急性循环衰竭-2015.ppt

Acute Circulatory Failure 急性循环衰竭急性循环衰竭 新医大一附院重症医学科新医大一附院重症医学科 于湘友于湘友“SOSD”是指抢救（salvage）抢救阶段通过补液、纠正低血压、吸氧和机械通气等措施挽救生命优化（optimization）优化阶段需评估患者还需要多少液体，维持多高的血压，监测哪些指标，不断调整，使患者血流动力学达到最佳状态 稳定（stabilization）稳定期的任务是预防器官功能衰竭降阶梯（de-escalation）逐渐停用血管活性药物，帮助患者排出体内过多的液体治疗。“SOSD”是休克分阶段治疗的指导思想。ACF与休克实际上是对同一疾病不同角度的表述。ACF指循环系统功能障碍导致组织器官灌注减少、氧输送不能满足机体代谢需要的病理生理状态。休克（shock）指ACF导致细胞氧利用不充足而产生的临床表现。因此，休克是ACF的临床表现。休克/ACF的常见临床表现包括低血压皮肤湿冷发绀神志改变和少尿等但其共同的病理生理学本质是细胞缺氧，这也是我们选择血乳酸（Lac）而非低血压作为主要诊断标准的原因。目前较为公认的理念为Lac1.0 mmol/L为正常范围，超过1.0 mmol/L认为异常，超过2.0 mmol/L即诊断休克/ACF。TREATMENT OF TREATMENT OF SHOCKSHOCKENHANCING ENHANCING PERFUSION/OXYGEN PERFUSION/OXYGEN DELIVERYDELIVERYOxygendelivery=HRXSVXHbXS0Oxygendelivery=HRXSVXHbXS022X1.34+0,0031xpaOX1.34+0,0031xpaO2 2CardiacCardiacoutputoutputArterialOArterialO2 2 contentcontentFluidsFluidsTransfuseTransfusePartially dependent Partially dependent on FIOon FIO2 2 and and pulmonary statuspulmonary statusInotropesInotropes CO=VasopressorsVasopressors(MAP-CVP)SVR休克的治疗原则 维持适当的血容量：维持适当的血容量：1.1.各种原因和类型的休克均伴有绝对性和（或）各种原因和类型的休克均伴有绝对性和（或）相对性循环容量不足。相对性循环容量不足。2.2.快速输液的容量取决于原发病因。失血性或感染快速输液的容量取决于原发病因。失血性或感染性休克常常使用较大的液体容量性休克常常使用较大的液体容量(1(1 2 L)2 L)；心源性；心源性休克时也可快速输注休克时也可快速输注100 100 200 ml 200 ml液体。液体。Fluid Challenge:WhyLVEDVCardiac Output/Stroke VolumeDynamic Parameters:WhyPreload ResponsivePreload ResponsivePreload Preload UnresponsiveUnresponsiveStroke VolumeLVEDVDynamic Parameters:WhyLVEDVStroke VolumeSVVSVVPreload ResponsivePreload ResponsivePreload Preload UnresponsiveUnresponsiveTIMETIMEBLOOD BLOOD VOLUMEVOLUMEColloidsColloidsCristalloidsCristalloidsWang et al.J Surg Res 50:163.1991Wang et al.J Surg Res 50:163.19913 major haemodynamic disorders in ICU patients3 major haemodynamic disorders in ICU patientsICUICU内主要的三个血流动力学紊乱现象内主要的三个血流动力学紊乱现象 hypovolemiahypovolemia血容量血容量血容量血容量过过过过低低低低 vascular tone vascular tone DepressionDepression血管血管血管血管紧张紧张紧张紧张度下降度下降度下降度下降 myocardial myocardial DepressionDepression心肌收心肌收心肌收心肌收缩缩缩缩力下降力下降力下降力下降It is important to assess It is important to assess the degree of each cardiovascular disorder the degree of each cardiovascular disorderfor applying the best therapy,for applying the best therapy,补补补补液液液液血管加血管加血管加血管加压药压药压药压药正性肌力正性肌力正性肌力正性肌力药药药药How to Perform Passive Leg Raising(PLR)Jabot J,Teboul JL,Richard C,et al.Passive leg raising for predicting fluid responsiveness:importance of the postural change.Intensive Care Med 2009;35:85-9045454545PLRSEMIRECPLRSUPINETime Frame(2 min)How to Perform Passive Leg Raising(PLR)Jabot J,Teboul JL,Richard C,et al.Passive leg raising for predicting fluid responsiveness:importance of the postural change.Intensive Care Med 2009;35:85-904545PLRSEMIRECConclusionPLRsemirec induces larger increase in cardiac preload than PLRsupine and may be preferred for predicting fluid responsivenessPiCCO2 Get the complete pictureDifferenzierung:Volumen/Katecholamine 1400200400600800100012002.55.07.5GEDI(ml/m2)CI(l/min/m2)Preload increased/Volume recruitmentInotropic drugsFrank-Starling curve容量最优化使心输出最大化容量达到最优以后，心输出的进一步提升需给予正性肌力药物前前负负荷荷 前前负负荷和荷和CO之之间间直接关直接关联联AB “Except on few occasions,the patient appears to die from the bodys response to infection rather than from it”.the Evolution of Modern Medicine(1904)炎症是机体的应激反应，炎症是机体的应激反应，称称之之为危险相关分子模式为危险相关分子模式（danger-associated danger-associated molecular patternsmolecular patterns，DAMPsDAMPs）。通通过抗炎治疗减少过抗炎治疗减少血管内皮损伤，是血管内皮损伤，是ACFACF治疗的治疗的重要手段。重要手段。Sir William Osler(1849-1919)SIRSSIRSCARSCARSSIRSSIRSCARSCARSMediators levels(Arbitr.Units)Mediators levels(Arbitr.Units)Pro-inflammatoryMediatorsAnti-inflammatoryMediators(inhibitors)Pro/Anti-inflammatoryMediatorsT i m eT i m eTNFIl-1PAFIl-10ActivationDepressionSIRSSIRS/CARSCARSSIRSCARST i m eT i m eT i m eT i m e乌司他丁乌司他丁乌司他丁乌司他丁Pro-inflammatoryPro-inflammatoryMediatorsMediatorsAnti-inflammatoryAnti-inflammatoryMediators(inhibitors)Mediators(inhibitors)Pro/Anti-inflammatoryPro/Anti-inflammatoryMediatorsMediators S.Sepsis and Ulinastatin:The Peak Concentration Hypothesis S.Sepsis and Ulinastatin:The Peak Concentration Hypothesis Intensive Care Med(2014)40:830-838 Intensive Care Med(2014)40:830-838TNFTNFIl-1Il-1PAFPAFIl-10Il-10ImmunohomeostasisImmunohomeostasisImmunohomeostasisImmunohomeostasisSepsis resucitation bundle（3小时内完成）（1）测定血乳酸，（2）应用抗生素前获得培养标本，（3）1小时内广谱抗生素应用；（4）在低血压和/或乳酸4mmol/L 时，1小时内启动液体复苏，补液量为30ml/kg晶体液。Septic shock bundle（6小时内完成）（1）初始液体复苏后仍存在低血压患者应使用缩血管药物维持 MAP 65mmHg。（2）仍持续动脉低血压者，和/或初始血乳酸4mmol/L者:CVP8mmHgSCVO270%