危重病患者的血流动力学监测与治疗课件

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,*,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,*,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,*,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,*,危重病患者的血流动力学监测与治疗How To Make It Simple?,北京协和医院,杜斌,危重病患者的血流动力学监测与治疗How To Make I,血流动力学监测与治疗,CO,MAP,SVR,=,x,SV,HR,x,后负荷,前负荷,心肌收缩力,血流动力学监测与治疗COMAPSVR=xSVHRx后负荷前负,血流动力学监测,血流动力学监测,血流动力学监测,:,基本内容,1,前负荷,Preload,3,组织灌注,Tissue Perfusion,2,灌注压,MAP,血流动力学监测: 基本内容1前负荷3组织灌注2灌注压,危重病患者的容量缺乏,危重病患者的容量缺乏,为何需要扩容治疗?,CVP (mmHg),CO (L/min),为何需要扩容治疗?CVP (mmHg)CO (L/min),根据临床表现判断容量状态,低容量表现,心动过速,低血压,(,严重者,),高乳酸,(,严重者,),肢端温度降低,脱水表现,皮肤充盈下降,口渴,口干,腋窝干燥,高血钠,高蛋白血症,高血红蛋白,高血球压积,体位性低血压,动脉血压或每,搏输出量的呼,吸波动,下肢被动抬高,容量负荷试验,结果阳性,肾脏灌注减少,浓缩尿,(,低尿钠,高尿渗,),BUN,升高,(,与肌酐升高不,成比例,),持续性代谢性,酸中毒,动态指标,静态指标,容量状态评价,根据临床表现判断容量状态低容量表现脱水表现体位性低血压肾脏灌,低血容量: 临床表现,体格检查发现,敏感性,/,特异性, %,+LR (95%CI),-LR (95%CI),大量失血,体位性脉搏加快, 30 bpm,97/98,48.5,0.03,仰卧位心动过速,( 90 bpm),12/96,3.0,0.9,仰卧位低血压,(SBP 30 bpm,22/98,11.0,0.8,仰卧位心动过速,( 90 bpm),0/96,仰卧位低血压,(SBP 30 bpm,43/75,1.7 (0.7 4.0),0.8 (0.5 1.3),体位性低血压,29/81,1.5 (0.5 4.6),0.9 (0.6 1.3),粘膜干燥,85/58,2.0 (1.0 4.0),0.3 (0.1 0.6),舌干,59/73,2.1 (0.8 5.8),0.6 (0.3 1.0),舌体皱缩,85/58,2.0 (1.0 4.0),0.3 (0.1 0.6),眼睛凹陷,62/82,3.4 (1.0 12.2),0.5 (0.3 0.7),意识模糊,57/73,2.1 (0.8 5.7),0.6 (0.4 1.0),肢体无力,43/82,2.3 (0.6 8.6),0.7 (0.5 1.0),言语不流利,56/82,3.1 (1.2 14.9),0.7 (0.5 0.9),脱水: 临床表现体格检查发现敏感性/特异性, %+LR (9,前负荷的维持: 指南建议,复苏目标,(1C),中心静脉压,(CVP) 8 12 mmHg*,平均动脉压,65 mmHg,尿量,0.5 ml/kg/hr,中心静脉,(,上腔静脉,),血氧饱和度,70%,，或混合静脉血氧饱和度,65%,Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,前负荷的维持: 指南建议复苏目标 (1C)Dellinger,中心静脉压: 影响因素,基础水平,出血,420 ml,(310 470 ml),NE,0.001,g/kg/min,HR (bpm),167 (35),210 (44)*,153 (56)*,MAP (mmHg),144 (42),85 (46)*,153 (36)*,CVP (mmHg),5.5 (4.2),3.0 (4.2),2.0 (4.0),PAOP (mmHg),6.0 (5.1),4.5 (4.0),3.5 (5.1),CO (lpm),4.68 (3.30),1.98 (0.86)*,3.08 (1.72)*,*,SVR (dyne.sec/cm,5,),2367 (1475),3313 (1900)*,3922 (2744)*,*,PVR (dyne.sec.cm,-5,),213 (182),303 (245)*,428 (310),PPV (%),12 (9),28 (11.5)*,14.5 (6.2)*,SPV (mmHg),12.5 (6.5),21 (8.2)*,15.5 (4.5)*,Nouira S, Elatrous S, Dimassi S, et al. Effects of norepinephrine on static and dynamic preload indicators in experimental hemorrhagic shock. Crit Care Med 2005; 33: 2339-2343,中心静脉压: 影响因素基础水平出血420 mlNEHR (b,容量负荷试验: 判断标准,每,10,分钟测定,CVP,CVP 2 mmHg,继续快速补液,CVP 2 5 mmHg,暂停快速补液,等待,10,分钟后再次评估,CVP 5 mmHg,停止快速补液,每,10,分钟测定,PAWP,PAWP 3 mmHg,继续快速补液,PAWP 3 7 mmHg,暂停快速补液,等待,10,分钟后再次评估,PAWP 7 mmHg,停止快速补液,Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock.,Anesth Analg,1979; 58:124132,容量负荷试验: 判断标准每10分钟测定CVP每10分钟测定P,病例,1:,现病史,男性, 70,岁, 2001,年,1,月,9,日入院,咳嗽,咳痰,12,天,发热,4,天,呼吸困难,1,天,12,天前,咳嗽,咳黄粘痰,伴全身乏力,4,天前,寒战高热,体温,39.5,C,CXR,：肺部感染,右上肺膨胀不全,头孢呋肟治疗无效,1,天前,呼吸困难,紫绀,伴血压下降,(50/20 mmHg),病例1: 现病史男性, 70岁, 2001年1月9日入院,病例,1:,入院情况,入,ICU,时,BT 37.2,C,HR 130 bpm,BP 84/40 mmHg (DA 10,g/kg/min),SpO,2,78%,双肺散在湿罗音,病例1: 入院情况入ICU时,病例,1:,入院诊断,诊断,重度社区获得性肺炎,急性呼吸功能衰竭,感染性休克,病例1: 入院诊断诊断,病例,1:,支持治疗,呼吸功能支持,(,SIMV + PSV),FiO,2,100%, PEEP 10 cmH,2,O,SpO,2,92%,循环支持,羟基淀粉,500 ml,扩容无效,DA 13,g/kg/min,NE 1.2,g/kg/min,BP 110/70 mmHg,病例1: 支持治疗呼吸功能支持(SIMV + PSV),病例,1:,血流动力学监测,放置肺动脉漂浮导管,HR130MAP71,CVP9PAWP9,CI1.96,SVRI2524PVRI529,NE1.0,病例1: 血流动力学监测放置肺动脉漂浮导管,病例,1:,血流动力学监测,扩容,3000,ml,后,HR103MAP118,CVP12PAWP18,CI3.63,SVRI2182PVRI331,NE1.0,病例1: 血流动力学监测扩容3000 ml后,白蛋白 vs. 晶体液: SAFE研究,多中心, 随机, 双盲, 对照试验,澳大利亚和新西兰16个,ICU,的7000名患者,2001/11,至2003,/6,入选标准: 需要输液治疗,+ 1,项低血容量的客观指标,排除标准,:,肝脏移植,心脏手术, 烧伤,4%,白蛋白(,n = 3499) vs.,生理盐水(,n = 3501),The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,白蛋白 vs. 晶体液: SAFE研究多中心, 随机, 双盲,白蛋白 vs. 晶体液: SAFE研究,白蛋白,生理盐水,28,天病死率,(%),20.9,21.1,ICU,住院日,(d),6.5,6.6,6.2,6.2,机械通气时间,(d),4.5,6.1,4.3,5.7,肾脏替代治疗时间,(d),0.48,2.28,0.39,2.00,新发器官功能衰竭,无,52.7,53.3,1,个器官,30.0,29.8,2,个器官,13.9,13.5,3,个器官,2.6,2.8,4,个器官,0.7,0.6,5,个器官,0.1,0,The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,白蛋白 vs. 晶体液: SAFE研究白蛋白生理盐水28天病,白蛋白 vs. 晶体液: SAFE研究,The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56,The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.,白蛋白 vs. 晶体液: SAFE研究The SAFE St,乳酸林格液 vs 羟乙基淀粉: VISEP,强化胰岛素治疗,传统胰岛素治疗,羟乙基淀粉,247,290,乳酸林格液,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP强化胰岛素治疗传统,乳酸林格液 vs 羟乙基淀粉: VISEP,强化胰岛素治疗,传统胰岛素治疗,羟乙基淀粉,262,乳酸林格液,275,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP强化胰岛素治疗传统,乳酸林格液 vs 羟乙基淀粉: VISEP,乳酸林格液,(n = 275),HES (n = 262),P,28,天病死率,n/N,66/274,70/262,0.48,%,24.1 (19.0 29.2),26.7 (21.4 32.1),90,天病死率,n/N,93/274,107/261,0.09,%,33.9 (28.3 39.6),41.0 (35.0 47.0),凝血系统,SOFA,评分,0.11 (0 0.83),0.46 (0 1.30), 0.001,肾脏,SOFA,评分,0.42 (0 1.33),0.67 (0 1.94),0.02,急性肾功能衰竭,n/N,62/272,91/261,0.002,%,22.8 (17.8 27.8),34.9 (29.1 40.7),肾脏替代治疗,n/N,51/272,81/261,0.001,%,18.8 (14.1 23.4),31.0 (25.4 36.7),输注,RBC,单位,4 (2 8),6 (4 12), 0.001,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEP乳酸林格液(n =,乳酸林格液 vs 羟乙基淀粉: VISEP,Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.,乳酸林格液 vs 羟乙基淀粉: VISEPBrunkhors,血流动力学监测: 前负荷,前负荷不足,危重病人中非常普遍,临床表现缺乏特异性,可能需要试验性治疗,不同种类液体有差异,血流动力学监测: 前负荷前负荷不足,血流动力学监测,:,基本内容,1,前负荷,Preload,3,组织灌注,Tissue Perfusion,2,灌注压,MAP,血流动力学监测: 基本内容1前负荷3组织灌注2灌注压,血流动力学中的欧姆定律,R =,P / flow,Pin,Pout,flow,R,血流动力学中的欧姆定律R = P / flowPinPou,器官灌注压,肾脏灌注,RPP = MAP IAP,FG = GFP PTP,= MAP IAP x 2,脑灌注,CPP = MAP ICP,器官灌注压肾脏灌注脑灌注,健康与疾病时的自身调节,0,150,50,100,Organ blood flow,(% Baseline),0,100,20,40,60,80,Organ artery pressure (mmHg),Autoregulatory threshold,Subautoregulatory slope,健康与疾病时的自身调节015050100Organ bloo,疾病时的自身调节机制,0,150,50,100,Organ blood flow,(% Baseline),0,100,20,40,60,80,Organ artery pressure (mmHg),control,3 weeks,1 week,疾病时的自身调节机制015050100Organ blood,升压药物: 指南建议,维持,MAP,65 mmHg (1C),首选升压药物应为去甲肾上腺素或多巴胺,并经中心静脉输注,(1C),肾上腺素,苯肾上腺素或血管加压素不应作为感染性休克的一线用药,(2C),在去甲肾上腺素基础上加用血管加压素,0.03 U/min,可能与单纯应用去甲肾上腺素效果相等,感染性休克时如血压对去甲肾上腺素反应不佳,可首选肾上腺素或多巴胺,(2B),不应使用小剂量多巴胺进行肾脏保护,(1A),需要升压药的患者应留置动脉导管,(1D),Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,升压药物: 指南建议维持MAP 65 mmHg (1C),平均动脉压应当多少?,无创血压不准确,高血压时读数低,低血压时读数高,有创血压与无创血压经常不一致,平均动脉压应当多少?无创血压不准确,血流动力学监测: 技巧,确认患者的平均动脉压,家属,病历记录,检查患者平均动脉压的测定方法,无创,vs.,有创,确定无创血压与有创血压的差值,血流动力学监测: 技巧确认患者的平均动脉压,病例2: 基本情况,男性, 74,岁,病历号,既往史,I,型糖尿病,18,年,糖尿病肾病,高血压病史,5,年,口服络活喜,倍他乐克等药物,平素,BP 160 180 / 70 90 mmHg,病例2: 基本情况男性, 74岁, 病历号,病例2: 现病史,2007,年,7,月,25,日入院,主因发现恶心,呕吐,1,周,伴心前区疼痛及少尿,3,天,1,周前出现恶心,呕吐,予对症治疗,3,天前出现心前区疼痛,憋闷,尿量减少,静脉泵入,NG 100,g/min,控制,BP 134/56 mmHg,血,Cr 861,mol/L, UO 500 ml/d (,速尿,400 mg/d),血液透析,透析过程中出现心绞痛,持续不缓解,病例2: 现病史2007年7月25日入院,病例2: 体格检查,GCSE4V5M6,BT36.2,C,HR70 bpm,RR20 bpm,BP103/45 mmHg,SpO,2,98 100% (,鼻导管吸氧,5 lpm),病例2: 体格检查GCSE4V5M6,病例2: 实验室检查,CBC: WCC 14.79, Hb 102, plt 215,Chemistry (8 2):,Na140mmol/L,Cl 97mmol/L,K 4.2mmol/L,Cr745,mol/L,BUN 31.14mmol/L,CK-MB 6.8u/L,cTnI 11.56,g/L,GLU 21.5mmol/L,病例2: 实验室检查CBC: WCC 14.79, Hb 1,病例2: MAP与组织灌注,心绞痛*,*,发作时,EKG: V3-6,导联,ST,段压低,0.1 0.2 mv,病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6,病例2: MAP与组织灌注,心绞痛*,*,发作时,EKG: V3-6,导联,ST,段压低,0.1 0.2 mv,病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6,病例2: MAP与组织灌注,心绞痛*,*,发作时,EKG: V3-6,导联,ST,段压低,0.1 0.2 mv,病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6,感染性休克: NE + DB vs. Epi,满足以下标准, 7 d,感染证据,SIRS,标准,2/4,组织低灌注或器官功能不全,(, 2,),PaO,2,/FiO,2, 280,UO 2 mmol/L,Plt 100 x 10,9,/L,满足以下标准, 24 h,SBP 90 mmHg,或,MAP 1000 ml,或,PCWP 12 18 mmHg,血管活性药物,多巴胺, 15,g/kg/min,Epi,或,NE:,任何剂量,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi满足以下标准 15,g/kg/min,63 (19%),38 (24%),25 (15%),Epi,137 (42%),61 (38%),76 (45%),NE,102 (31%),48 (30%),54 (32%),早期适当抗生素,(%),250 (76%),119 (74%),131 (78%),RRT (%),31 (9%),15 (9%),16 (10%),皮质激素,(%),263 (80%),133 (83%),130 (77%),APC (%),25 (21%),11 (19%),14 (23%),Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. Epi总计(n = 3,感染性休克: NE + DB vs. Epi,Epi (n = 161),NE + DB (n = 169),P,值,7,天病死率,(%),40 (25%),34 (20%),0.30,14,天病死率,(%),56 (35%),44 (26%),0.08,28,天病死率,(%),64 (40%),58 (34%),0.31,ICU,病死率,(%),75 (47%),75 (44%),0.69,住院病死率,(%),84 (52%),82 (49%),0.51,90,天病死率,(%),84 (52%),85 (50%),0.73,OR,HR,所有变量,(n = 308),0.90 (0.54 1.49),0.87 (0.59 1.28),除适当抗生素外的所有变量,(n = 319),0.82 (0.51 1.34),0.84 (0.58 1.22),除适当抗生素及乳酸外的所有变量,(n = 330),0.82 (0.51 1.31),0.87 (0.61 1.24),Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. EpiEpi (n =,感染性休克: NE + DB vs. Epi,Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684,感染性休克: NE + DB vs. EpiAnnane D,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克,需要血管活性药物,(NE, 5 ,g/min),(n = 779),起始剂量,0.01 U/min,增加剂量,0.005 U/min,最大剂量,0.03 U/min,(n = 397),起始剂量,5,g/min,增加剂量,2.5 g/min,最大剂量,1,5 ,g/min),(n = 382),血管加压素,(VP),(0.12 U/ml),(n = 397),去甲肾上腺素,(NE),(,60 ,g/ml),(n = 382),感染性休克: VP vs. NERussell JA, Wa,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,NE (n = 382),VP (n = 397),P,值,年龄,(,岁,),61.8, 16,59.3,16.4,0.03,男性,(%),229 (59.9),246 (62.0),0.56,APACHE II,27.1,6.9,27.0,7.7,0.84,MAP (mmHg),73,10,72,9,0.23,LA (mmol/L),3.5,3.0,3.5,3.2,0.96,DA (,g/kg/min),7.3,5.3,7.6,6.4,0.88,DB,(,g/kg/min),5.1,3.7,6.4,5.2,0.18,Epi (,g/kg/min),0.12,0.15,0.20,0.29,0.12,NE (,g/kg/min),0.28,0.26,0.26,0.27,0.97, 2,种升压药物,111 (29.1),124 (31.2),0.51,皮质激素,(%),293 (76.7),296 (74.6),0.49,APC (%),56 (14.7),61 (15.4),0.78,感染性休克: VP vs. NERussell JA, Wa,感染性休克: VP vs. NE,NE,组,(n = 382),VP,组,(n = 396),P,ARR,(95% CI),RR,(95% CI),校正,OR,28,天病死率,150/382,(39.3),140/396,(35.4),0.26,3.9,(-2.9 to 10.7),0.90,(0.75 1.08),0.88,(0.62 1.26),90,天病死率,188/379,(49.6),172/392,(43.9),0.11,5.7,(-1.3 to 12.8),0.88,(0.76 1.03),0.81,(0.57 1.16),Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克: VP vs. NENE组VP组PARRRR校正,感染性休克: VP vs. NE,Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.,感染性休克: VP vs. NERussell JA, Wa,Parrillo JE. Septic shock vasopressin, norepinephrine, and urgency. N Engl J Med 2008; 358: 954-956,Parrillo JE. Septic shock va,血流动力学监测: 灌注压,灌注压不足,灌注压没有固定数值,注意有创及无创血压的差异,根据患者情况确定目标血压,排除低血容量时应用升压药,具有受体激动作用的药物,(,多巴胺,去甲肾上腺素等,),血流动力学监测: 灌注压灌注压不足,血流动力学监测,:,基本内容,1,前负荷,Preload,3,组织灌注,Tissue Perfusion,2,灌注压,MAP,血流动力学监测: 基本内容1前负荷3组织灌注2灌注压,病例3,一名,25,岁体重,70 kg,肺炎患者, BP 100/50 (65) mmHg, CVP 0 mmHg,尿量,50 ml/hr, pH 7.4.,患者神志清楚,四肢温暖,.,最适宜的血流动力学处理措施为,:,IV,输注胶体液,250 ml,无需任何处理,IV,输注,5%,葡萄糖,250 ml,小剂量多巴胺输注,多巴酚丁胺输注,病例3一名25岁体重70 kg肺炎患者, BP 100/50,组织灌注不足的表现,皮肤花斑,四肢冰冷,毛细血管再充盈时间延长,尿量减少,意识障碍,代谢性酸中毒,乳酸酸中毒,ScvO,2, 4.5 L/min/m,2,DO,2,I 600 ml/min/m,2,VO,2,I 170 ml/min/m,2,Velmahos GC, Demetriades D, Shoemaker WC,et al.,: Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial.,Ann Surg,2000, 232: 409-418.,血流动力学指标: 超正常值CI 4.5 L/min/m2,Boyd O, Hayes M. The oxygen trial: the goal. Br Med Bull 1999; 55(1): 125-139,1,10,100,0.1,0.01,Tuschmidt,26 (50),25 (72),0.39 (0.12 1.24),Yu, 1993,35 (34),32 (34),1.00 (0.36 2.73),Hayes,50 (54),50 (34),2.28 (1.02 5.11),Gattinoni,252 (48),253 (49),0.99 (0.70 1.41),Yu, 1995,45 (38),44 (41),0.88 (0.37 2.05),Yu, 1998 ( 75 yo),21 (57),18 (61),0.85 (0.24 3.06),Yu, 1998 (50 75 yo),43 (21),23 (52),0.24 (0.08 1.18),Trial,Protocol,Control,OR (95%CI),Mortality n(%),Favor Protocol,Favor Control,超正常值与患者预后,Boyd O, Hayes M. The oxygen tr,循环支持治疗: 指南建议,正性肌力药物治疗,心肌功能障碍,(,心脏充盈压力升高及心输出量降低,),时使用多巴酚丁胺,(1C),不应使心脏指数增加到预先确定的超正常水平,(1B),Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.,循环支持治疗: 指南建议正性肌力药物治疗Dellinger,隐性低灌注与创伤预后,The Golden Hour and the Silver Day,入选标准,:,成年创伤患者,存活时间, 24,小时,ISS, 20,血流动力学稳定,SBP 100,HR 1 mL/kg/h,乳酸, 2.5 mmol/L,或其他灌注不足表现,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后The Golden Hour and,隐性低灌注与创伤预后,严重创伤患者两次,LA 2.5,输注液体或血液制品,重复,LA 2.5,Swan-Ganz,动脉插管,肾脏剂量多巴胺,将,PCWP,提高到,12 15,将,Hct,提高到,30%,重复,LA 2.5,升压药物,(,多巴酚丁胺,),心脏超声检查,若,LA,仍, 2.5,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后严重创伤患者两次LA 2.5输注液体,隐性低灌注与创伤预后,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后Blow O, Magliore L,感染患者的组织灌注与预后,Howell MD, Donnino M, Clardy P, et al. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007; 33: 1892-1899,感染患者的组织灌注与预后Howell MD, Donnino,感染患者的组织灌注与预后,OR,95%CI,P,值,年龄,(, 65,岁,),1.8,0.97 3.3,0.063,收缩压, 90 mmHg,1.0,70 90 mmHg,3.3,1 6.2,0.0002, 70 mmHg,8.5,3.9 18.4, 0.0001,乳酸, 2.5 mmol/L,1.0,2.5 4.0 mmol/L,2.2,1.1 4.2,0.023, 4.0 mmol/L,7.1,3.6 13.9, 0.0001,恶性肿瘤,2.8,1.5 5.3,0.001,血小板, 100,000,5.6,2.6 12.0, 20 mg/dL,3.5,1.6 7.5,0.002,Howell MD, Donnino M, Clardy P, et al. Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 2007; 33: 1892-1899,感染患者的组织灌注与预后OR95%CIP值年龄( 65岁),感染性休克的EGDT,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,感染性休克的EGDTRivers E, Nguyen B,感染性休克的EGDT,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,感染性休克的EGDTRivers E, Nguyen B,感染性休克的EGDT,血流动力学目标,前负荷,CVP,灌注压,MAP,组织灌注,UO,ScvO,2,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,感染性休克的EGDT血流动力学目标Rivers E, Ngu,血流动力学监测: 组织灌注,组织灌注不足,多种指标用于评估组织灌注,各种指标间的优劣缺乏评估,往往需要进行整体评价,急性肾功能衰竭,: BE,尿量,急性肝功能衰竭,:,乳酸,原发神经系统疾病,:,意识状态,血流动力学监测: 组织灌注组织灌注不足,血流动力学监测: 组织灌注,组织灌注不足,排除前负荷及灌注压的因素,应用强心药物,具有,受体兴奋作用的药物,(,多巴酚丁胺,肾上腺素等,),洋地黄类药物很少有效,血管扩张药物缺乏临床证据,血流动力学监测: 组织灌注组织灌注不足,危重病患者的血流动力学监测与治疗课件,血流动力学监测,:,总结,1,前负荷,(Preload),中心静脉压,(CVP),肺动脉楔压,(PAWP),输液治疗,3,组织灌注,(Tissue Perfusion),尿量,(UO),心指数,(CI),混合静脉血氧,(MVO,2,),中心静脉血氧,(ScvO,2,),强心药物,2,灌注压,(Perfusion Pressure),平均动脉压,(MAP),升压药物,血流动力学监测: 总结1前负荷3组织灌注2灌注压,后面内容直接删除就行,资料可以编辑修改使用,资料可以编辑修改使用,资料仅供参考，实际情况实际分析,后面内容直接删除就行,主要经营：,课件设计，文档制作，,网络软件设计、图文设计制作、发布广告等,秉着以优质的服务对待每一位客户，做到让客户满意！,致力于数据挖掘，合同简历、论文写作、,PPT,设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求,主要经营：课件设计，文档制作，网络软件设计、图文设计制作、发,感谢您的观看和下载,The user can demonstrate on a projector or computer, or print the presentation and make it into a film to be used in a wider field,