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Effects of fluid administration on renal perfusion in critically ill patients危重病人液体管理对肾灌注的影响,Contents,Diagram,oxygen delivery,oxygen demand,Imbalance,Introduction,Imbalance in oxygen delivery and oxygen demand is common in critically ill patients, especially those with acute circulatory failure of septic, hypovolemic or cardiogenic origin.,Introduction,Acute kidney injury (AKI) is a frequent complication of circulatory failure and associated with increased morbidity and mortality .急性肾损伤是循环衰竭状态下的常见并发症，它与发病率及死亡率的升高密切相关。,Introduction,Fluid resuscitation is a first-line therapy used to restore oxygen delivery to the organs and prevent AKI and yet the renal effects of fluid resuscitation are not easily assessed.液体复苏是恢复器官血氧输送及预防AKI的一线治疗方法，然而液体复苏对于肾脏的影响是不容易评估的。,Introduction,Physicians generally evaluate the effectiveness of fluid therapy by looking at systemic hemodynamic variables, such as mean arterial pressure (MAP) or cardiac output, because the increase in urine output may be delayed or inconsistent and the decrease in serum creatinine may be even slower. A direct evaluation of renal hemodynamics would be valuable.医师通常通过全身血流动力学变量来评估液体治疗的效果，比如：平均动脉压、心输出量，因为尿量增加可能会延迟或者与实际情况不一致，血肌酐的下降也非常慢，这些指标都不能及时有效的反应肾灌注情况。一种可以直接评估肾脏血流动力学的方法将非常有价值。,Introduction,We used Doppler techniques to investigate the effects of fluid administration on intrarenal hemodynamics and the relationship between changes in renal hemodynamics and urine output.我们用多普勒技术研究液体管理对肾内血流动力学的影响以及肾脏血流动力学与尿量的关系。,Fig. 1 Summary of the study design. The intervention was a fluid challenge that consisted of infusion of a minimum volume of 500 ml at a minimum rate of 1,000 ml/hour. Interlobar artery Doppler variables, blood pressure, heart rate and urine output were recorded before and after the fluid challenge and stabilization of hemodynamic variables. UO/3H: urine output volumes measured over 3 hours.,肾脏血管的测量和正常值,正常肾各段肾动脉的阻力指数（RI）,各段肾动脉RI,主肾动脉 段动脉 叶间动脉 弓状动脉 小叶间动脉,0.650.02 0.630.04 0.590.02 0.54 0.03 0.510.04,Fig. 2 Study Consort diagram. *Six patients had two Doppler waves instead of three or more, two patients had 5 % difference in RI between the kidneys. RIAD renal interlobar artery Doppler.,Criteria-Control group,The control groups included ICU patients with stable systemic hemodynamics receiving no specific intervention.对照组包括全身血流动力学稳定且没有接受特殊干预的ICU病人。,Control group A,评价观察者在测量肾叶间动脉RI自身偏差 测量3次（3个心动周期），每次间隔15min 同一超声医师测量，RI计算由统计员负责。,Control group B,评价多普勒变量的稳定性 测量2次，间隔60min 由同一超声医师测量，RI计算由统计员负责。,Criteria-Intervention group,需要液体冲击治疗的急性循环衰竭患者：并且至少包含以下一条标准：,神志改变四肢白斑动脉血乳酸2mmol/LScvO2 70%或SvO265%,低动脉压：收缩期动脉压90mmHg or MAP65mmHg需要升压药纠正低血压少尿（尿量0.5ml/kg/hour）,Diagram,age 40 kg/m2,Exclusive criteria,Diagram,研究期间监测项目,持续动态心电图监测心率有创平均动脉压、脉压（桡动脉or股动脉）血乳酸ScvO2 及SvO2,Diagram,Add Your Text,Add Your Text,Add Your Text,停止液体管理,0.9%Nacl 500ml or 6% 羟乙基淀粉在动脉压指导下维持最低1000ml/h.,,补液要求,MAP65mmHg,MAP stroke volume increase10-15%基础值,CVP15mmHg,Results,Results,Fluid administration resulted in increases in MAP from 75 15 to 80 14 mmHg (p 0.01)PP from 49 19 to 55 19 mmHg (p 0.01). RI decreased concurrently from 0.73 0.09 to 0.71 0.09 (p 0.01)urine output increased from 55 76 to 81 87 ml/hour (p 0.01).,Results,Fig. 4 Changes in hemodynamic variables before and after fluid challenge. A Changes in resistivity index (RI). B Changes in mean arterial pressure (MAP) and in pulse pressure (PP). The y-axes show the mean values standard deviation. MAP1, PP1, RI1 are values before fluid challenge and MAP2, PP2, RI2 are values after fluid challenge.,At baseline, RI predicted an increase in urine output following a fluid challenge at all thresholds and MAP predicted an increase at thresholds of 0.2 ml/kg/hour and 0.3 ml/kg/hour, but not 0.1 ml/kg/hour (Table 3).,Conclusions,We showed that fluid administration reduces intrarenal vasoconstriction and that changes in RI are more effective than changes in MAP and PP to predict an increase in urine output after fluid challenge. Dynamic analysis of intrarenal hemodynamics using RIAD can identify renal responsive patients. However, the use of RI to guide fluid therapy for renal hemodynamic management m