ScvO临床意义

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,*,此处添加公司信息,*,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,*,此处添加公司信息,*,*,*,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,ScvO,2,的临床意义,内 容,氧供与氧耗,SvO2,与,ScvO2,ScvO2,的临床应用,氧供与氧耗,15vol%=15ml/dl,5vol%=5ml/dl,氧供DO2与氧耗VO2,DO2=CaO2CO,=(1.34SaO2Hb+0.0031PaO2)CO,=1.34SaO2HbCO,VO2=(CaO2-CvO2)CO,= (SaO2- SvO2),1.34 HbCO,SvO2=SaO2-VO2/(1.34HbCO),呼吸,血红蛋白,循环,(Fick,方程,),氧摄取EO2,EO2=VO2/DO2,EO2=(SaO2,-,SvO2)/SaO2,当,SaO2=1,00%,时 ：,EO2=1-SvO2,全身,EO2,=1 - 75% = 25%,各组织,EO2,不同，其相应之静脉氧饱和度不同,SvO2,=,1,-,EO2,氧供氧耗失衡,SvO2,降低或增加,无氧代谢,组织缺氧,乳酸生成,影响SvO2的因素,75%,-,+,DO2,应激,发热,寒战,躁动,疼痛,呼吸做功,VO2,CO,(,心衰、低容量）,Hb,（贫血、出血）,SaO2,（缺氧、呼衰）,DO2,CO,（液体复苏、正性肌力）,Hb,（输血）,SaO2,（氧疗）,VO2,低体温,镇静,镇痛,麻醉,机械通气,氧摄取,（分流、,细胞死亡）,SvO2 的界值,Pinsky MR, Mancebo J, Applied physiology in intensive care.,ScvO2,与,SvO2,ScvO,2,与,SvO,2,ScvO2,与,SvO2,SvO2,由肺动脉导管测得,反映全身的氧耗量,正常值：,75%,ScvO2,由中心静脉（上腔静脉）导管测得,反映脑及上半身的氧耗量,正常值：,72%,测定方法,连续监测,光纤导管或光纤中心静脉导管,间断测定,中心静脉血气,正常各组织器官的静脉氧饱和度,Pinsky MR, Mancebo J, Applied physiology in intensive care.,休克时？,ScvO2,与,SvO2,的相关性,Charalambos Ladakis Pavlos Myrianthefs Andreas Karabinis et al.Central Venous and Mixed Venous Oxygen Saturation in Critically ill patients,Respairation,2001;68 279-285,Linear correlation of paired ScvO,2,and SvO,2,measurements for 296 paired samples ScvO,2,increases by 0.87% for every unit increase in SvO,2,ScvO2,与,SvO2,的相关性,Dueck MH et al. Anesthesiology 2005; 103:249 57,Moina and Podbregar Critical Care2010,14:R42 th,Moina and Podbregar Critical Care2010,14:R42,Moina and Podbregar Critical Care2010,14:R42,Moina and Podbregar Critical Care2010,14:R42,SvO2与ScvO2的一致性,绝对值相差,518%,ScvO2的临床应用,休克中的应用,VO2,DO2,ScvO2/SvO2,乳酸,休克的,本质,是组织缺氧和氧代谢障碍，最终结果是,MODS,。液体复苏、及早纠正氧供与氧耗的失衡、降低组织缺氧程度至关重要。,急诊患者的复苏,多数（,31,例,/36,例）存在休克的危重患者经初期复苏至正常生命体征后乳酸继续升高,(2mmol/L),，,ScvO2,仍低于正常,(65%),，提示存在无氧酵解和氧债。,这些患者进一步治疗后乳酸下降（,4.63.8 to 2.62.5, p0.05),，,ScvO2,升高（,5218 to 6513%, p0.05),ScvO2,能作为初期复苏后指导休克治疗的指标,Rady MY, Rivers EP, Novak RM: Resuscitation of the critically ill in the ED:,responses of blood pressure, heart rate, shock index, central venous,oxygen saturation, and lactate. Am J Emerg Med1996, 14:218-225.,重症感染与感染性休克中的应用,13681377 N Engl J Med, Vol. 345, No. 19 November 8, 2001,早期目标指导治疗（,EGDT,）,研究结果,死亡率,Rivers E, Nguyen B, Havstad S, et a1,Early goal directed therapy in the treatment of severe sepsis and septic shock. N Eng J Med,2001,345:1368,1377.,进行,ScvO,2,监测，达到,EGDT,目标，可使患者病死率下降,16%,（,46.5% vs 30.5%,）。,低,ScvO2,的预后差,2012,“,拯救脓毒症运动,”,指南,早期复苏目标,MAP 65mmHg,CVP 812mmHg ,机械通气,1215mmHg,尿量,ScvO2 70% or SvO2 65%,感染性休克高ScvO2的预后,单因素分析结果,存活组与死亡组的ScvO2,该研究共纳入,4,家医院急诊科脓毒症患者,619,名，按,EDGT,复苏方案治疗，据,ScvO2,水平分为三组：低,ScvO2,组,(,70%),、正常,ScvO2,组,(7189%),、高组,(90100%),。比较住院死亡率并进行多因素分析,23%,25%,31%,初始,ScvO2,与死亡率,(81/351),(56/223),(14/45),25/62,96/465,31/92,ScvO2在ACS 中的应用,该研究纳入患者,43,名，为收住,CCU,的急性冠脉综合征（,ACS,）并急性肺水肿或心源性休克患者，测定入室时、,24h,、,48h,的中心静脉和外周动脉血气，主要终点为致死性事件，次要终点为住院全因死亡率,Acta Cardiol Sin 2008;24:12633,结果：存活组与死亡组,ScvO2,的差异有显著性,Acta Cardiol Sin 2008;24:12633,所有患者,ScvO2,、,SaO2,的变化,存活患者,ScvO2,的变化,Acta Cardiol Sin 2008;24:12633,创伤患者的评估,Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prospective observational study,Alessandro Di Filippo*1, Chiara Gonnelli1, Lucia Perretta1,Rosario pina1, Marco Chiostri2, Gian Franco Gensini2 and Adriano Peris1,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23,ScvO265%,的患者住院时间延长，死亡率明显增加,急诊插管对重症患者,ScvO2,的影响,15min,Hernandez et al. Critical Care2009, 13:R63,Hernandez et al. Critical Care2009, 13:R63,插管改善ScvO2的机制,插管前预充纯氧，溶解氧增加，氧供提高,插管时镇静与肌松使氧摄取减少而降低氧耗,初始机械通气减轻了过度通气，使pH升高而使氧离曲线右移，利于氧释放,围术期ScvO2的应用,患者资料,单因素分析,After multivariate analysis, mean ScvO2 value (OR 1.23 95%CI 1.01 to 1.50, p = 0.037), hospital LOS (OR 0.75 95% CI 0.59 to 0.94, p = 0.012), and SAPS II (OR 0.90 95% CI 0.82 to 0.99, p = 0.029) were independently associated with postoperative complications.,多因素分析,低,ScvO2,与术后并发症相关,The optimal value of mean ScvO2 for discriminating between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%),ScvO2,与乳酸在感染性休克中应用比较,Jones的研究显示：在感染性休克的早期目标性治疗中，乳酸清除率达标与ScvO2达标，两组的住院死亡率无差别【25% （1730%）vs 17%（1124%）】。,Jones AE et al. JAMA. 2010 February 24; 303(8): 739746,ScvO2与容量反应性,大循环指标：血压、心率、尿量、,CVP,CO,、,CI,PPV,SVV,ScvO2,?,ScvO2 As a Marker to Define Fluid Responsiveness,Methods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR,Methods:A,total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsiveness,Results: ScvO2 and SvO2 variations after VE (SvO2) were significantly correlated with CI changes (CI) after VE (r 0.67 and r= 0.49,p0.001, respectively). AScvO2 threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 57,98%) and 81% specificity (95%CI; 54,96%),Giraud R, et al. J Trauma.2011;70: 802807,ScvO2的局限性,争论：ScvO2不能反映SvO2,Bias of difference was 4.2% and 95% limits of agreement ranged from 8.1% to 16.5%.,The central venous oxygen saturation overestimated the mixed venous oxygen saturation by a mean bias (or an absolute difference) of 6.9%, and the 95% limits of agreement were large (-5.0% to 18.8%). The difference between central and mixed venous oxygen saturation appeared to be more significant when mixed venous oxygen saturation was 70%,实验结果,根据,P(cv-a)CO,2,是否,6mmHg,实验结果,2,值，差异无统计学意义,0.00%,5.00%,10.00%,15.00%,20.00%,低,ScvO,2,组,中,ScvO,2,组,高,ScvO2,组,三组,ScvO,2,的病死率比较,图,7,实验结果,T6 P(cv-a)CO,2,AUROC,曲线下面积，与相比差异有统计学意义（），对预后有,中等,判断能力。,