血流动力学监测与心脏超声.pptx

指南解读：血流动力学监测与心脏超声（CUS）血流动力学监测与心脏超声1/331.SLAX:肋下长轴切面2.SIVC:肋下下腔静脉切面3.PLAX：胸骨旁长轴切面4.PSAX:胸骨旁短轴切面5.A4CH:心尖四腔心切面CUS最惯用五个切面血流动力学监测与心脏超声2/33Antonelli M,et al.Intensive Care Med.;33(4):575-90.Cecconi M,et al.Intensive Care Med.;40(12):1795-815.25位教授组成团体12位教授组成团体血流动力学监测与心脏超声3/33Five Specific Questions(1)What are the epidemiologic and pathophysiologic features of shock in the intensive care unit?(2)Should we monitor preload and fluid responsiveness in shock?(3)How and when should we monitor stroke volume or cardiac output in shock?(4)What markers of the regional and microcirculation can be monitored,and how can cellular function be assessed in shock?(5)What is the evidence for using hemodynamic monitoring to direct therapy in shock?血流动力学监测与心脏超声4/33 ConsensusRecommended against常规使用常规使用:(1)the pulmonary artery catheter in shock 休克患者使用肺动脉导管(2)static preload measurements used alone to predict fluid responsiveness 仅仅使用静态前负荷测量方法来预测液体反应性 血流动力学监测与心脏超声5/33Main differences血流动力学监测与心脏超声6/33Blood pressure statementsICM ICM 血流动力学监测与心脏超声7/33Fluid responsiveness statementsICM ICM 血流动力学监测与心脏超声8/33ICM 血流动力学监测与心脏超声9/33Hemodynamic monitoringICM 血流动力学监测与心脏超声10/33Cecconi M,et al.Intensive Care Med.;40(12):1795-815.血流动力学监测与心脏超声11/33Main new statements(1)Statements on individualizing blood pressure targets;(2)Statements on the assessment and prediction of fluid responsiveness;(3)Statements on the use of echocardiography and hemodynamic monitoring.血流动力学监测与心脏超声12/33 ConsensusIdentification of the type of shock We recommend further hemodynamic assessment(such as assessing cardiac function)to determine the type of shock if the clinical examination does not lead to a clear diagnosis.Best practiceWe suggest that,when hemodynamic assessment is needed,echocardiography is the preferred modality to initially evaluate the type of shock as opposed to more invasive technologies.Recommendation.Level 2;QoE(B)血流动力学监测与心脏超声13/33Rationale:Context analysis(trauma,infection,chest pain,etc.)and clinical evaluation which focuses on skin perfusion and jugular vein distension usually orient diagnosis to the type of shock,but complex situations may exist(e.g.cardiac tamponade in a patient with trauma or septic shock in a patient with chronic heart failure)in which a diagnosis is more difficult.血流动力学监测与心脏超声14/33Vincent JL,et al.N Engl J Med.;369(18):1726-34.血流动力学监测与心脏超声15/33Manifestation on Echo梗阻性心包填塞血流动力学监测与心脏超声16/33FOCUS测量很快速，即使是初学者，普通时间也小于3min；FOCUS应该被列入重症培训项目中去。Beraud AS,et al.Crit Care Med.;41(8):e179-81.血流动力学监测与心脏超声17/33IC-FoCUS 国际聚焦心脏超声循证提议Via G,et al.Journal of the American Society of Echocardiography.;27(7):683 e1-e33.血流动力学监测与心脏超声18/33名称确认：聚焦心脏超声（FoCUS）重点用于生命支持评定、复苏评定等。血流动力学监测与心脏超声19/33FoCUS statementShock and Hemodynamic Instability43.In the setting of shock,FoCUS accurately assesses global LV systolic function,when compared with comprehensive standard echocardiography.1A:Strong Recommendation,with Very Good Agreement;Level A Evidence44.In the setting of shock,FoCUS narrows the differential diagnosis.1A:Strong Recommendation,with Very Good Agreement;Level A Evidence血流动力学监测与心脏超声20/33 ConsensusMonitoring cardiac function and cardiac outputEchocardiography can be used for the sequential evaluation of cardiac function in shock.Statement of fact We recommend that less invasive devices are used,instead of more invasive devices,only when they have been validated in the context of patients with shock.Best practice血流动力学监测与心脏超声21/33Rationale:Echocardiography can help the ICU physician in three ways:(1)better characterization of the hemodynamic disorders;(2)selection of the best therapeutic options(intravenous fluids,inotropes and ultrafiltration);(3)assessment of the response of the hemodynamic disorders to therapy.VTI,LVEF,LVEDA,RVEDA,E/A ratio血流动力学监测与心脏超声22/33Lheritier G,et al.Intensive Care Med.;39(10):1734-42.急性肺心病 ACP:RVEDA/LVEDA 0.6,左室短轴可见室间隔矛盾运动卵圆孔未闭 PFO：左右心房之间可见右向左分流 结果：22.5%机械通气患者患ACP，15.5%患者患PFO，4.5%患者同时患ACP和PFO。血流动力学监测与心脏超声23/33FoCUS statementShock and Hemodynamic Instability血流动力学监测与心脏超声24/33FoCUS statementEstimating CVP,Diagnosing Hypovolemia,and Predicting Fluid Responsiveness血流动力学监测与心脏超声25/33shock subjectcontrol subject Yanagawa Y,et al.J Trauma.;58(4):825-9.IVC直径与创伤患者低血容量相关血流动力学监测与心脏超声26/33FoCUS statement血流动力学监测与心脏超声27/33在怀疑血容量不足自主呼吸患者中，在PLR前后使用FoCUS测量心输出量能够准确地识别出患者是否存在血容量不足以及能否获益于补液Maizel J,et al.Intensive Care Med.;33(7):1133-8.血流动力学监测与心脏超声28/33Preau S,et al.Crit Care Med.;38(3):819-25.Change(%)=100%*(post-VE value baseline 2 value)/baseline 2 value.Respond:change 15%PLR,passive leg raising;VE,volume expansionPP,radial pulse pressure;SV,stroke volume;VF,peak velocity of femoral artery flow血流动力学监测与心脏超声29/33血流动力学监测与心脏超声30/33FoCUS statement血流动力学监测与心脏超声31/33Summary 鉴于其无创性和便捷性，FoCUS在重症患者评定和治疗中占据越来越重要地位；近年来，FoCUS在一些非心脏疾病判别与评定中也展现出价值，尤其是在血流动力学监测和休克类型判别上;伴随重症医学发展，FoCUS应该成为每个重症医师必备技能。血流动力学监测与心脏超声32/33Thank you for your attention!血流动力学监测与心脏超声33/33