the puzzle togethercn感染性休克和心脏收缩液体治疗课件

HaemodynamicsHaemodynamics - putting the puzzle together.- putting the puzzle together. Associate Professor Brendan E. Smith.Associate Professor Brendan E. Smith. School of Biomedical Science, Charles Sturt University,School of Biomedical Science, Charles Sturt University, Specialist in Anaesthesia and Intensive Care,Specialist in Anaesthesia and Intensive Care, Bathurst Base Hospital,Bathurst Base Hospital, Bathurst, NSW, Australia.Bathurst, NSW, Australia. HRHR SVR SVR HbHb SV SV DODO 2 2 CVPCVP COCO SpOSpO2 2 BP BP 血液动力学血液动力学 - - 把难题集中起来把难题集中起来 布兰登布兰登. .爱德华德爱德华德. .史密斯史密斯 澳大利亚新南威尔士州查尔斯澳大利亚新南威尔士州查尔斯. .斯图特大学生物医学副教授、斯图特大学生物医学副教授、 澳大利亚新澳大利亚新 南威尔士州巴斯罗斯特医院麻醉和重症监护专家南威尔士州巴斯罗斯特医院麻醉和重症监护专家. . HRHR SVR SVR HbHb SV SV DODO 2 2 CVPCVP COCO SpOSpO2 2 BP BP Data Acquisition.Data Acquisition. 获得数据获得数据 Haemodynamic data can be acquired in many waysHaemodynamic data can be acquired in many ways 许多方法能得到血液动力学数据许多方法能得到血液动力学数据 Trans-Thoracic EchocardiographyTrans-Thoracic Echocardiography 经胸超声心动描记经胸超声心动描记 Trans-Oesphageal EchocardiographyTrans-Oesphageal Echocardiography 经食道超声心动描记经食道超声心动描记 USCOM Doppler examinationUSCOM Doppler examination USCOMUSCOM多普勒检查多普勒检查 Impedence PlethysmographyImpedence Plethysmography 阻抗体积描记法阻抗体积描记法 Pulmonary Artery CatheterPulmonary Artery Catheter 肺动脉导管肺动脉导管 PiCCOPiCCO 脉搏轮廓温度稀释连续心排量测量技术脉搏轮廓温度稀释连续心排量测量技术 Etc etc.Etc etc.等等等等 Each has its own benefits and drawbacks,Each has its own benefits and drawbacks, 每种方法都有优点和缺点每种方法都有优点和缺点 BUT.BUT.但是但是 However we obtain the raw data we still have a big However we obtain the raw data we still have a big problemproblem 但是得到原始数据后，我们仍有个大问题但是得到原始数据后，我们仍有个大问题 What do all these figures?What do all these figures? 这些数据意味着什么？这些数据意味着什么？ How can we put it all together to help our patients?How can we put it all together to help our patients? 如何将这些数据结合在一起帮助治疗病人？如何将这些数据结合在一起帮助治疗病人？ Cardiac OutputCardiac Output Stroke VolumeStroke Volume Blood PressureBlood Pressure PreloadPreload Inotropy AfterloadInotropy Afterload Hb SpOHb SpO 2 2 Oxygen Delivery DOOxygen Delivery DO 2 2 Heart RateHeart Rate SVRSVR X X 心心 排排 量量 每搏输出 血血 压压 前负荷前负荷 心脏收缩心脏收缩 后负荷后负荷 Hb SpOHb SpO 2 2 氧运氧运 DO DO 2 2 心心 率率 外周阻力外周阻力 X X To live we have to haveTo live we have to have 维持生命必须有维持生命必须有 Blood pressureBlood pressure and blood flow!and blood flow! 血压和血流血压和血流 Blood pressure Blood pressure doesnt tell us doesnt tell us anything about anything about the hearts ability the hearts ability to deliver to deliver oxygen!oxygen! 血压不能告诉我们血压不能告诉我们 关于心脏运氧能关于心脏运氧能 力的任何信息力的任何信息 Blood Pressure血压 Her blood pressure is normal.Her blood pressure is normal. 这个女婴血压正常这个女婴血压正常 Anybody Anybody NOTNOT want to know her C.O. and DO want to know her C.O. and DO 2 2 ?!?! 有人会不想知道她的心排量和氧运吗？！有人会不想知道她的心排量和氧运吗？！ (By permission of Dr Joe Brierley, GOSH, London.) Haemodynamics used to beHaemodynamics used to be a highly invasive science a highly invasive science 血液动力学曾经是个高创伤技术血液动力学曾经是个高创伤技术 Insertion of PA Catheter wasInsertion of PA Catheter was 肺动脉导管的插入是肺动脉导管的插入是 Difficult (especially in children)Difficult (especially in children) 困难的（尤其在儿童）困难的（尤其在儿童） DangerousDangerous 危险的危险的 Time consuming Time consuming 费时的费时的 ExpensiveExpensive 昂贵的昂贵的 Of doubtful value!Of doubtful value!数据可疑数据可疑 All the data provided by PAC All the data provided by PAC (and more) can be obtained non-invasively(and more) can be obtained non-invasively 用肺动脉导管（或其他有创方法）获得的数据可用肺动脉导管（或其他有创方法）获得的数据可 以用无创方法得到以用无创方法得到 Cardiac Output Stroke Volume Blood Pressure Preload Inotropy Afterload Hb SpO2 Oxygen Delivery DO2 Heart Rate SVR 心 排 量 每 搏 输 出 血压 前负荷 心脏收缩 后负荷 Hb SpO2 氧运 DO2 心 率 外周阻力 The Ultrasonic Cardiac Output MonitorThe Ultrasonic Cardiac Output Monitor - USCOM - USCOM 连续多普勒心排量监测仪连续多普勒心排量监测仪 Suprasternal CW Doppler Parasternal CW DopplerParasternal CW Doppler 胸骨上连续多普勒监测 胸骨旁连续多普勒监测胸骨旁连续多普勒监测 What other data do we get?What other data do we get? 还能得到其他什么数据？还能得到其他什么数据？ Vpk = Peak Ejection Velocity峰值速度 CO / CI = Cardiac Output / Index CO/CI 心排量/心脏指数 Why Cardiac Index v Cardiac Output?Why Cardiac Index v Cardiac Output? 为什么心脏指数要和心排量比较？为什么心脏指数要和心排量比较？ The same applies to Stroke Volume, SVR and The same applies to Stroke Volume, SVR and many other parameters in haemodynamicsmany other parameters in haemodynamics 同样可以应用于每搏输出、外周阻力和血液动力同样可以应用于每搏输出、外周阻力和血液动力 学的其他参数学的其他参数 so we useso we use因此可以用因此可以用 Stroke Volume Index Stroke Volume Index SVISVI 每搏输出分数每搏输出分数 SVR index SVR index SVRISVRI 外周阻力分数外周阻力分数 DODO 2 2 Index Index DODO 2 2 I I 氧运分数氧运分数 VOVO2 2 Index Index VOVO 2 2 I I 氧耗分数氧耗分数 EtcEtc等等等等 MD = Minute Distance = Aortic Velocity MD分钟距离=动脉速度 SV = Stroke volume每搏输出 Ejection Time + SV = Inotropy 射血时间+每搏输出=心脏收缩能力 SVR = Systemic Vascular Resistance 外周阻力 Cardiac Output Stroke Volume Blood Pressure Preload Inotropy Afterload Hb SpO2 Oxygen Delivery DO2 Heart Rate SVR Pulse Oximeters脉搏血氧计 Pulse Oximetry + Hb 脉搏血氧和血红蛋白 Central Venous Oxygen Saturation 中心静脉氧饱和度 Cardiac Output Stroke Volume Blood Pressure Preload Inotropy Afterload Hb SpO2 Oxygen Delivery DO2 Heart Rate SVR AfterloadAfterload后负荷后负荷 Depends on:Depends on:取决于取决于 Degree of vasoconstriction / dilationDegree of vasoconstriction / dilation 血管收缩血管收缩/ /扩张的程度扩张的程度 Density & viscosity of bloodDensity & viscosity of blood血液密度和粘滞度血液密度和粘滞度 Flow rate of blood / surface tension forcesFlow rate of blood / surface tension forces 血流速率血流速率/ /表面张力表面张力 Elasticity of arteriesElasticity of arteries动脉弹性动脉弹性 Stroke volumeStroke volume 每搏输出每搏输出 等等等等 These are all the same factors These are all the same factors that determine mean aortic root that determine mean aortic root pressurepressure So afterload is exactly the same as mean So afterload is exactly the same as mean aortic root pressure.aortic root pressure. MAP = diastolic + MAP = diastolic + (systolic diastolic) (systolic diastolic) But can we use radial artery pressure?But can we use radial artery pressure? 平均动脉基础压力也是这些同样的因素确平均动脉基础压力也是这些同样的因素确 定的定的 所以后负荷就是和平均动脉基础压力一样所以后负荷就是和平均动脉基础压力一样 的的. . 平均动脉压平均动脉压 = = 舒张压舒张压+ + ( (收缩压收缩压 舒张舒张 压压) ) 但是可以用桡动脉压吗但是可以用桡动脉压吗? ? Mean Pressure = Mean Pressure = P.dtP.dt = Pressure time integral = Pti= Pressure time integral = Pti t t t P P Integrated PressureIntegrated Pressure time P2P2 P1P1 P2P2 P1P1 平均压力平均压力= = P.dtP.dt = = 压力时间积分压力时间积分= Pti= Pti t t t P P 压力积分压力积分 time P2P2 P1P1 P2P2 P1P1 Pti-APti-R Pti-Aortic and Pti-Radial are close enoughPti-Aortic and Pti-Radial are close enough in clinical practice to make no significant in clinical practice to make no significant difference to haemodynamic calculations.difference to haemodynamic calculations. 主动脉压力时间积分和桡动脉压力时间积主动脉压力时间积分和桡动脉压力时间积 分在临床上是如此相近，以致于在血液动分在临床上是如此相近，以致于在血液动 力学计算上无明显差异。力学计算上无明显差异。 (error typically 95% of cases this is done by In 95% of cases this is done by clinical judgment alone!clinical judgment alone! Which inotrope and how much?Which inotrope and how much? What are our therapeutic targets?What are our therapeutic targets? How do we know weve reached them?How do we know weve reached them? If only we could If only we could measuremeasure inotropy! inotropy! 什么时候应用心肌药物呢? 在在95%95%的文献中只通过临床推断来决定的文献中只通过临床推断来决定 那么用什么心肌药物？用药量多少？那么用什么心肌药物？用药量多少？ 要达到什么样的治疗目标？要达到什么样的治疗目标？ 怎么知道已经到达目标了？怎么知道已经到达目标了？ 只要我们能只要我们能评价评价心肌收缩能力心肌收缩能力! ! How Can We Measure Inotropy?How Can We Measure Inotropy? 如何评价心脏收缩能力？如何评价心脏收缩能力？ Conservation of EnergyConservation of Energy The energy produced by cardiac contraction The energy produced by cardiac contraction must be converted to either Potential Energy must be converted to either Potential Energy (PE) in the form of blood (PE) in the form of blood pressurepressure or Kinetic or Kinetic Energy (KE) in the form of blood Energy (KE) in the form of blood flowflow. . But can we measure PE & KE?But can we measure PE & KE? Is the measurement reliable?Is the measurement reliable? How long does it take?How long does it take? Can we monitor Rx with it?Can we monitor Rx with it? 能量守恒能量守恒 心肌收缩产生的能量一定要转化为以血压压差形心肌收缩产生的能量一定要转化为以血压压差形 式的势能（式的势能（PEPE）或以血流流动形式的动能（）或以血流流动形式的动能（KEKE ） 但如何能测出势能和动能呢？但如何能测出势能和动能呢？ 测出的数值可信吗测出的数值可信吗? ? 测出数值需要多少时间测出数值需要多少时间? ? 我们可以用它指导治疗吗我们可以用它指导治疗吗? ? Potential EnergyPotential Energy PE developed by the heart appears in the form of the energy PE developed by the heart appears in the form of the energy needed to raise the stroke volume up to arterial pressure needed to raise the stroke volume up to arterial pressure in a given systolic time, the Flow Time.in a given systolic time, the Flow Time. Work Done = Work Done = P x P x V V PE = MAP x SVPE = MAP x SV Flow TimeFlow Time P = Mean Arterial Pressure - CVPP = Mean Arterial Pressure - CVP SV and Flow Time are measured directly using SV and Flow Time are measured directly using CW Doppler. CW Doppler. 势能势能 心脏产生的势能需要在一定的收缩时间内，即流动时间，把心脏产生的势能需要在一定的收缩时间内，即流动时间，把 每搏输出压力提高到动脉压水平。每搏输出压力提高到动脉压水平。 做功做功 = = 压力差压力差x x 容积差容积差 势能势能 = = 平均动脉压平均动脉压 x x 每搏输出每搏输出 流动时间流动时间 压力差压力差= = 平均动脉压平均动脉压- - 中心静脉压中心静脉压 每搏输出和流动时间可用连续多普勒直接测出每搏输出和流动时间可用连续多普勒直接测出 PE = BPm x SV x 10PE = BPm x SV x 10-3 -3 7.5 x FT7.5 x FT Potential EnergyPotential Energy 7.5 and 107.5 and 10-3 -3 are required to convert BP in mmHgare required to convert BP in mmHg to kPa and SV in ml to mto kPa and SV in ml to m 3 3 to conform with SI units. to conform with SI units. The unit for PE is therefore Joules/second, or The unit for PE is therefore Joules/second, or WattsWatts. . 势能 = 平均动脉压 x 每搏输出 x 10-3 7.5 x 流动时间 势能（势能（PEPE） 7.5 7.5 和和 10 10-3 -3 是用来转换血压单位由 是用来转换血压单位由 mmHg mmHg 到到kPa kPa 和每搏输出量由和每搏输出量由 ml ml 到到 m m 3 3 以符合国际单位。以符合国际单位。 因此势能的单位是焦耳因此势能的单位是焦耳/ /秒，即瓦。秒，即瓦。 . . Kinetic EnergyKinetic Energy The KE of any moving mass is given by The KE of any moving mass is given by KE = KE = mVmV 2 2 The mass of blood ejected per Stroke Volume is - The mass of blood ejected per Stroke Volume is - SV(ml) x 10SV(ml) x 10-6 -6 x Density of blood, x Density of blood, (1,055 kg/m (1,055 kg/m 3 3 ) ) The KE developed by the heart in a given flow time is The KE developed by the heart in a given flow time is KE = KE = 1 1 x SV x 10 x SV x 10-6 -6 x x x V x V 2 2 2 x Flow Time2 x Flow Time (V is measured directly by CW Doppler)(V is measured directly by CW Doppler) 移动物体的动能公式是移动物体的动能公式是 动能动能 = = mVmV 2 2 每搏输出的血量质量是每搏输出的血量质量是- - 每搏输出每搏输出SV(ml) x 10SV(ml) x 10-6 -6 x x 血液密度血液密度 (1,055 kg/m(1,055 kg/m 3 3 ) ) 在一给定流动时间内心脏产生的动能是在一给定流动时间内心脏产生的动能是 KE = 1 x SV x 10-6 x x Vm2 2 x F（流动时间） ( (mm平均速度由平均速度由USCOMUSCOM测量计算测量计算) ) 动能（动能（KEKE） Total Inotropy = PE + KE Total Inotropy = PE + KE ( = blood pressure + blood flow)( = blood pressure + blood flow) Inotropy = BPm x SV x 10Inotropy = BPm x SV x 10-3 -3 + + 1 x SV x 10 1 x SV x 10-6 -6 x x x V x V 2 2 7.5 x FT 7.5 x FT 2 x FT2 x FT (The Smith-Madigan Formula)(The Smith-Madigan Formula) The SI unit of inotropy is therefore the The SI unit of inotropy is therefore the WattWatt. . 总收缩力Total Inotropy = PE + KE ( = blood pressure血压 + blood flow血流) Inotropy = BPm x SV x 10-3 + 1 x SV x 10-6 x x Vm2 7.5 x FT 2 x FT (The Smith-Madigan Formula)(The Smith-Madigan Formula) 史密斯麦迪根公式史密斯麦迪根公式 Annals of Emergency Medicine 51, No 4. April 2008, 480.Annals of Emergency Medicine 51, No 4. April 2008, 480. 收缩能力的国际计量单位是瓦 Inotropy IndexInotropy Index But how do we judge inotropy in patients of varying size, e.g. large and small adults, children, infants? By analogy to cardiac index which is Cardiac Index = Cardiac Output Body Surface Area Smith-Madigan Inotropy Index = Inotropy BSA The SI unit of SMII is thereforeThe SI unit of SMII is therefore W/mW/m 2 2 但是如何判断体型大小不同的病人心脏收缩能力呢，但是如何判断体型大小不同的病人心脏收缩能力呢， 比如体型大和小的成人、儿童、婴儿？比如体型大和小的成人、儿童、婴儿？ 和心脏指数类似和心脏指数类似 心脏指数心脏指数 = = 心排量 心排量 体表面积体表面积 史密斯麦迪根心脏收缩指数史密斯麦迪根心脏收缩指数= = 收缩能力收缩能力 体表面积体表面积 收缩力指数收缩力指数Inotropy IndexInotropy Index 史密斯麦迪根心脏收缩指数的国际单位是史密斯麦迪根心脏收缩指数的国际单位是 W/mW/m 2 2 Smith-Madigan Inotropy IndexSmith-Madigan Inotropy Index 史密斯麦迪根心脏收缩指数史密斯麦迪根心脏收缩指数 Normal ControlsNormal Controls正常值正常值 1.6 2.2 W/m1.6 2.2 W/m 2 2 Left Ventricular FailureLeft Ventricular Failure左心衰竭左心衰竭 0.4 1.1 W/m0.4 1.1 W/m 2 2 Septicaemic ShockSepticaemic Shock 0.6 1.2 W/m0.6 1.2 W/m 2 2 Cardiogenic ShockCardiogenic Shock 心源性休克心源性休克 74 year old man with STEMI7474 year old man with STEMI74岁老年男性岁老年男性 BP 84/44, pulse 114, SpOBP 84/44, pulse 114, SpO 2 2 84% on 10L/min O 84% on 10L/min O 2 2 血压血压84/44, 84/44, 心率心率 114, SpO114, SpO 2 2 84% on 10L/min O 84% on 10L/min O 2 2 Pulmonary Oedema +Pulmonary Oedema +严重的肺水肿严重的肺水肿 No urine outputNo urine output 无尿无尿 PaOPaO 2 2 64mmHg, PaCO 64mmHg, PaCO 2 2 28mmHg 28mmHg Lactate 8.4Lactate 8.4乳酸盐乳酸盐8.48.4 8 1214 2.4 60-75 90 800-1200 0.62 0.97 1.13 1.38SMII W/m2 Dobutamine mcg/kg/min Cardiac Output Stroke Volume Blood Pressure Preload Inotropy Afterload (Hb) SpO2 Oxygen Delivery DO2 Heart Rate SVR PreloadPreload JVP / CVP - Only looking at the right side of the heart.- Only looking at the right side of the heart. - Tells us little about left heart preload.- Tells us little about left heart preload. - Tricuspid valve integrity? Stenosis and - Tricuspid valve integrity? Stenosis and regurgitation both lead to errors.regurgitation both lead to errors. - Arrythmias lead to error. - Arrythmias lead to error. - Even right ventricular - Even right ventricular pressurepressure tells us little tells us little about right ventricular about right ventricular volumevolume. . 前负荷前负荷 JVP / CVP 颈静脉压/中心静脉压 - - 只能反映右心功能。只能反映右心功能。 - - 很少地反映左心前负荷的情况。很少地反映左心前负荷的情况。 - - 三尖瓣是否完整三尖瓣是否完整? ? 狭窄和反流都会使数值偏差狭窄和反流都会使数值偏差 。 - - 心律失常也会造成误差心律失常也会造成误差 - - 甚至右心室压也很少能反映右心室容积的情况甚至右心室压也很少能反映右心室容积的情况. . Pulmonary artery catheter What pressure should we use?What pressure should we use? PA Diastolic Pressure (PADP)? PA Diastolic Pressure (PADP)? PA Wedge Pressure (PAWP)? PA Wedge Pressure (PAWP)? PA mean Pressure (PAPm)?PA mean Pressure (PAPm)? Is the catheter in the right place?Is the catheter in the right place? What about IPPV, PEEP, pulmonary What about IPPV, PEEP, pulmonary vascular patency, vasoconstriction, shunts, vascular patency, vasoconstriction, shunts, arrythmias, mitral valve problems.etc.arrythmias, mitral valve problems.etc. 肺动脉导管 应该用哪个压力更好呢应该用哪个压力更好呢? ? 肺动脉舒张压肺动脉舒张压 (PADP)? (PADP)? 肺动脉楔压肺动脉楔压(PAWP)? (PAWP)? 肺动脉平均压肺动脉平均压(PAPm)?(PAPm)? 导管是在正确的位置吗导管是在正确的位置吗? ? 如果有间歇正压通气、呼气末正压通气、如果有间歇正压通气、呼气末正压通气、 肺肺 血管开放血管开放, ,、血管收缩、血管收缩 、分流、分流, , 、心律失常、心律失常 、 二尖瓣病变二尖瓣病变 . .等等情况怎么办呢？等等情况怎么办呢？ PACPAC Attempts to measure left ventricular end Attempts to measure left ventricular end diastolic diastolic pressure pressure - - LVEDPLVEDP Left ventricular preload is strictly the left Left ventricular preload is strictly the left ventricular end diastolic ventricular end diastolic volumevolume LVEDVLVEDV Ventricular end diastolic pressure only acts Ventricular end diastolic pressure only acts as an acceptable surrogate if we know the as an acceptable surrogate if we know the ventricular ventricular compliancecompliance. . 肺动脉导管肺动脉导管 试图测出左心室舒张末期压试图测出左心室舒张末期压- - LVEDPLVEDP 左心室前负荷就是左心室舒张末期压左心室前负荷就是左心室舒张末期压 LVEDVLVEDV 如果我们知道心室顺应性心室舒张末期压