急危重症患者的血流动力学监测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,第二级,第三级,第四级,第五级,*,*,急危重症患者的血 流 动 力 学 监 测,北京协和医院重症医学科,陈秀凯,NiCO,CCO,LiDCO,PiCCO,Monitor,PAC,血流动力学理念,分析作用力、流量、容积三方面因素,分析循环系统中血液运动的规律性,定量、动态、连续的测量和分析,反馈性用于对病情发展的了解和临床治疗的指导,血流动力学理论的理解是基础,STARLING,定律与,ABC,理论,PAWP,CI,A,B,C,D,血流动力学监测的常用手段,神志精神状态,心率血压,尿量,CVP,ScVO2 OR SVO2,PAWP CO GEDI SVRI EVLWI,血流动力学监测的目标,最终目标：维持满意的,CO,血流动力学监测的直接目的,调整循环中的,3,个主要因素,前负荷,需不需输液,输多少液,能不能输液,后负荷,血管活性药,心肌收缩力,正性肌力药的使用,病例,女,28,岁,“,腹痛、发热,3,天 诊所静脉输入诺氟沙星 腹痛、皮疹,3,天,”,急诊尿常规提示尿路感染 停用原药，改为西力欣 病情迅速恶化,MODS,MAP40mmHg HR,130bpm,频发室早,呼吸,(,SpO290,%;,窒息,),恶心呕吐,昏迷,(GCS,评分,5,分）,拟诊：,过敏性休克,肾上腺素泵入、地塞米松静脉注射,PUMCH_ICU,早期目标指导治疗,BP 100/70 mmHg(E1.1ug/kg/min NE 0.5ug/kg/min),收入,ICU,Rivers E,Nguyen B,Havstad S,et al.Early goal-directed therapy in the treatment of severe sepsis and septic shock.N Engl J Med 2001,345:1368-1377,入室,入,ICU,时情况,BP 100/70 mmHg(E1.1ug/kg.min NE 0.5ug/kg.min),CVP14mmHg,VT400ml;f16bpm PEEP8cmH,2,O FiO,2,100%SpO,2,95%,心肌酶,CK384U/L CKMB25.7ug/L cTnI 21.24ug/L,PH7.18;,PCO,2,29.8 mmHg PO,2,104mmHg;,cLac18mmol/L,;BE-13.7mmol/L;,ScVO,2,61%,入室,急诊,CVP14mmHg,低血容量性休克或容量不足？,还需继续补液吗？,PEEP8cmH,2,O FiO,2,100%SpO,2,95%,还能继续补液吗？,心肌酶,CK384U/L CKMB25.7ug/L cTnI 21.24ug/L,心源性休克？,肾上腺素加量？,加多巴酚丁胺？,感染性休克？,有证据吗,去甲肾上腺素加量？,过敏性休克？,肾上腺素加量？,进一步的监测？怎么监测？,本病例监测的主要要求,了解前负荷状态,心功能或心肌收缩力,外周血管的阻力,血管外肺水,PiCCO,的技术原理,PiCCO,技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管,:,a.,经肺热稀释技术,b.,动脉脉搏轮廓分析技术,弹丸注射,肺,PiCCO,导管,如：股动脉,经肺热稀释技术需要在中心静脉注射冷盐水,(8C),或室温盐水,(100%,时,胸片才会发生改变,Bongard FS,Surgery 1984,胸片对,EVLW,的改变并不敏感,Helperin BD,Chest 1984确定患者是否符合,ARDS,影像学表现时,医生之间存在非常明显的差异,Rubenfeldet al,Chest 1999,血流动力容量管理决策树,CI(l/min/m,2,),GEDI(ml/m,2,),or,ITBI(ml/m,2,),ELWI*(ml/kg),(slowly responding),3.0,700,850,700,700,850,700,850,ELWI(ml/kg),GEDI(ml/m,2,),or,ITBI(ml/m,2,),CFI(1/min),or,GEF(%),10,10,10,10,10,10,V+,V+!,V+!,V+,Cat,Cat,OK!,V-,700,850,700-800,850-1000,4.5,25,5.5,30,4.5,25,700-800,850-1000,Cat,5.5,30,700,850,700-800,850-1000,700-800,850-1000,10,10,10,10,V-,V,+,=,增加容量,(!=,慎重,),V,-,=,减少容量,Cat=,儿茶酚胺心血管药物,*SVV,只能用于没有心律失常的完全机械通气病人,700,850,10,Optimise to,SVV*(%),10,10,10,测量结果,目标,治疗,1.,2.,不承诺完全合乎您的临床实践,10,10,10,10,PiCCO,参数分类,容量,/,前负荷参数：,胸腔内血容积,ITBV,全新舒张末期容积,GEDV,每搏量变异,SVV,脉压变异,PVV,流量,/,后负荷参数：,心输出量,CO,每搏量,SV,系统血管阻力,SVR,心率,HR,动脉压,AP,心肌收缩力参数：,全心射血分数,GEF,心功能指数,CFI,左心室收缩力指数,dPmx,肺相关参数：,血管外肺水,EVLW,肺血管通透性指数,PVPI,PiCCO,简单的建立方法,原上腔静脉连接,注射液温度探头容纳管（,T,型管）和,注射液温度电缆,穿刺股动脉,连接,PiCCO,机器或插件,PiCCO,plus,连接示意图,中心静脉导管,注射液温度探头容纳管（,T,型管）,动脉热稀释导管,注射液温度电缆,PULSION,一次性压力传感器,PCCI,AP,13.03 16.28,TB37.0,AP 140,117 92,(CVP)5,SVRI 2762,PC,CI 3.24,HR 78,SVI 42,SVV 5%,dPmx 1140,(GEDI)625,温度测量电缆,压力电缆,血流,动力,学,HR,BP,CI,EVLWI,CVP,GEDVI,SVRI,组织,代谢,Lac,BE,ScvO,2,U(ml/h),血管,活性,药物,NE,E,DOBU,2025/4/13 周日,治疗：,4.,准备行,CVVH,1.,尝试扩容,-,胶体约,200ml,2.,调整血管活性药,1h,148,123/802.32,16,17,650,3000,17,-13.7,63%,0,0.5,1.1,0,PUMCH_ICU,3.,给予激素,-,氢化可的松,100mg,1h,血流,动力,学,HR,148,BP,123/80,CI,2.32,EVLWI,16,CVP,17,GEDVI,650,SVRI,3000,组织,代谢,Lac,17,BE,-13.7,ScvO,2,63%,U(ml/h),0,血管,活性,药物,NE,0.5,E,1.1,DOBU,0,2025/4/13 周日,利尿,强心,3h,140,98/56,2.38,20,21,830,1800,18,-18,65%,0,0,1.0,3,PUMCHICU,1h,3h,血流,动力,学,HR,148,140,BP,123/80,98/56,CI,2.32,2.38,EVLWI,16,20,CVP,17,21,GEDVI,650,830,SVRI,3000,1800,组织,代谢,Lac,17,18,BE,-13.7,-18,ScvO,2,63%,65%,U(ml/h),0,0,血管,活性,药物,NE,0.5,0,E,1.1,1.0,DOBU,0,3,2025/4/13 周日,5h,148,117/71,2.71,13,13,620,2200,15,-2,71%,40,0,0.8,8,PUMCH_ICU,41,岁，男性,栓下肢间隙综合征,T 39,HR 102/min;,BP 65/50 mmHg,入院第一天,15 L,液体复苏,Saugel,et al.Scandinavian Journal of Trauma,Resuscitation and Emergency Medicine,2010,18,:38,血流动力学不等于各种导管与设备,血流动力学无处不在,血流动力学监测是连续的过程,监测的方法不等于血流动力学,没有导管的监测需要对有导管监测的理解,入,ICU,前,男，,56,岁，,2010-4-8,以急性白血病入院,4-12,日开始化疗,4-13,至,19 WBC 2.04-0.19X10,9,/L,NEUT 0.77-00010,9,/L,PLT 3-25 X10,9,/L,4-20,日,4,：,20,寒战，,T39 BP60/30mmHg,10,：,51,寒战、发热、一过性意识丧失,头颅,CT,未见颅内出血病灶,留置右股静脉导管,快速补液扩容,DOPA,、,NE,泵入,美罗培南,+,万古霉素,入室情况,4-20 19,：,00,呼吸困难,气管插管，转入,ICU,全身广泛皮疹及出血点，口鼻及股静脉穿刺点渗血,血压,103/60mmHg(Dopa16 NE 1.6ug/kg.m),WBC0.37X10,9,/L,，中性比为,0,，,Hgb:4.5g/L,PLT 8X10,9,/L,血气,PH7.34 PCO,2,23mmHg,PO,2,106mmHg,Lac 7.6mmol/L,感染性休克合并低血容量性休克,两种休克的复苏无有创的血流动力学监测,PLT 8X10,9,/L,，,APTT,延长,3,倍左右，补充,PLT,和血浆效果欠佳,锁骨下、颈静脉穿刺风险大,放置,PiCCO,导管风险大,血压、心率、尿量、乳酸、心肌酶,血流动力学改善,至,4,月,22,日,6:00,RBC12U,血浆,1200ml,血小板,2U,凝血酶原复合物,1200U,纤维蛋白原,3000mg,白蛋白,30g,停用,NE,及,DOPA,BP110/65mmHg,Lac 2.0mmol/L,新近的研究,CFI,等参数临床意义的验证,被动抬腿试验等判断容量状态和容量反应性的方法的监测,监测大循环与微循环的关系,AKI,、,ARDS,等脏器功能不全的防治中血流动力学的监测与调整,PiCCO,与,PAC,及新研发的无创监测手段的对比,CFI,的临床意义,Jabot,J.et.al.,Crit Care Med 2009;37:2913,2918,Jabot,J.et.al.,Crit Care Med 2009;37:2913,2918,CFI,的临床意义,passive leg raising(PLR)and volume expansion,To find the relationship between macrocirculation and microcirculation,Patients,severe sepsis or septic shock,25 mechanically ventilated,eligible for VE,in the first 24 h of their admission,Pottecher.J,Deruddre.S,，,Teboul Jean-Louis.,Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients.,Intensive Care Med,Conclusion,In preload-responsive patients with severe sepsis and septic shock patients during the first 24 h of their ICU stay,both,PLR and VE improved sublingual microcirculatory perfusion.,At the level of VE used in the study,changes in microcirculation were,not,explained by changes in,rheologic factors,or changes in,MAP,.,Different,mechanisms,were implicated in the regulation of microvascular perfusion and in the changes in CO.,Assessment of RBF responsiveness to fluid or vasopressor challenges,Deruddre S.Renal arterial resistance in septic shock.Intensive Care Med 2007;33:1557,1562.,E,ffects of increasing,MAP,with,NE,on the renal,RI,University teaching hospital,11 patients with septic shock,MAP at successively 65,75,and 85 mmHg (NE titrated),Hemodynamic parameters and renal function variables,Doppler ultrasonography to assess the renal resistive index,Deruddre S.Renal arterial resistance in septic shock.Intensive Care Med 2007;33:1557,1562.,RESULTS,Deruddre S.Renal arterial resistance in septic shock.Intensive Care Med 2007;33:1557,1562.,Copyright 2009 American College of Cardiology Foundation.Restrictions may apply.,Mullens,W.et al.J Am Coll Cardiol 2009;53:589-596,Relative Contributions of CVP and CI to GFR at Time of PAC Removal,Copyright 2009 American College of Cardiology Foundation.Restrictions may apply.,Mullens,W.et al.J Am Coll Cardiol 2009;53:589-596,ROC Curves for CVP and CI on Admission for the Development of WRF,Copyright 2009 American College of Cardiology Foundation.Restrictions may apply.,Mullens,W.et al.J Am Coll Cardiol 2009;53:589-596,Prevalence of Worsening Renal Function During Hospitalization According to Categories of Admission CVP,CI,SBP,and PCWP,无创的方法,结论,血流动力学监测有助于改变临床决策,肺动脉漂浮导管使用日益减少,PiCCO,操作简便,持续测定,CO,评价前负荷及对扩容的反应,评价血管外肺水,没有导管不等于没有血流动力学,合适的监测可使器官支持更进一步,谢谢各位！,