休克患者血容量的监测进展-杨毅教授

杨 毅东南大学医学院附属中大医院ICU东南大学急诊与危重病医学研究所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休克治疗的首要任务：

积极、合适补充血容量休克发生的始动因素：

有效循环血量下降合适的容量管理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PrincipleofEVLWmeasurementRAEDVLAEDVLVEDVPBVRVEDVEVLWInjectionPiccoThermo-dilutioncatheterSwan-ganz

catheter呼吁容量指标的应用来反映容量状态及肺水肿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)胸腔内血管容量(ITBV)左心舒张末期容量右心舒张末期容量肺血容量搏出量变异率(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ITBV—validestimateofpreloadinALIProspectiveanimalstudy15sheepwithALI---salinewashoutMV(PEEP0,7,14,21respectively60min)Measurement:LVEF,LVEDV-----CTscanITBV,RVEDV---PiCCOCVP,PAWP----PACLueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126LueckeT,etal.IntensiveCareMed,2004,30:119-126ITBVandRVEDVProvidevalidestimateofpreloadEvenathighintrathoracicpressureITBV----indicatorofpreloadinlivertransplantation60patientsundergoingLivertransplantationmonitoredwithPiCCOandPACthecorrelationbetweenPAOPandITBVIwithrespecttoCIandSVIthecorrelationbetweenITBVIandPAOP

DellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI----morereliableindicatorofpreloadthanPAWPDellaRoccaG,etal.EurJAnaesthesiol.2002,19:868-75ITBVI---validindicatorofpreloadinlungtransplantation50patientsduringlungtransplantationTime:6phaseduringoperationCorrelationbetweenPAWPandSVICorrelationbetweenITBVIandSVICorrelationbetween(Delta)ITBVI\PAWPandDeltaSVIDeltawerecalculatedbysubtractingthefirstfromthesecondmeasurementDellaRG,etal.AnesthAnalg.2002,95:835-43ITBV---superiorthanPAWPinpreloadDellaRG,etal.AnesthAnalg.2002,95:835-43CorrelationofITBV-

SVin4phasesNocorrelationofPAWP-

SVinanyphasesProspective,controlled,clinicalstudy18patientswithejectionfraction>50%undergoingcoronaryarterybypassgraftsurgeryAbaselinemeasurement:afterinductionofanesthesia(T1)treatedbyinfusionof6%hydroxyethylstarch200/0.5(7mL/kg)After10minutes,asecondmeasurement(T2)wasperformedWiesenackC,etal.CardiothoracVascAnesth.2001,15:584-8ITBVcorrelatedsignificantlywithCIandSVINCABGITBVhasGoodrelationship

betweenCI/SVI

CVP/PCWP与

CI/SV无相关性

ITBV与

CI的相关性r=0.55

ITBV与

SV的相关性为r=0.62WiesenackC,etal.CardiothoracVascAnesth.2001,15:584-8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/PAWPnotcorrelatedwithCI

SVVmayhelptodeterminethepreloadcondition

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%Atotalof140VLSswereperformedAnesthAnalg.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 <0.001AnesthAnalg.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 <0.001AnesthAn