严重心衰的容量管理分解课件

Titelmasterformat durch Klicken bearbeiten,Textmasterformate durch Klicken bearbeiten,Zweite Ebene,*,PiCCO,2,Get the complete picture,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,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,严重心衰等心脏重症的容量管理,山东大学第二医院,重症医学科,马承恩,容量管理,诊断,+,处理,主要内容,一、容量（前负荷）与心衰的关系,二、如何判断容量（前负荷）,1.,临床（病史、症状和体征）,2.CVP,等压力监测,3.BNP,、,NT-proBNP,4.,无创监测,5.,微创,(PICCO),监测,三、心衰的处理,一、容量与心衰,Frank Starling Curve,容量最佳,-,心输出最大,;,容量过多,-,心输出降低。,一、容量与心衰,各种原因的心衰都存在,Fluid overload,前、后负荷增加 心肌收缩力降低 心肌顺应性下降,CO,降低,液体潴留,Fluid overload,一、容量与心衰,心衰与,Fluid overload,Patients who are admitted to the hospital with either,new-onset or decompensated HF,are usually volume overloaded.,-,Tailored therapy to hemodynamic goals for advanced heart failure.,Eur J Heart Fail,.1999;,一、容量与心衰,心衰主要的病理生理机制,-,Fluid overload,Fluid overload is,a key pathophysiologic mechanism,acute decompensation episodes of HF,the progression of the syndrome.,the most important factor,high readmission rates,renal function worsening.,一、容量与心衰,减轻前负荷是治疗心衰的重要措施,D,ehydration,is a,key issue,in the therapeutic approach to the patient with,heart failure.,Diuretics is“,gold standard,”therapy to congestive heart failure.,二、如何正确判断容量（前负荷）？,后负荷、心肌收缩力与舒张功能,-,通过心脏超声、测血管阻力、测血压等基本能确诊。,但是容量（前负荷）的判断，却没有这么简单！,1.Is the,History and Physical,examination,important?,Value of Clinician Assessment of Hemodynamics in Advanced Heart Failure:,The ESCAPE Trial,ESCAPE,:,the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness,conducted in the United States and Canadaat 26 sites,-,Circ Heart Fail.2008;1:170177.,The ESCAPE Trial,研究对象：,NYHA 4,级的,HF,患者,433,人。,第一组：根据病人的症状和体征评估血流动力学,第二组：利用漂浮导管评估血流动力学（,215,人）,根据两种方法评估的血流动力学结果,指导治疗，观察,6,个月后的生存率。,结 果：,两组患者预后没有差别。,以前，监测容量的主要指标是,BP,、,CVP,和,PCWP,，,但,是,“,压力,容,量,”,，,压力监测易受到胸腔内压的影响,胸腔压力高时，左、右心监测的结果是不同的。,大量研究已证实，判断前负荷，容量监测更准确。,2.,压力指标判断容量,3.BNP,、,NT-proBNP,心室负荷重、室壁张力增加时，二者分泌增加。,临床意义,心脏负荷过重的血浆标志物。,发现早期心衰；排除心衰。,判断治疗效果及判断预后。,BNP,水平越高，病情越重，预后越差。,对心衰的评估价值类似于感染时的“,WBC”,。,(,the level of BNP has been proposed as,a“surrogate”of congestion),Relationship of BNP levels and PCWP in patients with volume-overloaded CHF.,-J Card Fail.2001 Mar;7(1):21-9.,20,例失代偿心衰（,NYHA,分级,III-IV,）患者中，,对个体化治疗有反应的,15,例患者的监测结果。,心肌病患者右室容量增加引起,BNP,升高,研究对象和方法：,41,例,(LVEF40%),的心肌病患者，,19,例健康对照者，,心脏核磁共振成像检测心室舒张、收缩末期容积,同时检测血浆,BNP,结果：,BNP,与右室舒张、收缩末期容积成正相关,结论：,RV fluid overload contributes independently,to plasma elevation of BNP,-,Int J Cardiol.2005 Sep 15;104(1):39-45.,BNP levels correlate closely with the NYHA classification of heart failure,-N Engl J Med.,2002:347(3);161167,BNP,诊断价值,-,diastolic VS systolic dysfunction,-Am Coll Cardiol.,2003;410(11):20102017,BNP,鉴别诊断,-,肺部疾病,一个呼吸困难的病人，,血浆,BNP,正常，则基本能排除心衰（特异性,95%,）。,BNP,鉴别诊断,-,肺水肿,一个肺水肿的病人，,血浆,BNP,正常，则基本能排除心源性肺水肿。,Why elevated BNP levels do not fall with treatment in some patients with HF.,“Wet”BNP,：,a volume/pressure-induced“wet”BNP,-reflecting hydration status,“Dry”BNP:,euvolemic,（正常血容量）“,dry”BNP,-reflecting myocardial status,Why elevated BNP levels do not fall with treatment in some patients with HF.,Firstly:,due to,“,dry”BNP,despite aggressive and prolonged diuretics or vasodilators therapy,some patients never reach target levels of BNP(250pg/ml).,at the expense of a trend of more complications(WRF and AKI),death,and rehospitalization.,NYHA,时，易出现这种情况。,Why elevated BNP levels do not fall with treatment in some patients with HF.,Secondly:,patient with left and right HF and significant ascites and/or edema,This is possibly because mobilization of third space fluid to circulation.,Continuing diuresis and/or vasodilatation should eventually lower BNP levels.,4.Noinvasive moniter,USCOM,（超声心排量监测）,NICOM,（,CO2,重吸收法心功能检测仪）,超声心动图,生物电阻抗矢量分析,能够检测心排量、血管阻力、容量等。,综合分析检测结果，对容量判断具有指导意义,PICCO,-,脉波指示剂连续心排血量监测,（,pulse indicator continuous cardiac,output,）,（,Pulseindexcontinuouscardiacoutput,）,5.Micro-invasive moniter,-PICCO,、,Vigileo,、,TEE,、,胸腔内相关,液体,容积的组成,GEDV,PTV,RAEDV,LAEDV,LVEDV,RVEDV,ITTV,PBV,EVLW,EVLW,：包括肺细胞内液，间质液以及肺泡内液,(,不受胸腔积液的影响,),PICCO,能同时获得,两部分,血流动力学参数,动脉脉搏轮廓分析,P,t,经,肺热稀释,曲线,injection,t,T,心输出量,胸腔内总容量,-,ITTV,全心舒张末期容积,-GEDV,血管外肺水,-,EVLW,肺血管通透性指数,-,PVPI,心功能指数,全心射血分数,连续心输出量,动脉压,心率,每搏量,每搏量变异,-SVV,脉压变异,-PVV,系统血管阻力,ITTV,、,GEDV,-,-,心脏前负荷的指标,左室容量,-GEDV+PTV,ARDS-PTV,右室容量,-GEDV,GEDV,PTV,RAEDV,LAEDV,LVEDV,RVEDV,ITTV,ITTV,PBV,EVLW,（,PTV,）,+,GEDV,均增加,左心容量增加,。,只有,EVLW,（,PTV,）增加,ARDS,（参考肺血管通透性指数,-PVPI,，诊断会更明确）,EVLW,-,左心前负荷的重要指标,EVLW,PBV,LAEDV,LVEDV,Preload,左心前负荷过度，,CO,降低，,血管外肺水增加。,血管外肺水（,EVLW,）,7,CO,EVLW,3,5,3,Preload,减轻左心前负荷，,CO,改善，,血管外肺水减少,。,血管外肺水（,EVLW,）,7,CO,EVLW,3,5,3,EVLW,少量（,10-15%,）增加，,PICCO,能及时发现。,肺水肿早期，胸片可以无异常改变,，,只有在肺水,100-300%,增长时,胸片,才能甄别。,因此，,EVLW,评估肺水肿,远,较,胸,片敏感,.,血管外肺水（,EVLW,）,综合分析判断容量,临床表现（呼吸困难、血压、尿量、胸片）,CVP,超声心动图,BNP,、乳酸,PICCO,检测,一定能获得准确的容量判断,三、心衰的治疗,New heart failure guidelines,-ACC/AHA,In June 2013,Pharmacotherapy:,Diuretics,vasodilators,inotropic agents,anticoagulants,beta blockers,and digoxin,.,The use of aldosterone antagonists in HF is strongly recommended,.,noninvasive positive pressure ventilation,Natriuretic p