急危重症患者的血流动力学监测课件

1、急危重症患者的血 流 动 力 学 监 测北京协和医院重症医学科陈秀凯 NiCOCCOLiDCOPiCCOMonitorPAC血流动力学理念分析作用力、流量、容积三方面因素分析循环系统中血液运动的规律性定量、动态、连续的测量和分析反馈性用于对病情发展的了解和临床治疗的指导血流动力学理论的理解是基础STARLING 定律与ABC理论PAWPCIABCD血流动力学监测的常用手段神志精神状态心率血压尿量CVP ScVO2 OR SVO2 PAWP CO GEDI SVRI EVLWI病例女,28岁,“腹痛、发热3天 诊所静脉输入诺氟沙星 腹痛、皮疹3天”急诊尿常规提示尿路感染 停用原药，改为西力欣 病

2、情迅速恶化 MODS MAP40mmHg HR130bpm, 频发室早 呼吸 (SpO290%; 窒息) 恶心呕吐昏迷(GCS评分5分）拟诊： 过敏性休克肾上腺素泵入 、地塞米松静脉注射PUMCH_ICU早期目标指导治疗BP 100/70 mmHg (E1.1ug/kg/min NE 0.5ug/kg/min)收入ICURivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 34

3、5:1368-1377入室急诊CVP14mmHg 低血容量性休克或容量不足？ 还需继续补液吗？ PEEP8cmH2O FiO2100% SpO2 95% 还能继续补液吗？心肌酶 CK384U/L CKMB25.7ug/L cTnI 21.24ug/L 心源性休克？肾上腺素加量？ 加多巴酚丁胺？感染性休克？ 有证据吗 去甲肾上腺素加量？过敏性休克？ 肾上腺素加量？ 进一步的监测？怎么监测？本病例监测的主要要求了解前负荷状态心功能或心肌收缩力外周血管的阻力血管外肺水PiCCO的技术原理PiCCO技术由下列两种技术组成, 用于更有效地进行血流动力和容量治疗, 使大多数病人不必使用肺动脉导管:a. 经

4、肺热稀释技术b. 动脉脉搏轮廓分析技术血管外肺水的测定当EVLW增加 100%时, 胸片才会发生改变Bongard FS, Surgery 1984胸片对EVLW的改变并不敏感Helperin BD, Chest 1984确定患者是否符合ARDS影像学表现时, 医生之间存在非常明显的差异Rubenfeldet al, Chest 1999血流动力容量管理决策树CI (l/min/m2)GEDI (ml/m2)or ITBI (ml/m2)ELWI* (ml/kg)(slowly responding)3.0700850700700850700850ELWI (ml/kg)GEDI (ml/m2

5、)or ITBI (ml/m2)CFI (1/min)or GEF (%)101010101010V+V+!V+!V+CatCatOK!V-700850700-800850-10004.5255.5304.525 700-800 850-1000Cat5.530700850 700-800 850-1000 700-800 850-100010101010V-V+ = 增加容量 (! = 慎重)V- = 减少容量Cat = 儿茶酚胺心血管药物* SVV 只能用于没有心律失常的完全机械通气病人700850 10Optimise to SVV* (%)101010测量结果目标治疗1.2.不承诺完全

6、合乎您的临床实践10101010PiCCO简单的建立方法原上腔静脉连接注射液温度探头容纳管（T型管）和注射液温度电缆 穿刺股动脉连接PiCCO机器或插件PiCCO plus 连接示意图中心静脉导管注射液温度探头容纳管（T型管）动脉热稀释导管 注射液温度电缆 PULSION 一次性压力传感器 PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP) 5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI) 625 温度测量电缆 压力电缆血流动力学HRBPCIEVLWICVPGEDVISVRI组织代谢LacBEScvO2U(m

7、l/h)血管活性药物NEEDOBU9/30/2022治疗：4. 准备行CVVH1. 尝试扩容-胶体约200ml2. 调整血管活性药1h148123/802.321617650300017-13.763%00.51.10PUMCH_ICU3. 给予激素-氢化可的松100mg1h血流动力学HR148BP123/80CI2.32EVLWI16CVP17GEDVI650SVRI3000组织代谢Lac17BE-13.7ScvO263%U(ml/h)0血管活性药物NE0.5E1.1DOBU09/30/2022利尿强心3h14098/562.382021830180018-1865%001.03PUMCH_

8、ICU1h3h血流动力学HR148140BP123/8098/56CI2.322.38EVLWI1620CVP1721GEDVI650830SVRI30001800组织代谢Lac1718BE-13.7-18ScvO263%65%U(ml/h)00血管活性药物NE0.50E1.11.0DOBU039/30/20225h148117/712.711313620220015-271%4000.88PUMCH_ICU41岁，男性 栓下肢间隙综合征T 39HR 102/min;BP 65/50 mmHg入院第一天15 L 液体复苏Saugel et al. Scandinavian Journal of

9、 Trauma, Resuscitation and Emergency Medicine 2010, 18:38血流动力学不等于各种导管与设备血流动力学无处不在血流动力学监测是连续的过程监测的方法不等于血流动力学没有导管的监测需要对有导管监测的理解入ICU前男，56岁，2010-4-8以急性白血病入院4-12日开始化疗4-13至19 WBC 2.04-0.19X109 /L NEUT 0.77-0.00109 /L PLT 3-25 X109 /L 4-20日 4：20 寒战，T39 BP60/30mmHg 10：51寒战、发热、一过性意识丧失 头颅CT未见颅内出血病灶 留置右股静脉导管 快

10、速补液扩容 DOPA、NE泵入 美罗培南+万古霉素两种休克的复苏无有创的血流动力学监测PLT 8X109 /L，APTT延长3倍左右，补充PLT和血浆效果欠佳锁骨下、颈静脉穿刺风险大放置PiCCO导管风险大血压、心率、尿量、乳酸、心肌酶血流动力学改善至4月22日6:00RBC12U,血浆1200ml,血小板2U凝血酶原复合物1200U纤维蛋白原3000mg白蛋白30g停用NE及DOPA,BP110/65mmHgLac 2.0mmol/L新近的研究CFI等参数临床意义的验证被动抬腿试验等判断容量状态和容量反应性的方法的监测监测大循环与微循环的关系AKI、ARDS等脏器功能不全的防治中血流动力学的

11、监测与调整PiCCO与PAC及新研发的无创监测手段的对比CFI的临床意义Jabot,J.et.al.Crit Care Med 2009; 37:29132918Jabot,J.et.al.Crit Care Med 2009; 37:29132918CFI的临床意义passive leg raising (PLR) and volume expansionTo find the relationship between macrocirculation and microcirculationPatients severe sepsis or septic shock25 mechanica

12、lly ventilated eligible for VE in the first 24 h of their admissionPottecher.J, Deruddre.S，Teboul Jean-Louis.Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients. Intensive Care MedConclusionIn preload-re

13、sponsive patients with severe sepsis and septic shock patients during the first 24 h of their ICU stay, both PLR and VE improved sublingual microcirculatory perfusion.At the level of VE used in the study, changes in microcirculation were not explained by changes in rheologic factors or changes in MA

14、P.Different mechanisms were implicated in the regulation of microvascular perfusion and in the changes in CO.Assessment of RBF responsiveness to fluid or vasopressor challengesDeruddre S. Renal arterial resistance in septic shock. Intensive Care Med 2007; 33:15571562.Effects of increasing MAP with N

15、E on the renal RIUniversity teaching hospital11 patients with septic shock MAP at successively 65, 75, and 85 mmHg (NE titrated)Hemodynamic parameters and renal function variables Doppler ultrasonography to assess the renal resistive indexDeruddre S. Renal arterial resistance in septic shock. Intens

16、ive Care Med 2007; 33:15571562.RESULTSDeruddre S. Renal arterial resistance in septic shock. Intensive Care Med 2007; 33:15571562.Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.Mullens, W. et al. J Am Coll Cardiol 2009;53:589-596Relative Contributions of CVP and CI

17、to GFR at Time of PAC RemovalCopyright 2009 American College of Cardiology Foundation. Restrictions may apply.Mullens, W. et al. J Am Coll Cardiol 2009;53:589-596ROC Curves for CVP and CI on Admission for the Development of WRFCopyright 2009 American College of Cardiology Foundation. Restrictions may apply.Mullens,