ScvO2的临床意义课件

ScvO2的临床意义1精选2021版课件内容氧供与氧耗SvO2与ScvO2ScvO2的临床应用2精选2021版课件氧供与氧耗3精选2021版课件15vol%=15ml/dl5vol%=5ml/dl4精选2021版课件5精选2021版课件氧供DO2与氧耗VO2DO2=CaO2×CO=(1.34×SaO2×Hb+0.0031×PaO2)×CO

=1.34×SaO2×Hb×COVO2=(CaO2-CvO2)×CO

=(SaO2-SvO2)

×1.34×Hb×COSvO2=SaO2-VO2/(1.34×Hb×CO)

呼吸血红蛋白循环(Fick方程)6精选2021版课件氧摄取EO2EO2=VO2/DO2EO2=(SaO2

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SvO2)/SaO2当SaO2=100%时：EO2=1-SvO2全身

EO2=1-75%=25%各组织EO2不同，其相应之静脉氧饱和度不同SvO2

=

1

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EO27精选2021版课件氧供氧耗失衡SvO2降低或增加无氧代谢组织缺氧乳酸生成8精选2021版课件影响SvO2的因素75%-+DO2应激发热寒战躁动疼痛呼吸做功VO2CO(心衰、低容量）Hb（贫血、出血）SaO2（缺氧、呼衰）DO2CO（液体复苏、正性肌力）Hb（输血）SaO2（氧疗）VO2低体温镇静镇痛麻醉机械通气氧摄取（分流、细胞死亡）9精选2021版课件SvO2的界值PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.

10精选2021版课件ScvO2与SvO211精选2021版课件ScvO2与SvO212精选2021版课件ScvO2与SvO2SvO2由肺动脉导管测得反映全身的氧耗量正常值：75%ScvO2由中心静脉（上腔静脉）导管测得反映脑及上半身的氧耗量正常值：72%13精选2021版课件测定方法连续监测光纤导管或光纤中心静脉导管间断测定中心静脉血气14精选2021版课件15精选2021版课件正常各组织器官的静脉氧饱和度PinskyMR,ManceboJ,Appliedphysiologyinintensivecare.

16精选2021版课件休克时？17精选2021版课件ScvO2与SvO2的相关性CharalambosLadakisPavlosMyrianthefsAndreasKarabinisetal.CentralVenousandMixedVenousOxygenSaturationinCriticallyillpatients,Respairation,2001;68279-285LinearcorrelationofpairedScvO2andSvO2measurementsfor296pairedsamplesScvO2increasesby0.87%foreveryunitincreaseinSvO218精选2021版课件ScvO2与SvO2的相关性DueckMHetal.Anesthesiology2005;103:249–5719精选2021版课件MožinaandPodbregarCriticalCare2010,14:R42th20精选2021版课件MožinaandPodbregarCriticalCare2010,14:R4221精选2021版课件MožinaandPodbregarCriticalCare2010,14:R4222精选2021版课件MožinaandPodbregarCriticalCare2010,14:R4223精选2021版课件SvO2与ScvO2的一致性绝对值相差5~18%24精选2021版课件ScvO2的临床应用25精选2021版课件休克中的应用VO2DO2ScvO2/SvO2乳酸休克的本质是组织缺氧和氧代谢障碍，最终结果是MODS。液体复苏、及早纠正氧供与氧耗的失衡、降低组织缺氧程度至关重要。26精选2021版课件急诊患者的复苏多数（31例/36例）存在休克的危重患者经初期复苏至正常生命体征后乳酸继续升高(>2mmol/L)，ScvO2仍低于正常(<65%)，提示存在无氧酵解和氧债。这些患者进一步治疗后乳酸下降（4.6±3.8to2.6±2.5,p<0.05)，ScvO2升高（52±18to65±13%,p<0.05)ScvO2能作为初期复苏后指导休克治疗的指标RadyMY,RiversEP,NovakRM:ResuscitationofthecriticallyillintheED:responsesofbloodpressure,heartrate,shockindex,centralvenousoxygensaturation,andlactate.AmJEmergMed1996,14:218-225.27精选2021版课件重症感染与感染性休克中的应用1368·1377NEnglJMed,Vol.345,No.19·November8,2001早期目标指导治疗（EGDT）28精选2021版课件29精选2021版课件研究结果——死亡率30精选2021版课件RiversE,NguyenB,HavstadS,eta1．Earlygoaldirectedtherapyinthetreatmentofseveresepsisandsepticshock.NEngJMed,2001,345:1368—1377.进行ScvO2监测，达到EGDT目标，可使患者病死率下降16%（46.5%vs30.5%）。低ScvO2的预后差31精选2021版课件2012“拯救脓毒症运动”指南

——早期复苏目标MAP≥65mmHgCVP8~12mmHg,机械通气12~15mmHg尿量≥0.5ml/kg/hScvO2≥70%orSvO2≥65%32精选2021版课件感染性休克高ScvO2的预后33精选2021版课件34精选2021版课件单因素分析结果35精选2021版课件存活组与死亡组的ScvO236精选2021版课件该研究共纳入4家医院急诊科脓毒症患者619名，按EDGT复苏方案治疗，据ScvO2水平分为三组：低ScvO2组(＜70%)、正常ScvO2组(71~89%)、高组(90~100%)。比较住院死亡率并进行多因素分析37精选2021版课件23%25%31%初始ScvO2与死亡率(81/351)(56/223)(14/45)38精选2021版课件25/6296/46531/9239精选2021版课件ScvO2在ACS中的应用该研究纳入患者43名，为收住CCU的急性冠脉综合征（ACS）并急性肺水肿或心源性休克患者，测定入室时、24h、48h的中心静脉和外周动脉血气，主要终点为致死性事件，次要终点为住院全因死亡率ActaCardiolSin2008;24:1263340精选2021版课件结果：存活组与死亡组ScvO2的差异有显著性ActaCardiolSin2008;24:1263341精选2021版课件所有患者ScvO2、SaO2的变化存活患者ScvO2的变化ActaCardiolSin2008;24:1263342精选2021版课件创伤患者的评估Lowcentralvenoussaturationpredictspooroutcomeinpatientswithbraininjuryaftermajortrauma:aprospectiveobservationalstudyAlessandroDiFilippo*1,ChiaraGonnelli1,LuciaPerretta1,Rosariopina1,MarcoChiostri2,GianFrancoGensini2andAdrianoPeris1ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:2343精选2021版课件ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2009,17:23ScvO2≤65%的患者住院时间延长，死亡率明显增加44精选2021版课件急诊插管对重症患者ScvO2的影响15minHernandezetal.CriticalCare2009,13:R6345精选2021版课件Hernandezetal.CriticalCare2009,13:R6346精选2021版课件插管改善ScvO2的机制插管前预充纯氧，溶解氧增加，氧供提高插管时镇静与肌松使氧摄取减少而降低氧耗初始机械通气减轻了过度通气，使pH升高而使氧离曲线右移，利于氧释放47精选2021版课件围术期ScvO2的应用48精选2021版课件患者资料49精选2021版课件单因素分析Aftermultivariateanalysis,meanScvO2value(OR1.23[95%CI1.01to1.50],p=0.037),hospitalLOS(OR0.75[95%CI0.59to0.94],p=0.012),andSAPSII(OR0.90[95%CI0.82to0.99],p=0.029)wereindependentlyassociatedwithpostoperativecomplications.多因素分析50精选2021版课件低ScvO2与术后并发症相关P=0.004TheoptimalvalueofmeanScvO2fordiscriminatingbetweenpatientswhodidordidnotdevelopcomplicationswas73%(sensitivity72%,specificity61%)51精选2021版课件ScvO2与乳酸在感染性休克中应用比较Jones的研究显示：在感染性休克的早期目标性治疗中，乳酸清除率达标与ScvO2达标，两组的住院死亡率无差别【25%（17~30%）vs17%（11~24%）】。JonesAEetal.JAMA.2010February24;303(8):739–74652精选2021版课件ScvO2与容量反应性大循环指标：血压、心率、尿量、CVPCO、CIPPVSVVScvO2?53精选2021版课件ScvO2AsaMarkertoDefineFluidResponsivenessMethods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNRMethods:Atotalof30patientsrequiringVEwereincludedinthisprospectivecohortstudy,allequippedwithradialarteriallineandpulmonaryarterycatheters.CI,mixedvenousoxygensaturation(SvO2)andScvO2weremeasuredbeforeandafterVE.CI,SvO2,andScvO2changesaftervolumewereanalyzedusinglinearregression.ReceiveroperatingcharacteristicscurveanalysiswasusedtotesttheirabilitytodistinguishRandNRGiraudR,etal.JTrauma.2011;70:802–80754精选2021版课件ScvO2AsaMarkertoDefineFluidResponsivenessGiraudR,etal.JTrauma.2011;70:802–80755精选2021版课件ScvO2AsaMarkertoDefineFluidResponsivenessGiraudR,etal.JTrauma.2011;70:802–80756精选2021版课件ScvO2AsaMarkertoDefineFluidResponsivenessResults:ScvO2andSvO2variationsafterVE(SvO2)weresignificantlycorrelatedwithCIchanges(CI)afterVE(r0.67andr=0.49,p<0.001,respectively).AScvO2thresholdvalueof4%allowedthedefinitionofRandNRpatientswith86%sensitivity(95%CI;57–98%)and81%specificity(95%CI;54–96%)GiraudR,etal.JTrauma.2011;70:802–80757精选2021版课件ScvO2的局限性58精选2021版课件争论：ScvO2不能反映SvO2Biasofdifferencewas4.2%and95%limitsofagreementrangedfrom–8.1%to16.5%.Thecentralvenousoxygensaturationoverestimatedthemixedvenousoxygensaturationbyameanbias(oranabsolutedifference)of6.9%,andthe95%limitsofagreementwerelarge(-5.0%to18.8%).Thedifferencebetweencentralandmixedvenousoxygensaturationappearedtobemoresignificantwhenmixedvenousoxygensaturationwas<70%VarpulaMetal.IntensiveCareMed(2006)32:1336–1343HoKMetal.JCardiothoracVascAnesth.2010Jun;24(3):434-9.

59精选2021版课件56.7%36%7.3%ScvO2初始值差异大(351)(223)(45)PopeJVetal.AnnEmergMed.2010January;55(1):40–46总数61960精选2021版课件组织氧代谢指标胃粘膜pH组织氧饱和度（StO2）微透析测组织代谢联合指标……？SvO2/ScvO2不能很好反应组织氧代谢61精选2021版课件微透析？62精选2021版课件63精选2021版课件ScvO2+CO2gap的意义KocsiSetal.CriticalCareResearchandPracticeVolume2013,ArticleID583598,7pages64精选2021版课件InICUresuscitatedpatients,targetingonlyScvO2maynotbesufficienttoguidetherapy.Whenthe70%ScvO2goalvalueisreached,thepresenceofaP(cv-a)CO2largerthan6mmHgmightbeausefultooltoidentifypatientswhostillremaininadequatelyresuscitated.IntensiveCareMed(2008)34:2218-222550consecutivesepticshockpatientswithScvO2＞70%ScvO2+CO2gap的意义65精选2021版课件SvO2ScvO2DO2VO2氧利用66精选2021版课件67精选2021版课件

改善氧供——改善氧耗？线粒体RampalT.CurrOpinCritCare16:244–24968精选2021版课件总结ScvO2与SvO2相关性较好，动态监测可反映机体的全身氧代谢状况ScvO2可作为重症患者病情评估、预后判断的有效参考指标ScvO2可用于重症患者的治疗指导ScvO2存在其局限性，不能替代医师的临床综合判断将来——细胞水平缺氧的判断与治疗？！69精选2021版课件谢谢！70精选2021版课件ScvO2与P(cv-a)CO2对外科感染性休克液体复苏的临床研究昆明医科大学第二附属医院71精选2021版课件研究背景本研究是针对腹部外科术后感染性休克患者，监测入ICU最初6小时复苏前后ScvO2、P(cv-a)CO2，探讨其变化是否能更好的指导患者早期复苏治疗，寻找最佳的复苏目标，以及是否能对病情和预后作出评估和判断。72精选2021版课件

本研究共纳入2012年1月～2013年3月期间所有收入昆明医科大学第二附属医院重症医学科（ICU）外科术后感染性休克患者46例，其中住ICU死亡10例，28天死亡16例，住ICU病死率21.7%，28天病死率34.8%。实验结果73精选2021版课件检测项目T0T6t值P值HR（次/分）113.43±22.46106.96±21.632.3730.022MAP（mmHg）75.11±17.375.11±13.320.0001.000CVP（cmH2O）14.58±5.8214.47±5.470.1710.860CO（L/min）8.15±6.866.42±3.451.0680.296P(cv-a)CO2（mmHg）7.93±6.165.87±3.101.8960.044*ScvO2（%）69.67±10.9772.28±9.42-2.0020.049*Lac（mmol/L）4.47±2.693.40±2.584.5010.000*BE（mmol/L）-6.32±4.33-4.19±4.58-2.9700.005*PaO2/FiO2（mmHg/%）207.02±74.54199.11±83.790.6820.499Cr（μmol/L）151.35±129.48140.52±105.651.1670.3086小时复苏前后参数资料比较实验结果P=0.044P=0.005P=0.00074精选2021版课件实验结果

lac丨BE丨T0时ScvO2r值-0.1690.107P值0.2610.480T6时ScvO2r值-0.342-0.299P值0.0200.044ScvO2与lac、BE相关性分析lac丨BE丨T0时P(cv-a)CO2r值0.171-0.111P值0.2570.461T6时P(cv-a)CO2r值0.652-0.495P值0.0000.000P(cv-a)CO2与lac、BE相关性分析75精选2021版课件实验结果ScvO2与CO相关性分析P(cv-a)CO2与CO相关性分析COT0时ScvO2r值0.391P值0.048T6时ScvO2r值0.664P值0.039COT0时P(cv-a)CO2r值-0.183P值0.040T6时P(cv-a)CO2r值-0.521P值0.00276精选2021版课件实验结果ScvO2与P(cv-a