休克与血流动力学监测课件课件.ppt

1、休克与血流动力学监测休克与血流动力学监测pptppt课件课件2022-11-152PUMCH2022-11-159PUMCH2022-11-1510PUMCH2022-11-1511PUMCH2022-11-1512PUMCH2022-11-1513PUMCH14西安交大红会医院15PUMCH ICU瞬瞬间间即即时时2022-11-1516PUMCH2022-11-1517PUMCHElastic band demonstrating the concept of unstressed volume.There is no tension in the wall of the elastic

2、until it isstretched beyond the resting volumeCrit Care Med 1998;26:1061-10642022-11-1518PUMCHBritish Journal of Anaesthesia 94(6):74855(2005)2022-11-1519右室舒张末容积右室舒张末容积(RVEDV/CEDV)(pulmonary artery thermodilution)肺动脉漂浮导管左室舒张末面积左室舒张末面积(LVEDA)(echocardiography)超声心动图Global end-diastolic volume(GEDV)全心舒

3、张末容积全心舒张末容积(transpulmonary thermodilution)胸腔内血液容积胸腔内血液容积(ITBV)(thermo-dye transpulmonary dilution)热染料双指示剂法容量指标容量指标前负荷及评估容量反应性2022-11-1520PUMCH2022-11-1521PUMCH矛盾矛盾!?2022-11-1522PUMCH Homodynamic Evaluation and Monitoring in the ICU CHEST,2007,132,2020-20292022-11-1523PUMCHIntensive Care Med(2007)33:

4、575590Vincent JL,Weil MH(2006)Fluid challenge revisited.Crit Care Med 34:133313372022-11-1524Crit Care Med 2006 Vol.34,No.5PLR as a“reversible volume challenge”2022-11-1526PUMCH2022-11-1527PUMCH2022-11-1529PUMCH2022-11-1530PUMCHNiCOCCOLiDCOPiCCOMonitorPAC2022-11-1531PUMCH2022-11-1532PUMCH2022-11-153

5、3PUMCH2022-11-1534PUMCHSwan-Ganz导管2022-11-1535PUMCH2022-11-1536PUMCH2000年前后年前后几乎被打几乎被打倒倒2022-11-1537PUMCH最近：不最近：不好也不坏好也不坏2022-11-1538PUMCH更公正评价借专家一句话！更公正评价借专家一句话！2022-11-1539PUMCHt sP mm Hg心脏每搏输出量心脏每搏输出量SVSV不同的不同的专有计算公式专有计算公式2022-11-1540PUMCH经肺热稀释方法脉搏波形分析PiCCO最经典最经典内容最丰富全面内容最丰富全面2022-11-1541PUMCHPiC

6、CO中心静脉注射右心左心肺PiCCO导管插在股动脉内2022-11-1542PUMCH静脉注射静脉注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDVSwan-Ganz热稀释热稀释 测量位置测量位置 PiCCO动脉热稀释动脉热稀释测量位置测量位置2022-11-1543PUMCHPiCCOPiCCO的专有公式的专有公式“Beat to beat”连续测量连续测量CO曲线下曲线下面积面积曲线曲线形态形态PCCO=cal HR SystoleP(t)SVR+C(p)dPdt()dt主动脉主动脉顺应性顺应性心率心率校正系数校正系数（经肺热稀释方（经肺热稀释方法得到）法得到）2022-1

7、1-1544PUMCHFLO-Trac/Vigileosystem简单但指标少LiDCO需要特殊物质2022-11-1545PUMCH2022-11-1546PUMCH2022-11-1547PUMCH2022-11-1548PUMCH血流动力学评估全面全面无创无创2022-11-1549PUMCH尚不成熟尚不成熟2022-11-1550PUMCH2022-11-1551PUMCH2022-11-1552PUMCH2022-11-1553PUMCH2022-11-1554PUMCH2022-11-1555PUMCHThere was an approximately 11%decrease l

8、ikelihood of mortality for each 10%increase in lactate clearance.Patients with a lactate clearance 10%had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate(p .007).2022-11-1556PUMCHArterial and venous oxygen saturations in various vascular regions202

9、2-11-1557PUMCHindicator of the 2022-11-1558PUMCH2022-11-1559PUMCH2022-11-1560PUMCH2022-11-1561PUMCHLamia B,Monnet X,Teboul JL.Meaning of arterio-venous PCO2 difference in circulatory shock.Minerva Anestesiol.2006 Jun;72(6):597-604.P P(cv-a)(cv-a)COCO2 2-a useful tool-a useful tool容量-流量评价2022-11-1564

10、PUMCH临床评估非常重要临床评估非常重要 皮肤温度皮肤温度 外周灌注指数外周灌注指数2022-11-1565PUMCH2022-11-1566PUMCH正正 常常Septic ShockSeptic ShockMale 47 YMale 47 YMAP 68 mmHg,MAP 68 mmHg,lactate 3.6 mEq/Llactate 3.6 mEq/Ldopa 20,ne 0.13dopa 20,ne 0.13 2022-11-1567PUMCH血流动力学监测其他重要内容血流动力学监测其他重要内容n心肌收缩性心肌收缩性 -来源于来源于PiCCO/PiCCO/心脏超声心脏超声n后负荷后

11、负荷n血管外肺水血管外肺水/肺血管通透性指数肺血管通透性指数 -EVLW/PVPI-EVLW/PVPI2022-11-1568PUMCHContractility is a measure for the performance of the heart muscle 心肌收缩性是流量监测心肌收缩性是流量监测COCO的必须补充的必须补充Contractility parameters of PiCCO technology:-dPmx(maximum rate of the increase in pressure)-GEF(Global Ejection Fraction)-CFI(Card

12、iac Function Index)心肌收缩性心肌收缩性 kgkg2022-11-1569PUMCH来源于脉搏轮廓分析的心肌收缩性参数dPmx=maximum velocity of pressure increasedPmx代表了代表了左心室压力左心室压力上升的最大速度上升的最大速度心肌收缩性心肌收缩性 2022-11-1570PUMCH 反映全心收缩性反映全心收缩性GEF=Global Ejection Fraction来源于热稀释法的心肌收缩性参数来源于热稀释法的心肌收缩性参数4 x SVGEF=GEDVLALVRARV心肌收缩性心肌收缩性2022-11-1571PUMCH与与 GEF

13、 相似相似 全心收缩性参数全心收缩性参数CICFI=GEDVI心肌收缩性心肌收缩性来源于经肺热稀释法的心肌收缩性参数来源于经肺热稀释法的心肌收缩性参数CFI=Cardiac Function IndexCFI=Cardiac Function Index心脏功能指数心脏功能指数2022-11-1572PUMCH 心血管状态信息的重要心血管状态信息的重要 控制容量和血管活性药物应用的重要决定因素控制容量和血管活性药物应用的重要决定因素(MAP CVP)x 80SVR=CO后负荷后负荷SVR=Systemic Vascular ResistanceMAP=Mean Arterial Pressur

14、eCVP=Central Venous PressureCO=Cardiac Output80=Factor for correction of units2022-11-1573PUMCH血流动力学监测的别样选择血流动力学监测的别样选择-来源于来源于 PiCCO PiCCO 技术的技术的EVLWEVLW和和PVPIPVPI血管外肺水血管外肺水 Extravascular Lung Water（EVLW）肺血管通透性指数肺血管通透性指数 Pulmonary vascular Permeability(PVPI)2022-11-1574PUMCHITTV ITBV=EVLWExtravascular Lung Water(EVLW)Extravascular Lung Water(EVLW)的计算的计算2022-11-1575PUMCHPVPI肺血管通透性指数 区分肺水肿类型区分肺水肿类型 静水压增高型静水压增高型 通透性增高型通透性增高型EVLWPVPI=PBVPBVEVLW 长轴、圆周收缩COPAWP液体治疗强心治疗滴定治疗2022-11-1577PUMCHICUICU医生名言医生名言Chest.2007;132:2020-2029 2022-11-1578PUMCH79 结束语结束语