利用PICCO减少容量的不足与过多

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,利用,Picco,减少容量复苏,不足与过多,结论：早期充分复苏降低休克患者死亡率,结论：,充分复苏降低休克患者死亡率,2740 ml/d vs.5388 ml/d,围术期患者,ARF AKI,透析患者,非透析患者,结论,1,容量不足：器官和组织的缺血,结论,2,容量过多：器官和组织的水肿,容量的天平,容量监测在前进,（技术、理念）,血压（,BP,）、心率,(HR),、皮肤弹性、尿量,中心静脉压（,CVP,）、肺动脉楔嵌压,(PAWP),右室舒张末期容积,(RVEDV),、左室舒张末期容积,(LVEDV),每搏输出量,(SV),、每分钟心输出量,(CO),症状、体征：,压力监测：,容量监测：,氧代谢监测：,微循环监测：,OPS,、,SDF,SVO2,、,StO2,、,Pcv-aCO2,、,Lactate,血压,?,心率,?,尿量,?,CVP PAWP?,Svo2?,乳酸或乳酸清除率,?,Pcv-aCO2?,OPS SDF?,Phi?,但是，迄至今天我们仍未找到理想的复苏终点，,将来,？,整合的监测,个体化的监测：,个体的容量反应性,容量反应性的评估,术后转入,ICU,的患者,CVP,组,SVV,组,股动脉置管，,连接,PICCO,液体复苏目标：,CVP:10-12mmHg,MAP65mmHg,UO0.5ml/(kg.h),液体复苏目标：,SVV65mmHg,UO0.5ml/(kg.h),SVV10%,的患者,比较围术期,CVP,与,SVV,指导下的液体复苏,2011,年,4,月至,2012,年,2,月共纳入外科术后,SVV10%,的低血容量患者,41,例，剔除,活动性出血患者,3,例，随机分为,CVP,组（,n=17,例）及,SVV,组（,n=1,例）。,两组患者一般情况及手术术中情况比较,无差异,CVP,（,n=17,）,SVV,组（,n=21,）,P,年龄,6314,5820,0.385,性别（男,/,女）,11/6,12/9,0.744,身高,165.66.4,164.69.0,0.702,体重,60.413.0,52.710.3,0.051,APACHE II,评分,94,84,0.438,ASA,分级,2.80.7,2.80.7,0.952,手术时间,5.82.6,6.22.8,0.620,术中出血,400(175,1250),500(175,3250),0.816,术中输血,400(0,1500),600(0,2100),0.383,术中尿量,800(300,1400),800(350,2150),0.728,术中输液,5900(3950,8250),5900(3325,9550),0.839,术中液体平衡,41051840,35161704,0.313,SVV,的动态观察,复苏前,复苏后,P,平均,动脉压,(MAP),8015,9010,0.009,中心静脉压,(CVP),7.12.1,12.22.0,0.000,心输出量,(CO),4.81.2,5.81.4,0.002,心指数,(CI),2.90.6,3.60.9,0.002,每搏量,(SV),5616,6817,0.015,每,搏指数,(SVI),349,4111,0.018,每搏变异率,(SVV),173,52,0.000,中心静脉血氧饱和度,(ScVO2),609,709,0.000,乳酸,3.31.6,2.91.3,1.206,血红蛋白,Hb,10619,8816,0.002,DO2,709157,727184,0.574,CVP,组,SVV,组,复苏前,复苏后,P,平均,动脉压,(MAP),8315,9916,0.000,中心静脉压,(CVP),5.63.1,8.34.4,0.000,心输出量,(CO),4.51.4,6.52.4,0.000,心指数,(CI),2.90.8,4.11.4,0.000,每搏量,(SV),349,5220,0.000,每,搏指数,(SVI),349,5220,0.000,每搏变异率,(SVV),185,62,0.000,中心静脉血氧饱和度,(ScVO2),6216,7010,0.014,乳酸,4.32.5,3.61.8,0.023,血红蛋白,(Hb),11126,10323,0.012,DO2,713290,945399,0.000,注：,P,0.05,有统计学意义；：,P,0.05,CVP,组和,SVV,组：达到复苏目标后血流动力学指标均较复苏前明显改善,复苏前,复苏后,P,平均,动脉压,(MAP),8015,9010,0.009,中心静脉压,(CVP),7.12.1,12.22.0,0.000,心输出量,(CO),4.81.2,5.81.4,0.002,心指数,(CI),2.90.6,3.60.9,0.002,每搏量,(SV),5616,6817,0.015,每,搏指数,(SVI),349,4111,0.018,每搏变异率,(SVV),173,52,0.000,中心静脉血氧饱和度,(ScVO2),609,709,0.000,乳酸,3.31.6,2.91.3,1.206,血红蛋白,Hb,10619,8816,0.002,DO2,709157,727184,0.574,CVP,组,SVV,组,研究结果,：,第二部分,复苏前,复苏后,P,平均,动脉压,(MAP),8315,9916,0.000,中心静脉压,(CVP),5.63.1,8.34.4,0.000,心输出量,(CO),4.51.4,6.52.4,0.000,心指数,(CI),2.90.8,4.11.4,0.000,每搏量,(SV),349,5220,0.000,每,搏指数,(SVI),349,5220,0.000,每搏变异率,(SVV),185,62,0.000,中心静脉血氧饱和度,(ScVO2),6216,7010,0.014,乳酸,4.32.5,3.61.8,0.023,血红蛋白,(Hb),11126,10323,0.012,DO2,713290,945399,0.000,注：,P,0.05,有统计学意义；：,P,0.05,注：,P,0.05,有统计学意义；：,P,0.05,SVV,组乳酸较复苏前降低更显著，氧输送增加更显著,SVV,组,在,达到液体复苏目标,时的,CVP,明显低于,CVP,组,CVP,组,（,n=17,）,SVV,组,（,n=21,）,P,复苏终点所需要时间,3.81.4,1.40.6,0.000,复苏晶体量,0(0,0),0(0,100),0.920,复苏中输入红细胞量,0(0,87.5),0(0,0),0.249,总液体,量,1476741,611453,0.000,复苏液体量,1294685,573427,0.001,复苏胶体量,1185617,490421,0.000,出入量,942532,366290,0.001,SVV,组达到复苏终点时间短、需要液体少,注：,P,0.05,有统计学意义；：,P,30bpm,不能用于低潮气量通气时：,Vt8ml/kg,可能掩盖对液体的反应性，出现假,阴性,不能用于,低,气道驱动压时：气,道驱动压（平台压,-PEEP,）,=,20cmH2O,出现假阴性,不能用于严重心律失常患者,血管活性药物对结果的干扰,腹高压、肺高压、右室功能不全对结果的干扰,被动抬腿实验,被动抬腿实验（,PLR,）,患者因,“,上腹剧痛,2,天,”,到当地医院就诊,检查血淀粉酶升高，,CT,显示胰腺炎症,诊断为,“,重症急性胰腺炎,”,住院治疗,患者出现高热、血压低，呼吸促，血氧差，,氧合指数,100,，给予紧急气管插管机械通气，,2012,年,9,月,23,日转送至我院,ICU,进一步治疗,谭,XX,，女性，,20,岁，肥胖,90kg,但是，我们常常面临更复杂的临床情况,心率,120,次,/,分,血压,126/75mmHg,CVP18cmH,2,O,，膀胱压,26cmH,2,O,呼吸,35,次,/,分,FiO2 80%,PEEP 11cmH2O,PaO2 56mmHg,，,PaCO2 38mmHg,Lactate,：,3.2mmol/L,入,ICU,时,腹围,118cm,腹压,26mmHg,全腹压痛，轻反跳痛,叩浊音,未闻及肠鸣音,心率,120,次,/,分,血压,126/75mmHg,CVP18cmH,2,O,，,膀胱压,26cmH,2,O,呼吸,35,次,/,分,FiO2 80%,PEEP 11cmH2O,PaO2 56mmHg,，,PaCO2 38mmHg,Lactate,：,3.2mmol/L,因腹压高,CVP,无参考意义,因自主呼吸强,SVV,、,PPV,无参考意义,被动抬腿试验 （,-,）,胸片肺水肿：渗出？漏出？,印象：,心率快、呼吸快、氧合差、乳酸高、严重腹胀、腹压高、全身水肿,血流动力学状态诊断：,不清楚,血流动力学治疗：,不清楚,患者心率快、乳酸高，可能需要更多液体复苏,患者腹腔高压达,26cmH2O,液体输注可能导致患者,ACS,患者严重,ARDS,，氧合指数,100,，扩容可能加重低氧,患者胸片提示肺门粗，扩容可能导致心衰,我们需要更完整全面的监测,用,Picco,辅助血流动力学治疗,容量情况,ITBW,GEDV,患者存在血流动力学障碍,心功能情况,SV(SVI),CO(CI),GEF,CFI,dpmx,外周血管阻力情况,SVRI,渗透性,or,漏出性,PVPI,肺水情况,EVLW,容量反应性监测：,SVV,、,PPV,生命体征,9,月,23,日,MAP(mmHg),117,HR(,次,/,分,),114,CVP,（,mmHg,）,/,膀胱压,18/26,心功能,CI(3.0-5.0),4.0,SVI(40-60),33,CFI(4.5-6.5),10,GEF(25-35%),33,dPmx(1200-2000),1510,后负荷：,SVRI(1700-2400),2190,前负荷：,GEDI(680-800),410,肺水：,ITBI(850-1000),512,ELWI(3.0-7.0),6,肺通透性：,PVPI(1.0-3.0),2.1,容量反应性：,SVV/PPV,PiCCO,血压低,心率快,每搏量低,容量不足,需要扩容,但考虑呼吸与腹压给予了脱水,ICU,的初步处理,禁食，胃肠减压,抑制胰液分泌：制酸剂、生长抑素、乌司他丁,呼吸、心脏等脏器功能支持治疗,CVVH,脱水,(-1866ml),B,超引导腹腔穿刺引流,维持内环境稳定,CT,检查、床边胸片检查,对容量有反应,需要给予立即扩容，仍需考虑是否肺、肝或脑组织有脱水的需要,生命体征,9,月,23,日,9,月,24,日,MAP(mmHg),117,98,HR(,次,/,分,),114,120,CVP/,膀胱压,（,mmHg,）,18/26,13/21,心功能,CI(3.0-5.0),4.0,2.67,SVI(40-60),33,21,CFI(4.5-6.5),10,8,GEF(25-35%),33,26,dPmx(1200-2000),1510,1030,后负荷：,SVRI(1700-2400),2190,2520,前负荷：,GEDI(680-800),410,411,肺水：,ITBI(850-1000),512,513,ELWI(3.0-7.0),6,10,肺通透性：,PVPI(1.0-3.0),2.1,3.3,容量反应性：,SVV/PPV,心率更快,每搏量更低,容量更不足,扩容,治疗,2,天后表现,液体平衡：,第,1,天：,-1866ml,第,2,天：,+2550ml,心率,85-95,次,/,分,血压平稳,呼吸机支持，,PaO2/FiO2 160mmHg,3,天后，,患者再度发热，,T38.2,C-39,C,，心率,120-140,次,/,分,生命体征,9,月,23,日,9,月,24,日,9,月,27,日,MAP(mmHg),117,98,10