相关系数r相关系数rITBV-CIITBV-CISVV-CISVV-CIPAWP-C

20、IPAWP-CICVPnot correlatedSVV反映机体对容量治疗的反应反映机体对容量治疗的反应15例脑外科手术患者例脑外科手术患者麻醉诱导后麻醉诱导后容量负荷实验：容量负荷实验：100 mL of 6%hydroxyethylstarch given for 2 min 分组：分组：responsive:SV5%nonresponsive:SV5%A total of 140 VLSs were performednAnesth Analg.2001,92:984-9两组负荷试验前血流动力学状态两组负荷试验前血流动力学状态Response(70)nonresponse(70)PHR7

21、675 NSSBP102116 0.001CVP9.39.3 NSSVV12.66.8 0.001nAnesth Analg.2001,92:984-9两组负荷试验后血流动力学改变两组负荷试验后血流动力学改变Response(70)nonresponse(70)P HR-1-1NS SBP 92 0.001 CVP9.811.9NS SVV-25.8-100.001nAnesth Analg.2001,92:984-9以上指标与以上指标与SV改变的相关性改变的相关性Pearsons correlationPHR0.142NSSBP-0.448 0.001SV-0.3720.001CVP0.05

22、5NSSVV0.722 0.001 HR-0.089NS SBP 0.472 0.001 CVP-0.084NS SVV-0.505 0.001nAnesth Analg.2001,92:984-9Responsive VLS:SVV/SV有较高的特异性和敏有较高的特异性和敏感性感性0.4930.4930.5930.5930.7290.7290.870.870 00.10.10.20.20.30.30.40.40.50.50.60.60.70.70.80.80.90.9ROCROCCVP/SVCVP/SVHR/SVHR/SVSBP/SVSBP/SVSVV/SVSVV/SVnAnesth Ana

23、lg.2001,92:984-9SVV对失血性休克犬容量状态的评价对失血性休克犬容量状态的评价复制犬失血性休克模型复制犬失血性休克模型v稳定稳定30分钟，改良的分钟，改良的 Wiggers法制备失血性休克犬模法制备失血性休克犬模型型v适当放血维持适当放血维持MAP在在50 mmHg左右并稳定左右并稳定60分钟，分钟，模型成功模型成功vHR MAP vPiCCO监测仪监测仪:CO、ITBVI、SV、SVVvSwan-Ganz导管导管:CO、CVP、PAWPv共进行容量负荷试验共进行容量负荷试验134次，每只犬平均次，每只犬平均9.61.7次，次，v其中其中94次为反应组，次为反应组，40次为无反

24、应组次为无反应组容量负荷实验前各指标的比较容量负荷实验前各指标的比较 60608080100100120120反应组反应组无反应组无反应组MAPMAP40040050050060060070070080080090090010001000反应组反应组无反应组无反应组ITBIITBI8 89 9101011111212131314141515161617171818反应组反应组无反应组无反应组SVVSVV反应组 无反应组 HR111.333.6 115.644.1 CVP5.42.4 6.22.5 PAWP7.92.98.62.9P 0.05 容量负荷试验前各指标与容量负荷试验前各指标与SV的相

25、关性的相关性 DESV20100-10-20ITBI200010000DESV20100-10-20SVV.3.2.10.0rP值值HR(bpm)-0.1480.089MAP(mmHg)-0.0910.296CVP(mmHg)-0.0920.292PAWP(mmHg)-0.0910.297ITBVI(ml/m2)0.3560.000SVV(%)0.5310.001容量负荷试验前后各指标的变化与容量负荷试验前后各指标的变化与SV的相关性的相关性 DESV20100-10-20DCVP1086420-2-4-6DESV20100-10-20DPAWP121086420-2-4-6DESV20100

26、-10-20DEITBI10000-1000-2000DESV20100-10-20DELTASVV.04.020.00-.02-.04-.06-.08-.10rP值值HR(bpm)-0.0810.353MAP(mmHg)0.0200.820CVP(mmHg)-0.3710.000PAWP(mmHg)-0.4480.000ITBVI(ml/m2)0.4380.000SVV(%)0.3760.000各指标对容量负荷反应各指标对容量负荷反应(SV)的的ROC曲线分析曲线分析HR1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.250.00MAP

27、1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.250.00CVP1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.250.00PAWP1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.250.00ITBI1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.250.00SVV1-Specificity1.00.75.50.250.00Sensitivity1.00.75.50.25

28、0.00 AUC95 CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.4340.6510.2070.3810.3130.5170.3360.5390.5830.7910.8050.939AUC=曲线下面积,CI=可信区间 vSVV和和ITBVI可用于容量状态的评价可用于容量状态的评价v优于优于HR、MAP、CVP和和PAWP内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结CVP/P

29、AWP能反映能反映EVLW吗吗?nProspectively studyn16 pats with septic shock and pul edema(ACCP/SCCM)nSAPS II:56nMonitor:PiCCO vs PACnOptimal PAWP:CI no longer increasednMonitor time:0,24hFrom intensive Care Med,2002,28,712-18Intensive Care Med,2002,28,712-1805101520253035404505101520253035PAWP(mmHg)PAWP(mmHg)EVL

30、W(ml/kg)EVLW(ml/kg)051015202530354045051015202530CVP(mmHg)CVP(mmHg)EVLW(ml/kg)EVLW(ml/kg)CVP/PAWP能反映能反映EVLW吗吗?No0.560.560.640.640.520.520.540.540.560.560.580.580.60.60.620.620.640.64r rITBV-EVLWITBV-EVLWTEDV-EVLWTEDV-EVLWIntensive Care Med,2002,28,712-180.220.220.10.10.60.60.680.680.30.30 00.10.10.2

31、0.20.30.30.40.40.50.50.60.60.70.7r rCVPCVPPAWPPAWPITBVITBVTEDVTEDVFBFBndelta与与EVLW相关性相关性,FB：fluid balanceCVP/PAWP能反映能反映EVLW吗吗?No肺水含量是肺水含量是ARDS的预后指标的预后指标Retrospective analysis373 ICU pats in university hosp1996-2000PiccoTwo groupsnSurvivorsnNon-survivors Sakka SG,et al.Chest,2002,122:2080-2086记录和观察指标

32、记录和观察指标o 两组两组EVLW的最大值的最大值(211例在入院后例在入院后24h内内)o EVLW与与SAPS II、APACH II、SOFA比比较预后价值较预后价值30305050606067672020404060608080mortality（%）mortality（%）21EVLW(mg/kg)EVLW(mg/kg)l肺水含量与病死率正相关肺水含量与病死率正相关Sakka SG,et al.Chest,2002,122:2080-208612.212.215.615.60 05 5101015152020EVLW(ml/kg)EVLW(ml/kg)survivor-n=187su

33、rvivor-n=187non-survivor-n=186non-survivor-n=186肺水含量是肺水含量是ARDS的预后指标的预后指标0 00.20.20.40.40.60.60.80.8ROCROCAPACHIIAPACHIISAPSSAPSSOFASOFAEVLW-adEVLW-adEVLWmaxEVLWmaxEVLW反映疾病严重程度反映疾病严重程度Sakka SG,et al.Chest,2002,122:2080-2086肺水含量是肺水含量是ARDS的预后指标的预后指标EVLW 指导脱离呼吸机指导脱离呼吸机n101 patients with pulmonary edeman

34、End point of two groupsnPAWP18mmHgnEVLW7ml/kgAM Rev Respir Dis,1992,145:990-998不同指标对不同指标对MV/ICU时间的影响时间的影响22229 90 05 51010151520202525days on MVdays on MVPAWPPAWPEVLWEVLWnAM Rev Respir Dis,1992,145:990-99816167 70 02 24 46 68 81010121214141616days in ICUdays in ICUPAWPPAWPEVLWEVLW内容简介内容简介n容量管理的基本目标容量管理的基本目标n容量监测的现状及局限性容量监测的现状及局限性n容量监测的进展容量监测的进展nITBV的应用的应用nSVV的应用的应用nEVLW的应用的应用n小结小结小小结结n容量指标可以较好反映机体前负荷容量指标可以较好反映机体前负荷及肺水肿状态及肺水肿状态n压力指标需要慎重对待，动态评价压力指标需要慎重对待，动态评价n呼吁更多的研究及监测手段呼吁更多的研究及监测手段