微循环与血管活性药课件

,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,*,Sepsis微循环与血管活性药,奚佳瑞,2011年2月,Sepsis微循环与血管活性药奚佳瑞,1,引言,Sepsis：,疑问：临床上血流动力学稳定、氧传递指标等均可，但依然进展、乳酸升高？,早期亦已存在微循环功能障碍！,引言Sepsis：,2,引言,微循环：如此重要、关键,应成为危重患者复苏中的一个关键指标,但：,传统的评价指标难以准确评价微循环！,引言微循环：如此重要、关键,3,主要问题：,1. 有什么新的方法监测微循环？,2. 现有血管活性药物微循环的影响如何？,主要问题：1. 有什么新的方法监测微循环？,4,微循环的结构,直径500m2,组成：微动脉，后微动脉，毛细血管前括约肌，真毛细血管、通血毛细血管、动静脉交通支、微静脉,微循环的结构直径300um的血管,5,微循环的功能及分类,1.迂回通路：物质交换，交替开放（又称营养通路）,2.直捷通路 ：不进行物质交换，血液快速回流，骨骼肌多见,3.动静脉短路：不进行物质交换，皮肤多见,微循环的功能及分类 1.迂回通路：物质交换，交替开放（又称,6,微循环与血管活性药课件,7,Sepsis时微循环的改变,1994年，Lam C等对血压稳定的鼠sepsis微循环活体显微镜在体观察，发现sepsis时：,1.灌注毛细血管密度减少，血流停止的毛细血管数增加；,2.灌注毛细血管空间分布不均，平均毛细血管间距增加,2002年，De Backer等利用OPS成像观察sepsis舌下微循环，发现：,1.微血管密度显著减少，血流停滞和血流灌注间断的小血管比例增加；,2.各区域间灌注血管的变异系数明显大于健康志愿者,De Backer D,CreteurJ,PreiserJC,etal.Microvascular blood flow is altered in patients with sepsis. AM J Respir Crit Care Med,2002,166:98-104,Sepsis时微循环的改变1994年，Lam C等对血压稳定,8,OPS图像,9,Sepsis时微循环的改变,特征：,1.a decrease in capillary density,2.an increase in,heterogeneity,of perfusion with non-perfused in close vicinity to well-perfused capillaries,后果？,Sepsis时微循环的改变特征：,10,Tissues tolerate better a homogeneous decrease in blood flow better than a heterogeneous one,Daniel De Backer,，,Gustavo Ospina-Tascon,，et al. Intensive Care Med (2010) 36:18131825.,Tissues tolerate better a homo,11,微循环与血管活性药课件,12,How to evaluate the microcirculation,Intensive Care Med (2010) 36:18131825.,How to evaluate the microcircu,13,Nailfold videocapillaroscopy,The first method used at the bedside,the nailfold area is very sensitive to changes in temperature: one can control ambient but not body temperature.,Peripheral vasoconstriction can also occur during chills and acute circulatory failure,Of limited use in critically ill patients.,Nailfold videocapillaroscopyTh,14,Laser Doppler,Main limitation：measures flow in a variable volume of tissue，unable to detect it in individual vessels,Sampling volume:0.5 and 1 mm3, about 50 vessels,Cannot show the,heterogeneity,Laser DopplerMain limitation：m,15,SvO2,Venous O2 saturation can be high or low for the same degree of microvascular shuntingcan be misleading,Several studies have shown that measuring SvO2 does not provide much,information about microvascular alterations,-,Podbregar M, Mozina H .Skeletal muscle oxygen saturation does not estimate mixed venous oxygen saturation in patients with severe left heart failure and additional severe sepsis or septic shock. Crit Care2007,11:R6,Marik PE, Bankov A ,Sublingual capnometry versustraditional markers of tissue oxygenation in critically ill patients.,Crit Care Med 2003,31:818822,SvO2Venous O2 saturation can b,16,Gastric tonometry,A gastric PCO2 gap above 20 mmHg discriminated survivors from non-survivors,-Levy B, Gawalkiewicz P. Crit Care Med 2003, 31:47448,Gastric PCO2 gap-mostly reflects gut mucosal microcirculation-In sepsis, no correlation between the gastric PCO2 gap and total splanchnic perfusion,Duodeno-gastric reflux and feeding can,interfere,Gastric tonometryA gastric PCO,17,Lactate,Time lag-Cannot detect alterations in microvascular perfusion before they are associated with cellular hypoxia,LactateTime lag-Cannot d,18,OPS/SDF,OPS成像：正交偏振光谱成像orthogonal polarization spectral imaging,原理：利用血细胞对偏振入射绿光产生消偏振光散射和对正偏振光的成像特征，能在皮下0.5mm深度内产生高清晰度和高分辨率的成像。,局限性：敏感性偏差；需具备高能光源，难以应用到临床。,OPS/SDFOPS成像：正交偏振光谱成像orthogona,19,OPS/SDF,SDF成像：旁流暗场成像，sidestream dark-field，2007年开始应用于临床,优点：,更加清晰,所需能量小，可以方便的使用电池床边操作,OPS/SDFSDF成像：旁流暗场成像，sidestream,20,SDF image,SDF image,21,OPS/SDF,Advantage:,1. visible,2. different variables can be observed and be measured,- vascular density, heterogeneity of perfusion, microvascular blood flow,The consensus advises reporting of PVD,PPV, MFI and heterogeneity index, in order to describe the functional perfusion of the microcirculation.,-,How to evaluate the microcirculation: report of a round table conference,Critical Care,2007,11,:R101,OPS/SDFAdvantage:,22,血管活性药物对微循环的影响,Vasopressors: Norepinephrine, Epinephrine, Vasopressin,Inotropes: Dopamine ,Dobutamine,Vasodilators: Nitroglycerin, Prostacyclin,血管活性药物对微循环的影响Vasopressors: Nor,23,NE does not improve microcirculatory blood flow,20 septic shock patients,Basal measurement of MAP 65mmHg,NE was titrated to reach a MAP of 75mmHg,then 85mmHg,Sublingual microcirculation was evaluated by SDF imaging,Dubin A, Pozo MO, et al. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit care,2009,13(3):R92,NE does not improve microcircu,24,NE does not improve microcirculatory blood flow,NE does not improve microcircu,25,NE does not improve microcirculatory blood flow,NE does not improve microcircu,26,NE does not improve microcirculatory blood flow,1.NE does not improve microcirculatary perfusion further increase MAP from 65mmHg.,2. Reductions in the perfused capillary densities further increase MAP from 65mmHg.,结论：使用去甲升高MAP并不是改善感染性休克患者微循环的一个恰当方法，反而可能对患者有害。,NE does not improve microcircu,27,The effect of increasing doses of NE on tissue oxygenation and microvascular flow in patients with septic shock,16 septic shock patients,NE from 0.18 to 0.25,0.35,0.41ug/kg.min,MAP from 60-70-80-90mmHg,SDF imaging,Shaman Jhanji,et al.Crit care Med 2009;37:1961-1966,The effect of increasing doses,28,The effect of increasing doses of NE on tissue oxygenation and microvascular flow in patients with septic shock,MAP 高于60-65mmHg不能改善感染性休克患者微循环,增加NE 对感染性休克患者微循环无明显影响,Shaman Jhanji,et al. Crit care Med 2009;37:1961-1966,The effect of increasing doses,29,多巴胺对微循环的影响,1.1 Meier-Hellmann A, Bredle DL, SpechtM, Spies C, Hannemann L, Reinhart K(1997) The effects of low-dose dopamine on splanchnic blood flow and oxygen uptake in patients with septic shock. Intensive Care Med 23:3137,1.2 Olson D, Pohlman A, Hall JB (1996)Administration of low-dose dopamine,to nonoliguric patients with sepsis syndrome does not raise intramucosal,gastric pH nor improve creatinine clearance. Am J Respir Crit Care Med,154:16641670,2. Marik PE, Mohedin M (1994) The contrasting effects of dopamine and,norepinephrine on systemic and splanchnic oxygen utilization in,hyperdynamic sepsis. JAMA 272:13541357,多巴胺对微循环的影响1.1 Meier-Hellmann A,30,NG对微循环的影响,NG对微循环的影响,31,NG in septic shock after intravascular volume resuscitation,8 septic shock patients,MAP was greater than 60 mm Hg and CVP greater than 12 mmHg after infusion of crystalloids and colloids, and the lowest possible dose of dopamine,NG：an intravenous loading dose of 05 mg, then subsequent continuous infusion of 2 mg/h,OPS ：used to produce images of sublingual microcirculation,Lancet 2002;360:1395-1396,NG in septic shock after intra,32,NG in septic shock after intravascular volume resuscitation,NG in septic shock after intra,33,OPS images,OPS images,34,70个 Severe sepsis和septic shock患者,充分复苏后给予硝酸甘油或安慰剂,SDF评估舌下微循环,主要终点：sublingual microcirculatory blood flow of small vessels,Crit Care Med 2010;38:93-100,70个 Severe sepsis和septic shock,35,Microvascular variables over time,Microvascular variables over t,36,Take Home Message,1.重视微循环检测,2.sepsis微循环功能障碍：异质性,3.传统指标不足以反映微循环,4.OPS/SDF有较好临床应用前景,5.血管活性药对微循环的作用？,Take Home Message1.重视微循环检测,37,谢谢捧场！,谢谢捧场！,谢谢捧场！谢谢捧场！,38,2. LeDoux D, Astiz ME, Carpati CM,Rackow EC (2000) Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 28:27292732,3. Bourgoin A, Leone M, Delmas A,Garnier F, Albanese J, Martin C (2005) Increasing mean arterial pressure in patients with septic shock:effects on oxygen variables and renal function. Crit Care Med 33:780786,4. Deruddre S, Cheisson G, Mazoit JX,Vicaut E, Benhamou D, Duranteau J(2007) Renal arterial resistance in septic shock: effects of increasing mean arterial pressure with norepinephrine on the renal resistive index assessed with Doppler ultrasonography. Intensive Care Med 33:15571562.,2. LeDoux D, Astiz ME, Carpati,39,