血管加压素和危重病优质PPT课件.ppt

*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,血管加压素和危重病,Contents,C,ase,report,T,he,picture,of,AVP,AVP-R,and,antagonists,R,elated,agents,Clinical,use,Case,1,X,X,M,60,y,r,s,服,DDV,300ml,24,小时 转入我院,ICU,被发现时昏迷,大汗,瞳孔针尖样,入当地医院气管插管,MV,后洗胃,4,h,shock,DOPA,转入时,20ug/kg/min,2,4,小时应用阿托品,45mg,Case,report,Case,2,X,X,F,3,1,y,r,s,足月经阴分娩后阴道出血 分娩后,1.5,小时,CPR,CPR5,分钟成功,分娩后,3,小时 子宫全切术,分娩后,5,小时转入,ICU:,七窍出血,持续低血压,7,小时,NE2-4,DOPA10-20,AVP,2-8U/h,入,ICU7,小时,F,FP,3200ml,冷沉淀,20U,RBC32U,血小板,1,人份,问题,Why?,When?,Who,?,Dose?,AVP,合成,释放,代谢,合成,:,视上核和室旁核,储存,:,垂体后叶,代谢,:,肝脏和肾脏,半衰期,10-35min,受体,分布,作用,V1a,血管,血管平滑肌,肝脏,肾小球出球小动脉,收缩血管,促进肝糖元分解,增加血小板聚集,增加肾小球灌注压,GFR,增加,V2,肾脏,肾集合管,促进水重吸收,抗利尿,V3(,V,1b),垂体,垂体,刺激,ACTH,释放,加压素受体拮抗剂,V2R,Antagonist,(Tolvaptan,托伐普坦,商品名,-,苏麦卡,satavaptan,lixivaptan),V,1a,-,V2,R,Antagonist,(conivaptan),肝硬化腹水,心衰,SIADH,Related,agents,加压素,(vasopressin),血管加压素 精氨酸加压素,(AVP),抗利尿激素,(ADH),抗利尿作用,/,血管平滑肌收缩作用,特利加压素,(terlipresssin,t-GLVP),一种新型人工合成血管加压素,垂体后叶素,含催产素和加压素,收缩子宫,/,抗利尿,/,升高血压,猪牛羊脑神经垂体中提取,Related,agents,鞣酸加压素,(,长效尿崩停,),去氨加压素,(,弥凝,),抗利尿作用,/,血管加压作用比,约为加压素的,1200-3000,倍,Clinical use.,中枢性尿崩症,CDI,CPR,Septic,shock,AVP and CPR,Because the effects of,A,VP have not been shown to differ from those of,E,in,C,A,1 dose of,A,VP 40 units IV/IO may replace either the,1,st or,2,nd dose of,E,in the treatment of,C,A(Class IIb,LOE A).,加压素,40u,1,次,I,V/,I,O,可用于替代,CPR,时首剂或第二剂副肾素,The,introduction,of,AVP,AVP improves vital organ blood flow during closed-chest cardiopulmonary resuscitation in pigs,Circulation,.1995;91:215221,AVP and shock,A,VP 0.03 u/min can be added to NE with intent of either raising MAP or decreasing NE dosage(UG).,在,NE,应用的基础上,感染性休克病人可加用,AVP,0.03u/min,以进一步提高,MAP,或减少,NE,用量,AVP and shock,Low dose,A,VP is not recommended as the single initial vasopressor for treatment of sepsis-induced hypotension,不推荐小剂量加压素作为脓毒症性低血压单独的初始升压药物,AVP and shock,AVP doses,0.03-0.04 u/min should be reserved for salvage therapy(failure to achieve adequate MAP with other vasopressor agents)(UG).,高剂量,AVP(0.03-0.04u/min),可用于脓毒性休克病人其他升压药物效果不满意的补救性治疗,Rationale,relative vasopressin deficiency,AVP concentrations are elevated in early S.,Shock,but decrease to normal range in the majority of patients between 24 and 48 hrs as shock continues.,In the presence of hypotension,vasopressin would be expected to be elevated,Timing,The VASST trial,an RCT:,comparing,N,E to,N,E+AVP 0.03 U/min,no difference in outcome,An a priori defined subgroup analysis demonstrated that survival among patients receiving 15 g/min,N,E at the time of randomization was better with the addition of,A,VP;,N Engl J Med,2008;358:877887,Adverse,effects,Higher doses of,vasopressin,have been associated with cardiac,digital,and splanchnic ischemia and,Should be reserved for situations where alternative vasopressors have failed,Crit Care Med,2003;31:13941398,Children?,A,VP levels,are reduced in adults with septic shock,A,VP levels,seem to vary extensively in children,no,recommandation,Thanks for your atention,