1、CVP (mmHg)CO (L/min)容量缺乏更为严重低容量表现低容量表现心动过速心动过速低血压低血压(严重者严重者)高乳酸高乳酸(严重者严重者)肢端温度降低肢端温度降低脱水表现脱水表现皮肤充盈下降皮肤充盈下降口渴口渴口干口干腋窝干燥腋窝干燥高血钠高血钠高蛋白血症高蛋白血症高血红蛋白高血红蛋白高血球压积高血球压积体位性低血压体位性低血压动脉血压或每动脉血压或每搏输出量的呼搏输出量的呼吸波动吸波动下肢被动抬高下肢被动抬高容量负荷试验容量负荷试验结果阳性结果阳性肾脏灌注减少肾脏灌注减少浓缩尿浓缩尿(低尿钠低尿钠,高尿渗高尿渗)BUN升高升高(与肌酐升高不与肌酐升高不成比例成比例)持续性代谢性持续
2、性代谢性酸中毒酸中毒动态指标动态指标静态指标静态指标容量状态评价容量状态评价Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-55301015191915100Predicted PAWP (mmHg)Observed PAWP (mmHg)No change in
3、planned therapy after catheterizationChange in planned therapy after catheterization004.57.0Predicted CO (L/min)Observed CO (L/min)4.57.0Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Cri
4、t Care Med 1984; 12(7): 549-553参数参数预测正确比例预测正确比例预测正确百分比预测正确百分比Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553RVEDV (ml)CVP (mmHg)Kumar A, Anel R, Bunnell
5、E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 2004; 32: 691-
6、69935-30-25-20-15-10-5-0-CO (l/min)-5 0 5 10 15 20 25 30 35 40CVP (mmHg)Notarius et al Am Heart J 1998时间(hr)血管内容量Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med 2006; 34Dellinger RP, Carlet JM, Masur H, et al: Surviving Sepsis Campaign guidelines for management of severe sepsis and sep
7、tic shock. Crit Care Med 2004; 32: 858-873Mateer JR, et al. Rapid fluid resuscitation with central venous catheters. Ann Emerg Med 1983; 12: 149-52.外周静脉置管中心静脉插管血管活性药物液体死腔 每10分钟测定CVPnCVP 2 mmHg继续快速补液nCVP 2 5 mmHg暂停快速补液, 等待10分钟后再次评估nCVP 5 mmHg停止快速补液每10分钟测定PAWPnPAWP 3 mmHg继续快速补液nPAWP 3 7 mmHg暂停快速补液, 等待
8、10分钟后再次评估nPAWP 7 mmHg停止快速补液Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:1241320105201073CVP2 5 rulePAWP3 7 rule血管内容量CVP (mmHg) 5 mmHg10CVP (mmHg)时间(hr)容量不足容量足够容量过多每搏输出量每搏输出量心输出量心输出量Calvin SV 0%Reuse CO 0%Schneider SV 0%Diebel CO 10%Wagner SV 10%Michard CO 15%Tavernier SV 15%Feissel CO 15%Tousignant SV 20%Diebel CO 20%Magder CO 250 ml/min
