ScvO2的临床意义ppt课件

.,ScvO2的临床意义,.,内容,氧供与氧耗SvO2与ScvO2ScvO2的临床应用,.,氧供与氧耗,.,15vol%=15ml/dl,5vol%=5ml/dl,.,.,氧供DO2与氧耗VO2,DO2=CaO2CO=(1.34SaO2Hb+0.0031PaO2)CO=1.34SaO2HbCOVO2=(CaO2-CvO2)CO=(SaO2-SvO2)1.34HbCOSvO2=SaO2-VO2/(1.34HbCO),呼吸,血红蛋白,循环,(Fick方程),.,氧摄取EO2,EO2=VO2/DO2EO2=(SaO2-SvO2)/SaO2当SaO2=100%时：EO2=1-SvO2全身EO2=1-75%=25%各组织EO2不同，其相应之静脉氧饱和度不同SvO2=1-EO2,.,氧供氧耗失衡,SvO2降低或增加,无氧代谢组织缺氧乳酸生成,.,影响SvO2的因素,75%,-,+,DO2,应激发热寒战躁动疼痛呼吸做功,VO2,CO(心衰、低容量）Hb（贫血、出血）SaO2（缺氧、呼衰）,DO2,CO（液体复苏、正性肌力）Hb（输血）SaO2（氧疗）,VO2,低体温镇静镇痛麻醉机械通气氧摄取（分流、细胞死亡）,.,SvO2的界值,PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.,.,ScvO2与SvO2,.,ScvO2与SvO2,.,ScvO2与SvO2,SvO2由肺动脉导管测得反映全身的氧耗量正常值：75%ScvO2由中心静脉（上腔静脉）导管测得反映脑及上半身的氧耗量正常值：72%,.,测定方法,连续监测光纤导管或光纤中心静脉导管间断测定中心静脉血气,.,.,正常各组织器官的静脉氧饱和度,PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.,.,休克时？,.,ScvO2与SvO2的相关性,CharalambosLadakisPavlosMyrianthefsAndreasKarabinisetal.CentralVenousandMixedVenousOxygenSaturationinCriticallyillpatients,Respairation,2001;68279-285,LinearcorrelationofpairedScvO2andSvO2measurementsfor296pairedsamplesScvO2increasesby0.87%foreveryunitincreaseinSvO2,.,ScvO2与SvO2的相关性,DueckMHetal.Anesthesiology2005;103:24957,.,MoinaandPodbregarCriticalCare2010,14:R42th,.,MoinaandPodbregarCriticalCare2010,14:R42,.,MoinaandPodbregarCriticalCare2010,14:R42,.,MoinaandPodbregarCriticalCare2010,14:R42,.,SvO2与ScvO2的一致性,绝对值相差518%,.,ScvO2的临床应用,.,休克中的应用,VO2,DO2,ScvO2/SvO2乳酸,休克的本质是组织缺氧和氧代谢障碍，最终结果是MODS。液体复苏、及早纠正氧供与氧耗的失衡、降低组织缺氧程度至关重要。,.,急诊患者的复苏,多数（31例/36例）存在休克的危重患者经初期复苏至正常生命体征后乳酸继续升高(2mmol/L)，ScvO2仍低于正常(65%)，提示存在无氧酵解和氧债。这些患者进一步治疗后乳酸下降（4.63.8to2.62.5,p0.05)，ScvO2升高（5218to6513%,p0.05)ScvO2能作为初期复苏后指导休克治疗的指标,RadyMY,RiversEP,NovakRM:ResuscitationofthecriticallyillintheED:responsesofbloodpressure,heartrate,shockindex,centralvenousoxygensaturation,andlactate.AmJEmergMed1996,14:218-225.,.,重症感染与感染性休克中的应用,13681377NEnglJMed,Vol.345,No.19November8,2001,早期目标指导治疗（EGDT）,.,.,研究结果死亡率,.,低ScvO2的预后差,.,2012“拯救脓毒症运动”指南早期复苏目标,MAP65mmHgCVP812mmHg,机械通气1215mmHg尿量0.5ml/kg/hScvO270%orSvO265%,.,感染性休克高ScvO2的预后,.,.,单因素分析结果,.,存活组与死亡组的ScvO2,.,该研究共纳入4家医院急诊科脓毒症患者619名，按EDGT复苏方案治疗，据ScvO2水平分为三组：低ScvO2组(70%)、正常ScvO2组(7189%)、高组(90100%)。比较住院死亡率并进行多因素分析,.,23%,25%,31%,初始ScvO2与死亡率,(81/351),(56/223),(14/45),.,25/62,96/465,31/92,.,ScvO2在ACS中的应用,该研究纳入患者43名，为收住CCU的急性冠脉综合征（ACS）并急性肺水肿或心源性休克患者，测定入室时、24h、48h的中心静脉和外周动脉血气，主要终点为致死性事件，次要终点为住院全因死亡率,ActaCardiolSin2008;24:12633,.,结果：存活组与死亡组ScvO2的差异有显著性,ActaCardiolSin2008;24:12633,.,所有患者ScvO2、SaO2的变化,存活患者ScvO2的变化,ActaCardiolSin2008;24:12633,.,创伤患者的评估,Lowcentralvenoussaturationpredictspooroutcomeinpatientswithbraininjuryaftermajortrauma:aprospectiveobservationalstudyAlessandroDiFilippo*1,ChiaraGonnelli1,LuciaPerretta1,Rosariopina1,MarcoChiostri2,GianFrancoGensini2andAdrianoPeris1,ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:23,.,ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:23,ScvO265%的患者住院时间延长，死亡率明显增加,.,急诊插管对重症患者ScvO2的影响,15min,Hernandezetal.CriticalCare2009,13:R63,.,Hernandezetal.CriticalCare2009,13:R63,.,插管改善ScvO2的机制,插管前预充纯氧，溶解氧增加，氧供提高插管时镇静与肌松使氧摄取减少而降低氧耗初始机械通气减轻了过度通气，使pH升高而使氧离曲线右移，利于氧释放,.,围术期ScvO2的应用,.,患者资料,.,单因素分析,Aftermultivariateanalysis,meanScvO2value(OR1.2395%CI1.01to1.50,p=0.037),hospitalLOS(OR0.7595%CI0.59to0.94,p=0.012),andSAPSII(OR0.9095%CI0.82to0.99,p=0.029)wereindependentlyassociatedwithpostoperativecomplications.,多因素分析,.,低ScvO2与术后并发症相关,P=0.004,TheoptimalvalueofmeanScvO2fordiscriminatingbetweenpatientswhodidordidnotdevelopcomplicationswas73%(sensitivity72%,specificity61%),.,ScvO2与乳酸在感染性休克中应用比较,Jones的研究显示：在感染性休克的早期目标性治疗中，乳酸清除率达标与ScvO2达标，两组的住院死亡率无差别【25%（1730%）vs17%（1124%）】。,JonesAEetal.JAMA.2010February24;303(8):739746,.,ScvO2与容量反应性,大循环指标：血压、心率、尿量、CVPCO、CIPPVSVVScvO2,?,.,ScvO2AsaMarkertoDefineFluidResponsiveness,Methods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNR,Methods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNR,GiraudR,etal.JTrauma.2011;70:802807,.,ScvO2AsaMarkertoDefineFluidResponsiveness,GiraudR,etal.JTrauma.2011;70:802807,.,ScvO2AsaMarkertoDefineFluidResponsiveness,GiraudR,etal.JTrauma.2011;70:802807,.,ScvO2AsaMarkertoDefineFluidResponsiveness,Results:ScvO2andSvO2variationsafterVE(SvO2)weresignificantlycorrelatedwithCIchanges(CI)afterVE(r0.67andr=0.49,p0.001,respectively).AScvO2thresholdvalueof4%allowedthedefinitionofRandNRpatientswith86%sensitivity(95%CI;5798%)and81%specificity(95%CI;5496%),GiraudR,etal.JTrauma.2011;70:802807,.,ScvO2的局限性,.,争论：ScvO2不能反映SvO2,Biasofdifferencewas4.2%and95%limitsofagreementrangedfrom8.1%to16.5%.Thecentralvenousoxygensaturationoverestimatedthemixedvenousoxygensaturationbyameanbias(oranabsolutedifference)of6.9%,andthe95%limitsofagreementwerelarg