微循环与血管活性药

Sepsis微循环

与血管活性药奚佳瑞2011年2月5/8/20241微循环与血管活性药引言Sepsis：疑问：临床上血流动力学稳定、氧传递指标等均可，但依然进展、乳酸升高？早期亦已存在微循环功能障碍！！

5/8/20242微循环与血管活性药引言微循环：如此重要、关键应成为危重患者复苏中的一个关键指标但：传统的评价指标难以准确评价微循环！5/8/20243微循环与血管活性药主要问题：1.有什么新的方法监测微循环？2.现有血管活性药物微循环的影响如何？5/8/20244微循环与血管活性药微循环的结构直径<300um的血管100亿个毛细血管血管表面积>500m2组成：微动脉，后微动脉，毛细血管前括约肌，真毛细血管、通血毛细血管、动静脉交通支、微静脉

5/8/20245微循环与血管活性药微循环的功能及分类1.迂回通路：物质交换，交替开放（又称营养通路）2.直捷通路：不进行物质交换，血液快速回流，骨骼肌多见3.动静脉短路：不进行物质交换，皮肤多见5/8/20246微循环与血管活性药5/8/20247微循环与血管活性药Sepsis时微循环的改变1994年，LamC等对血压稳定的鼠sepsis微循环活体显微镜在体观察，发现sepsis时：1.灌注毛细血管密度减少，血流停止的毛细血管数增加；2.灌注毛细血管空间分布不均，平均毛细血管间距增加2002年，DeBacker等利用OPS成像观察sepsis舌下微循环，发现：1.微血管密度显著减少，血流停滞和血流灌注间断的小血管比例增加；2.各区域间灌注血管的变异系数明显大于健康志愿者

DeBackerD,CreteurJ,PreiserJC,etal.Microvascularbloodflowisalteredinpatientswithsepsis.AMJRespirCritCareMed,2002,166:98-1045/8/20248微循环与血管活性药

OPS图像5/8/20249微循环与血管活性药Sepsis时微循环的改变特征：1.adecreaseincapillarydensity2.anincreaseinheterogeneityofperfusionwithnon-perfusedinclosevicinitytowell-perfusedcapillaries后果？5/8/202410微循环与血管活性药Tissuestoleratebetterahomogeneous

decreaseinbloodflowbetterthanaheterogeneousoneDanielDeBacker，GustavoOspina-Tascon，etal.IntensiveCareMed(2010)36:1813–1825.5/8/202411微循环与血管活性药5/8/202412微循环与血管活性药HowtoevaluatethemicrocirculationIntensiveCareMed(2010)36:1813–1825.5/8/202413微循环与血管活性药NailfoldvideocapillaroscopyThefirstmethodusedatthebedsidethenailfoldareaisverysensitivetochangesintemperature:onecancontrolambientbutnotbodytemperature.PeripheralvasoconstrictioncanalsooccurduringchillsandacutecirculatoryfailureOflimiteduseincriticallyillpatients.5/8/202414微循环与血管活性药LaserDopplerMainlimitation：measuresflowinavariablevolumeoftissue，unabletodetectitinindividualvesselsSamplingvolume:0.5and1mm3,about50vesselsCannotshowtheheterogeneity5/8/202415微循环与血管活性药SvO2VenousO2saturationcanbehighorlowforthesamedegreeofmicrovascularshunting—canbemisleadingSeveralstudieshaveshownthatmeasuringSvO2doesnotprovidemuchinformationaboutmicrovascularalterations---PodbregarM,MozinaH.Skeletalmuscleoxygensaturationdoesnotestimatemixedvenousoxygensaturationinpatientswithsevereleftheartfailureandadditionalseveresepsisorsepticshock.CritCare2007,11:R6MarikPE,BankovA,Sublingualcapnometryversustraditionalmarkersoftissueoxygenationincriticallyillpatients.CritCareMed2003,31:818–8225/8/202416微循环与血管活性药GastrictonometryAgastricPCO2gapabove20mmHgdiscriminatedsurvivorsfromnon-survivors-------LevyB,GawalkiewiczP.CritCareMed2003,31:474–48

GastricPCO2gap---mostlyreflectsgutmucosalmicrocirculation----Insepsis,nocorrelationbetweenthegastricPCO2gapandtotalsplanchnicperfusionDuodeno-gastricrefluxandfeedingcaninterfere5/8/202417微循环与血管活性药LactateTimelag-------Cannotdetectalterationsinmicrovascularperfusionbeforetheyareassociatedwithcellularhypoxia5/8/202418微循环与血管活性药OPS/SDFOPS成像：正交偏振光谱成像orthogonalpolarizationspectralimaging原理：利用血细胞对偏振入射绿光产生消偏振光散射和对正偏振光的成像特征，能在皮下0.5mm深度内产生高清晰度和高分辨率的成像。局限性：敏感性偏差；需具备高能光源，难以应用到临床。5/8/202419微循环与血管活性药OPS/SDFSDF成像：旁流暗场成像，sidestreamdark-field，2007年开始应用于临床优点：更加清晰所需能量小，可以方便的使用电池床边操作

5/8/202420微循环与血管活性药SDFimage5/8/202421微循环与血管活性药OPS/SDFAdvantage:1.visible2.differentvariablescanbeobservedandbemeasured---vasculardensity,heterogeneityofperfusion,microvascularbloodflowTheconsensusadvisesreportingofPVD,PPV,MFIandheterogeneityindex,inordertodescribethefunctionalperfusionofthemicrocirculation.-------Howtoevaluatethemicrocirculation:reportofaroundtableconference,CriticalCare2007,11:R101

5/8/202422微循环与血管活性药血管活性药物对微循环的影响Vasopressors:Norepinephrine,Epinephrine,VasopressinInotropes:Dopamine,Dobutamine,Vasodilators:Nitroglycerin,Prostacyclin5/8/202423微循环与血管活性药NEdoesnotimprovemicrocirculatorybloodflow20septicshockpatientsBasalmeasurementofMAP65mmHg,NEwastitratedtoreachaMAPof75mmHg,then85mmHgSublingualmicrocirculationwasevaluatedbySDFimagingDubinA,PozoMO,etal.Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudy.Critcare,2009,13(3):R925/8/202424微循环与血管活性药NEdoesnotimprovemicrocirculatorybloodflow5/8/202425微循环与血管活性药NEdoesnotimprovemicrocirculatorybloodflow5/8/202426微循环与血管活性药NEdoesnotimprovemicrocirculatorybloodflow1.NEdoesnotimprovemicrocirculataryperfusionfurtherincreaseMAPfrom65mmHg.2.ReductionsintheperfusedcapillarydensitiesfurtherincreaseMAPfrom65mmHg.结论：使用去甲升高MAP并不是改善感染性休克患者微循环的一个恰当方法，反而可能对患者有害。5/8/202427微循环与血管活性药TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshock16septicshockpatientsNEfrom0.18to0.25,0.35,0.41ug/kg.minMAPfrom60-70-80-90mmHgSDFimaging

ShamanJhanji,etal.CritcareMed2009;37:1961-19665/8/202428微循环与血管活性药TheeffectofincreasingdosesofNEontissueoxygenationandmicrovascularflowinpatientswithsepticshockMAP高于60-65mmHg不能改善感染性休克患者微循环增加NE对感染性休克患者微循环无明显影响

ShamanJhanji,etal.CritcareMed2009;37:1961-19665/8/202429微循环与血管活性药多巴胺对微循环的影响1.1Meier-HellmannA,BredleDL,SpechtM,SpiesC,HannemannL,ReinhartK(1997)Theeffectsoflow-dosedopamineonsplanchnicbloodflowandoxygenuptakeinpatientswithsepticshock.IntensiveCareMed23:31–371.2OlsonD,PohlmanA,HallJB(1996)Administrationoflow-dosedopaminetononoliguricpatientswithsepsissyndromedoesnotraiseintramucosalgastricpHnorimprovecreatinineclearance.AmJRespirCritCareMed154:1664–16702.MarikPE,MohedinM(1994)Thecontrastingeffectsofdopamineandnorepinephrineonsystemicandsplanchnicoxygenutilizationinhyperdynamicsepsis.JAMA272:1354–13575/8/202430微循环与血管活性药NG对微循环的影响5/8/202431微循环与血管活性药NGinsepticshockafterintravascularvolumeresuscitation8septicshockpatientsMAPwasgreaterthan60mmHgandCVPgreaterthan12mmHgafterinfusionofcrystalloidsandcolloids,andthelowestpossibledoseofdopamineNG：anintravenousloadingdoseof0·5mg,thensubsequentcontinuousinfusionof2mg/hOPS：usedtoproduceimagesofsublingualmicrocirculationLancet2002;360:1395-13965/8/202432微循环与血管活性药NGinsepticshockafterintravascularvolumeresuscitation5/8/202433微循环与血管活性药OPSimages5/8/202434微循环与血管活性药70个Severesepsis和septicshock患者充分复苏后给予硝酸甘油或安慰剂SDF评估舌下微循环主要终点：sublingualmicrocirculatorybloodflowofsmallvesselsCritCareMed2010;38:93-1005/8/202435微循环与血管活性药Microvascularvariablesovertime5/8/202436微循环与血管活性药TakeHomeMessage1.重视微循环检测2.s