休克患者血容量的监测进展课件

ICU休克患者血容量的监测进展内容简介容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结休克的概念感染、创伤、烧伤等引起有效循环血量明显减少组织器官的灌注不足氧输送不能满足组织代谢需要导致组织缺氧代谢障碍和细胞受损临床综合征容量管理的基本目标保证容量－合适的心脏前负荷预防肺水肿二者必须平衡内容简介容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结容量监测的现状容量监测：TEE，CT，核素扫描临床表现:血压、心率、尿量、皮肤粘膜等压力监测：漂浮导管(CVP/PAWP)心脏前负荷：VEDVRVEDP/LVEDP的测定压力反映容量及肺水肿的局限性心脏顺应性瓣膜功能肺毛细血管通透性机械通气对循环的影响PAC对容量监测的有效性和可信性受到置疑？？许多文献：CVP/PAWP不能准确反映容量状态内容简介容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结AphysiologicalsystemmodelITTV:IntrathoracictotalvolumeGEDV:

Globalend-diastolicvolume

ITBV:Intrathoracicbloodvolume

PTV:PulmonarytotalvolumeEVLW:extra-pulmonarylungwater

胸內总容量全心舒张期血容量胸內血液容量肺部容积血管外肺水容量指标的应用胸腔内血管容量(ITBV)血管外肺水(EVLW)搏出量变异率(SVV)搏出量变异率(SVV)SVV=(SVmax–SVmin)/SVmeanSvmax:meanvalueoffourSVmax/30sSVmin:meanvalueoffourSVmin/30sSVmean血管外肺水组成(EVLW)细胞内液间质液体肺泡内液体内容简介管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结LueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressureITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.Anesth

Analg.2002,95:835-43ITBV---superiorthanPAWPinpreloadDellaRG,etal.Anesth

Analg.2002,95:835-43CorrelationofITBV-SVin4phasesNocorrelationofPAWP-SVinanyphases前瞻性临床研究40例心脏移植术后患者男34例，女6例观察术后3、6、12、24、36、48、72hITBV/GEDV和CVP/PAWP与SV的相关性ITBV/GEDV---goodpreloadindicatorinhearttransplantationGoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781GoedjeO,etal.Chest,2000,118:775-781^GEDV-^SV:R2=0.4016^ITBV-^SV:R2=0.2979GoedjeO,etal.Chest,2000,118:775-781^PAWP-^SV:R2=0.0043^CVP-^SV:R2=0.0552ITBV的改变反映肺水含量Prospectivelystudy16patientswithsepticshockandpulmonaryedema(ACCP/SCCM)SAPSII:56Monitor:Picco,PACOptimalPAWP:CInolongerincreasedMonitortime:0,24hIntensiveCareMed,2002,28,712-18FromintensiveCareMed,2002,28,712-18CVP与EVLW的相关性PAWP与EVLW的相关性CorrelationbetweenITBV/TEDVandEVLWFromintensiveCareMed,2002,28,712-18ITBV

与EVLW有良好相关性优于

CVP

与PAWP内容简介容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结SVV可以反映机体前负荷Prospectivestudy20MVpatientsfollowingcardiacsurgeryVolumeloading(HES20ml*BSA/10min)Measurement:CVP,PAWP---PACLVEDAI----TEEITBV,SVV----PiCCOReuterDA,etal.IntensiveCareMed.2002,28:392-8.血流动力学监测SVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVP/PAWPnotcorrelatedwithCISVVmayhelptodeterminethepreloadcondition

ReuterDA,etal.IntensiveCareMed.2002,28:392-8.CVPnotcorrelatedSVV反映机体对容量治疗的反应15例脑外科手术患者麻醉诱导后容量负荷实验：100mLof6%hydroxyethylstarchgivenfor2min分组：responsive:SV>5%

nonresponsive:SV<5%Atotalof140VLSswereperformedAnesth

Analg.2001,92:984-9两组负荷试验前血流动力学状态 Response(70) nonresponse(70)PHR 76 75 NSSBP 102 116 0.001CVP 9.3 9.3 NSSVV 12.6 6.8 <0.001Anesth

Analg.2001,92:984-9两组负荷试验后血流动力学改变Response(70)nonresponse(70)PHR -1 -1 NSSBP 9 2 <0.001CVP 9.8 11.9 NS SVV -25.8 -10 <0.001Anesth

Analg.2001,92:984-9以上指标与SV改变的相关性Pearson’scorrelation PHR 0.142 NSSBP -0.448 <0.001SV -0.372 <0.001CVP 0.055 NSSVV 0.722 <0.001HR -0.089 NSSBP 0.472 <0.001CVP -0.084 NSSVV -0.505 <0.001Anesth

Analg.2001,92:984-9ResponsiveVLS:SVV/SV有较高的特异性和敏感性Anesth

Analg.2001,92:984-9SVV对失血性休克犬容量状态的评价成年健康杂种犬共14只，体重12.1±1.1公斤复制犬失血性休克模型稳定30分钟，改良的Wiggers’法制备失血性休克犬模型适当放血维持MAP在50mmHg左右并稳定60分钟，模型成功容量负荷试验2分钟内快速滴入林格氏液7ml.kg-115分钟后重复，记录容量负荷前及后5分钟的监测指标分组△SV是否大于容量负荷试验前SV的5％分为两组反应组(△SV＞5％)无反应组(△SV＜5％)直至连续两次△SV均小于容量负荷试验前的5%时终止实验监测指标HRMAPPiCCO监测仪:CO、ITBVI、SV、SVVSwan-Ganz导管:CO、CVP、PAWP共进行容量负荷试验134次，每只犬平均9.6±1.7次，其中94次为反应组，40次为无反应组容量负荷实验前各指标的比较

反应组

无反应组

HR111.3±33.6115.6±44.1CVP5.4±2.46.2±2.5PAWP7.9±2.98.6±2.9P<0.05

容量负荷试验前各指标与△SV的相关性

rP值HR(bpm)-0.1480.089MAP(mmHg)-0.0910.296CVP(mmHg)-0.0920.292PAWP(mmHg)-0.0910.297ITBVI(ml/m2)0.3560.000SVV(%)0.5310.001容量负荷试验前后各指标的变化与△SV的相关性

rP值△HR(bpm)-0.0810.353△MAP(mmHg)0.0200.820△CVP(mmHg)-0.3710.000△PAWP(mmHg)-0.4480.000△ITBVI(ml/m2)0.4380.000△SVV(%)–0.3760.000各指标对容量负荷反应(△SV)的ROC曲线分析

AUC95％CIHRMAPCVPPAWPITBVISVV0.5930.2940.4150.4380.6890.8720.434－0.6510.207－0.3810.313－0.5170.336－0.5390.583－0.7910.805－0.939AUC=曲线下面积,CI=可信区间

SVV大于9.5％时，对容量评价的敏感性为92.6％，特异性为62.5％。

SVV和ITBVI可用于容量状态的评价优于HR、MAP、CVP和PAWP内容简介容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结CVP/PAWP能反映EVLW吗?Prospectivelystudy16patswithsepticshockandpuledema(ACCP/SCCM)SAPSII:56Monitor:PiCCOvsPACOptimalPAWP:CInolongerincreasedMonitortime:0,24hFromintensiveCareMed,2002,28,712-18IntensiveCareMed,2002,28,712-18CVP/PAWP能反映EVLW吗?

NoIntensiveCareMed,2002,28,712-18delta与EVLW相关性,FB：fluidbalanceCVP/PAWP能反映EVLW吗?

No肺水含量是ARDS的预后指标Retrospectiveanalysis373ICUpatsinu