危重病患者的血流动力学监测与治疗

危重病患者的血流动力学监测与治疗

HowToMakeItSimple?北京协和医院杜斌血流动力学监测与治疗COMAPSVR=xSVHRx后负荷前负荷心肌收缩力精选课件血流动力学监测精选课件血流动力学监测:基本内容1前负荷Preload3组织灌注TissuePerfusion2灌注压MAP精选课件危重病患者的容量缺乏精选课件为何需要扩容治疗?CVP(mmHg)CO(L/min)精选课件根据临床表现判断容量状态低容量表现心动过速低血压(严重者)高乳酸(严重者)肢端温度降低脱水表现皮肤充盈下降口渴口干腋窝干燥高血钠高蛋白血症高血红蛋白高血球压积体位性低血压动脉血压或每搏输出量的呼吸波动下肢被动抬高容量负荷试验结果阳性肾脏灌注减少浓缩尿(低尿钠,高尿渗)BUN升高(与肌酐升高不成比例)持续性代谢性酸中毒动态指标静态指标容量状态评价精选课件低血容量:临床表现体格检查发现敏感性/特异性,%+LR(95%CI)-LR(95%CI)大量失血体位性脉搏加快>30bpm97/9848.50.03仰卧位心动过速(>90bpm)12/963.00.9仰卧位低血压(SBP<95mmHg)33/9711.00.7中等程度失血体位性低血压(年龄65岁)*9/941.81.0体位性低血压(年龄65岁)*27/861.90.9体位性脉搏加快>30bpm22/9811.00.8仰卧位心动过速(>90bpm)0/96仰卧位低血压(SBP<95mmHg)13/974.30.9精选课件脱水:临床表现体格检查发现敏感性/特异性,%+LR(95%CI)-LR(95%CI)体位性脉搏加快>30bpm43/751.7(0.7–4.0)0.8(0.5–1.3)体位性低血压29/811.5(0.5–4.6)0.9(0.6–1.3)粘膜干燥85/582.0(1.0–4.0)0.3(0.1–0.6)舌干59/732.1(0.8–5.8)0.6(0.3–1.0)舌体皱缩85/582.0(1.0–4.0)0.3(0.1–0.6)眼睛凹陷62/823.4(1.0–12.2)0.5(0.3–0.7)意识模糊57/732.1(0.8–5.7)0.6(0.4–1.0)肢体无力43/822.3(0.6–8.6)0.7(0.5–1.0)言语不流利56/823.1(1.2–14.9)0.7(0.5–0.9)精选课件前负荷的维持:指南建议复苏目标(1C)中心静脉压(CVP)8–12mmHg*平均动脉压65mmHg尿量0.5ml/kg/hr中心静脉(上腔静脉)血氧饱和度70%，或混合静脉血氧饱和度65%DellingerRP,LevyMM,CarletJM,etal.SurvivingSepsisCampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2008.CritCareMed2008;36(1):296-327.Erratumin:CritCareMed2008;36(4):1394-1396.精选课件中心静脉压:影响因素基础水平出血420ml(310–470ml)NE0.001g/kg/minHR(bpm)167(35)210(44)*153(56)**MAP(mmHg)144(42)85(46)*153(36)**CVP(mmHg)5.5(4.2)3.0(4.2)2.0(4.0)PAOP(mmHg)6.0(5.1)4.5(4.0)3.5(5.1)CO(lpm)4.68(3.30)1.98(0.86)*3.08(1.72)*,**SVR(dyne.sec/cm5)2367(1475)3313(1900)*3922(2744)*,**PVR(dyne.sec.cm-5)213(182)303(245)*428(310)PPV(%)12(9)28(11.5)*14.5(6.2)**SPV(mmHg)12.5(6.5)21(8.2)*15.5(4.5)**NouiraS,ElatrousS,DimassiS,etal.Effectsofnorepinephrineonstaticanddynamicpreloadindicatorsinexperimentalhemorrhagicshock.CritCareMed2005;33:2339-2343精选课件容量负荷试验:判断标准每10分钟测定CVPCVP2mmHg继续快速补液CVP2–5mmHg暂停快速补液,等待10分钟后再次评估CVP5mmHg停止快速补液每10分钟测定PAWPPAWP3mmHg继续快速补液PAWP3–7mmHg暂停快速补液,等待10分钟后再次评估PAWP7mmHg停止快速补液WeilMH,HenningRJ:Newconceptsinthediagnosisandfluidtreatmentofcirculatoryshock.AnesthAnalg1979;58:124–132精选课件病例1:现病史男性,70岁,2001年1月9日入院咳嗽,咳痰12天,发热4天,呼吸困难1天12天前咳嗽,咳黄粘痰,伴全身乏力4天前寒战高热,体温39.5CCXR：肺部感染,右上肺膨胀不全头孢呋肟治疗无效1天前呼吸困难,紫绀,伴血压下降(50/20mmHg)精选课件病例1:入院情况入ICU时BT37.2CHR130bpmBP84/40mmHg(DA10g/kg/min)SpO278%双肺散在湿罗音精选课件病例1:入院诊断诊断重度社区获得性肺炎急性呼吸功能衰竭感染性休克精选课件病例1:支持治疗呼吸功能支持(SIMV+PSV)FiO2100%,PEEP10cmH2OSpO292%循环支持羟基淀粉500ml扩容无效DA13g/kg/minNE1.2g/kg/minBP110/70mmHg精选课件病例1:血流动力学监测放置肺动脉漂浮导管HR 130 MAP 71CVP 9 PAWP 9CI 1.96SVRI 2524 PVRI 529NE 1.0精选课件病例1:血流动力学监测扩容3000ml后HR 103 MAP 118CVP 12 PAWP 18CI 3.63SVRI 2182 PVRI 331NE 1.0精选课件白蛋白vs.晶体液:SAFE研究多中心,随机,双盲,对照试验澳大利亚和新西兰16个ICU的7000名患者2001/11至2003/6入选标准:需要输液治疗+1项低血容量的客观指标排除标准:肝脏移植,

心脏手术,烧伤4%白蛋白(n=3499)vs.生理盐水(n=3501)TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.精选课件白蛋白vs.晶体液:SAFE研究白蛋白生理盐水28天病死率(%)20.921.1ICU住院日(d)6.2机械通气时间(d)5.7肾脏替代治疗时间(d)0.482.280.392.00新发器官功能衰竭无52.753.31个器官30.029.82个器官13.913.53个器官2.62.84个器官0.70.65个器官0.10TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.精选课件白蛋白vs.晶体液:SAFE研究TheSAFEStuyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-56TheSAFEStudyInvestigators.Acomparisonofalbuminandsalineforfluidresuscitationintheintensivecareunit.NEnglJMed2004;350:2247-2256.精选课件乳酸林格液vs羟乙基淀粉:VISEP强化胰岛素治疗传统胰岛素治疗羟乙基淀粉247290乳酸林格液BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.精选课件乳酸林格液vs羟乙基淀粉:VISEP强化胰岛素治疗传统胰岛素治疗羟乙基淀粉262乳酸林格液275BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.精选课件乳酸林格液vs羟乙基淀粉:VISEP乳酸林格液(n=275)HES(n=262)P28天病死率n/N66/27470/2620.48%24.1(19.0–29.2)26.7(21.4–32.1)90天病死率n/N93/274107/2610.09%33.9(28.3–39.6)41.0(35.0–47.0)凝血系统SOFA评分0.11(0–0.83)0.46(0–1.30)<0.001肾脏SOFA评分0.42(0–1.33)0.67(0–1.94)0.02急性肾功能衰竭n/N62/27291/2610.002%22.8(17.8–27.8)34.9(29.1–40.7)肾脏替代治疗n/N51/27281/2610.001%18.8(14.1–23.4)31.0(25.4–36.7)输注RBC单位4(2–8)6(4–12)<0.001BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.精选课件乳酸林格液vs羟乙基淀粉:VISEPBrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.NEnglJMed2008;358:125-139.精选课件血流动力学监测:前负荷前负荷不足危重病人中非常普遍临床表现缺乏特异性可能需要试验性治疗不同种类液体有差异精选课件血流动力学监测:基本内容1前负荷Preload3组织灌注TissuePerfusion2灌注压MAP精选课件血流动力学中的欧姆定律R=P/flowPinPoutflowR精选课件器官灌注压肾脏灌注RPP=MAP–IAPFG=GFP–PTP=MAP–IAPx2脑灌注CPP=MAP–ICP精选课件健康与疾病时的自身调节015050100Organbloodflow(%Baseline)010020406080Organarterypressure(mmHg)AutoregulatorythresholdSubautoregulatoryslope精选课件疾病时的自身调节机制015050100Organbloodflow(%Baseline)010020406080Organarterypressure(mmHg)control3weeks1week精选课件升压药物:指南建议维持MAP65mmHg(1C)首选升压药物应为去甲肾上腺素或多巴胺,并经中心静脉输注(1C)肾上腺素,苯肾上腺素或血管加压素不应作为感染性休克的一线用药(2C)在去甲肾上腺素基础上加用血管加压素0.03U/min,可能与单纯应用去甲肾上腺素效果相等感染性休克时如血压对去甲肾上腺素反应不佳,可首选肾上腺素或多巴胺(2B)不应使用小剂量多巴胺进行肾脏保护(1A)需要升压药的患者应留置动脉导管(1D)DellingerRP,LevyMM,CarletJM,etal.SurvivingSepsisCampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2008.CritCareMed2008;36(1):296-327.Erratumin:CritCareMed2008;36(4):1394-1396.精选课件平均动脉压应当多少?无创血压不准确高血压时读数低低血压时读数高有创血压与无创血压经常不一致

精选课件血流动力学监测:技巧确认患者的平均动脉压家属病历记录检查患者平均动脉压的测定方法无创vs.有创确定无创血压与有创血压的差值精选课件病例2:基本情况男性,74岁,病历号既往史I型糖尿病18年糖尿病肾病高血压病史5年口服络活喜,倍他乐克等药物平素BP160–180/70–90mmHg精选课件病例2:现病史2007年7月25日入院主因发现恶心,呕吐1周,伴心前区疼痛及少尿3天1周前出现恶心,呕吐,予对症治疗3天前出现心前区疼痛,憋闷,尿量减少静脉泵入NG100g/min,控制BP134/56mmHg血Cr861mol/L,UO<500ml/d(速尿400mg/d)血液透析,透析过程中出现心绞痛,持续不缓解精选课件病例2:体格检查GCS E4V5M6BT 36.2CHR 70bpmRR 20bpmBP 103/45mmHgSpO2 98–100%(鼻导管吸氧5lpm)精选课件病例2:实验室检查CBC:WCC14.79,Hb102,plt215Chemistry(8–2):Na 140 mmol/LCl 97 mmol/LK 4.2 mmol/LCr 745 mol/LBUN 31.14 mmol/LCK-MB 6.8 u/LcTnI 11.56 g/LGLU 21.5 mmol/L精选课件病例2:MAP与组织灌注心绞痛**发作时EKG:V3-6导联ST段压低0.1–0.2mv精选课件病例2:MAP与组织灌注心绞痛**发作时EKG:V3-6导联ST段压低0.1–0.2mv精选课件病例2:MAP与组织灌注心绞痛**发作时EKG:V3-6导联ST段压低0.1–0.2mv精选课件感染性休克:NE+DBvs.Epi满足以下标准<7d感染证据SIRS标准2/4组织低灌注或器官功能不全(2)PaO2/FiO2<280UO<0.5ml/kg/h或30ml/h1hLac>2mmol/LPlt<100x109/L满足以下标准<24hSBP<90mmHg或MAP<70mmHg快速补液>1000ml或PCWP12–18mmHg血管活性药物多巴胺>15g/kg/minEpi或NE:任何剂量AnnaneD,VignonP,RenaultA,etal.Norepinephrineplusdobutamineversusepinephrinealoneformanagementofsepticshock:arandomisedtrial.Lancet2007;370:676-684精选课件感染性休克:NE+DBvs.EpiAnnaneD,VignonP,RenaultA,etal.Norepinephrineplusdobutamineversusepinephrinealoneformanagementofsepticshock:arandomisedtrial.Lancet2007;370:676-684精选课件感染性休克:NE+DBvs.Epi总计(n=330)Epi(n=161)NE+DB(n=169)年龄(岁)63(50–73)65(53–75)60(47–72)男性(%)202(61%)103(64%)99(59%)SAPSII53(40–65)54(42–67)52(38-64)SOFA11(9–14)11(9–13)11(9–14)MAP(mmHg)69(19)70(19)68(19)DA>15g/kg/min63(19%)38(24%)25(15%)Epi137(42%)61(38%)76(45%)NE102(31%)48(30%)54(32%)早期适当抗生素(%)250(76%)119(74%)131(78%)RRT(%)31(9%)15(9%)16(10%)皮质激素(%)263(80%)133(83%)130(77%)APC(%)25(21%)11(19%)14(23%)AnnaneD,VignonP,RenaultA,etal.Norepinephrineplusdobutamineversusepinephrinealoneformanagementofsepticshock:arandomisedtrial.Lancet2007;370:676-684精选课件感染性休克:NE+DBvs.EpiEpi(n=161)NE+DB(n=169)P值7天病死率(%)40(25%)34(20%)0.3014天病死率(%)56(35%)44(26%)0.0828天病死率(%)64(40%)58(34%)0.31ICU病死率(%)75(47%)75(44%)0.69住院病死率(%)84(52%)82(49%)0.5190天病死率(%)84(52%)85(50%)0.73ORHR所有变量(n=308)0.90(0.54–1.49)0.87(0.59–1.28)除适当抗生素外的所有变量(n=319)0.82(0.51–1.34)0.84(0.58–1.22)除适当抗生素及乳酸外的所有变量(n=330)0.82(0.51–1.31)0.87(0.61–1.24)AnnaneD,VignonP,RenaultA,etal.Norepinephrineplusdobutamineversusepinephrinealoneformanagementofsepticshock:arandomisedtrial.Lancet2007;370:676-684精选课件感染性休克:NE+DBvs.EpiAnnaneD,VignonP,RenaultA,etal.Norepinephrineplusdobutamineversusepinephrinealoneformanagementofsepticshock:arandomisedtrial.Lancet2007;370:676-684精选课件感染性休克:VPvs.NERussellJA,WalleyKR,SingerJ,etal.VasopressinversusNorepinephrineInfusioninPatientswithSepticShock.NEnglJMed2008;358:877-87.感染性休克需要血管活性药物(NE5g/min)(n=779)起始剂量0.01U/min增加剂量0.005U/min最大剂量0.03U/min(n=397)起始剂量5g/min增加剂量2.5g/min最大剂量15g/min)(n=382)血管加压素(VP)(0.12U/ml)(n=397)去甲肾上腺素(NE)(60g/ml)(n=382)精选课件感染性休克:VPvs.NERussellJA,WalleyKR,SingerJ,etal.VasopressinversusNorepinephrineInfusioninPatientswithSepticShock.NEnglJMed2008;358:877-87.NE(n=382)VP(n=397)P值年龄(岁)61.81659.316.40.03男性(%)229(59.9)246(62.0)0.56APACHEII27.16.927.07.70.84MAP(mmHg)73107290.23LA(mmol/L)3.53.06DA(g/kg/min)6.40.88DB(g/kg/min)5.20.18Epi(g/kg/min)00.290.12NE(g/kg/min)0.280.260.260.270.972种升压药物111(29.1)124(31.2)0.51皮质激素(%)293(76.7)296(74.6)0.49APC(%)56(14.7)61(15.4)0.78精选课件感染性休克:VPvs.NENE组(n=382)VP组(n=396)PARR(95%CI)RR(95%CI)校正OR28天病死率150/382(39.3)140/396(35.4)0.263.9(-2.9to10.7)0.90(0.75–1.08)0.88(0.62–1.26)90天病死率188/379(49.6)172/392(43.9)0.115.7(-1.3to12.8)0.88(0.76–1.03)0.81(0.57–1.16)RussellJA,WalleyKR,SingerJ,etal.VasopressinversusNorepinephrineInfusioninPatientswithSepticShock.NEnglJMed2008;358:877-87.精选课件感染性休克:VPvs.NERussellJA,WalleyKR,SingerJ,etal.VasopressinversusNorepinephrineInfusioninPatientswithSepticShock.NEnglJMed2008;358:877-87.精选课件ParrilloJE.Septicshock–vasopressin,norepinephrine,andurgency.NEnglJMed2008;358:954-956精选课件血流动力学监测:灌注压灌注压不足灌注压没有固定数值注意有创及无创血压的差异根据患者情况确定目标血压排除低血容量时应用升压药具有受体激动作用的药物(多巴胺,去甲肾上腺素等)精选课件血流动力学监测:基本内容1前负荷Preload3组织灌注TissuePerfusion2灌注压MAP精选课件病例3一名25岁体重70kg肺炎患者,BP100/50(65)mmHg,CVP0mmHg,尿量50ml/hr,pH7.4.患者神志清楚,四肢温暖.最适宜的血流动力学处理措施为:IV输注胶体液250ml无需任何处理IV输注5%葡萄糖250ml小剂量多巴胺输注多巴酚丁胺输注精选课件组织灌注不足的表现皮肤花斑四肢冰冷毛细血管再充盈时间延长尿量减少意识障碍代谢性酸中毒乳酸酸中毒ScvO2<70%…精选课件病例4:基本情况男性,80岁既往史平时血压110–120/70–80mmHg2007年7月发现皮肤发黑,嗜酸粒细胞增多诊断不清激素治疗(强的松40mgqd)精选课件病例4:现病史于2007年8月7日入院主因咳嗽,胸闷,咯血1周,加重伴少尿2天咳嗽时伴夜间不能平卧咳粉红色泡沫痰及鲜红色血痰双下肢水肿尿量减少应用呋塞米160mg/d无效精选课件病例4:体格检查GCS E4V5M6BT 35CHR 95bpmRR 20bpmBP 120/75mmHgSpO2 99%(面罩吸氧5lpm)精选课件病例4:辅助检查CBC:WCC21.02,Hb99,plt87生化(8月2日)Na 135 mmol/LCl 106 mmol/LK 5.3 mmol/LCr 428 mol/LBUN 35.66 mmol/LCK 488 U/LcTnI 32.68 g/LECG:V2-6导联T波倒置精选课件病例4:初步诊断急性心肌梗死心功能不全急性肾功能不全肺部感染皮肤色素沉着,嗜酸性粒细胞增多原因不明精选课件病例4:血流动力学监测平时血压110–120/70–80mmHg当前情况BP 132/71 mmHgCVP 13 mmHgBE -11.2 mmol/L无尿精选课件病例4:血流动力学监测8月7日15:00BP132/71CVP13CO2.03SVRI6721GEDI717ELWI12BE-11Lac3.1精选课件病例4:血流动力学监测8-715:008-722:00BP132/71130/60CVP1312CO2.035.83SVRI67212265GEDI717888ELWI127BE-11-10cLac3.11.1Dobutamine10Nitropruside15扩容1000ml精选课件病例4:血流动力学监测8-715:008-722:008-9BP132/71130/60123/59CVP131213CO2.035.835.62SVRI672122651826GEDI717888922ELWI1278BE-11-10-0.4cLacDobutamine1020Nitropruside1510I:5807O:2900扩容1000ml精选课件病例4:血流动力学监测8-715:008-722:008-98-10BP132/71130/60123/59120/60CVP1312139CO2.035.835.626.0SVRI6721226518261698GEDI717888922877ELWI127811BE-11-10-0.40.4cLac0.9Dobutamine102020Nitropruside151020I:7152O:5590I:5807O:2900扩容1000ml精选课件血流动力学指标:超正常值CI>4.5L/min/m2DO2I>600ml/min/m2VO2I>170ml/min/m2

VelmahosGC,DemetriadesD,ShoemakerWC,etal.:Endpointsofresuscitationofcriticallyinjuredpatients:normalorsupranormal?Aprospectiverandomizedtrial.AnnSurg2000,232:409-418.精选课件BoydO,HayesM.Theoxygentrial:thegoal.BrMedBull1999;55(1):125-1391101000.10.01Tuschmidt26(50)25(72)0.39(0.12–1.24)Yu,199335(34)32(34)1.00(0.36–2.73)Hayes50(54)50(34)2.28(1.02–5.11)Gattinoni252(48)253(49)0.99(0.70–1.41)Yu,199545(38)44(41)0.88(0.37–2.05)Yu,1998(>75yo)21(57)18(61)0.85(0.24–3.06)Yu,1998(50–75yo)43(21)23(52)0.24(0.08–1.18)TrialProtocolControlOR(95%CI)Mortalityn(%)FavorProtocolFavorControl超正常值与患者预后精选课件循环支持治疗:指南建议正性肌力药物治疗心肌功能障碍(心脏充盈压力升高及心输出量降低)时使用多巴酚丁胺(1C)不应使心脏指数增加到预先确定的超正常水平(1B)DellingerRP,LevyMM,CarletJM,etal.SurvivingSepsisCampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2008.CritCareMed2008;36(1):296-327.Erratumin:CritCareMed2008;36(4):1394-1396.精选课件隐性低灌注与创伤预后TheGoldenHourandtheSilverDay入选标准:成年创伤患者存活时间>24小时ISS20血流动力学稳定SBP>100HR<120UO>1mL/kg/h乳酸>2.5mmol/L或其他灌注不足表现BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964精选课件隐性低灌注与创伤预后严重创伤患者两次LA>2.5输注液体或血液制品重复LA>2.5Swan-Ganz,动脉插管,肾脏剂量多巴胺将PCWP提高到12–15将Hct提高到30%重复LA>2.5升压药物(多巴酚丁胺)心脏超声检查若LA仍>2.5BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964精选课件隐性低灌注与创伤预后BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDa