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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,*,Effects of fluid administration on renal perfusion in critically ill patients,危重病人液体管理对肾灌注的影响,Contents,Introduction,1,Methods,2,Results,3,Conclusions,4,Diagram,oxygen delivery,oxygen demand,Imbalance,Introduction,Imbalance in oxygen delivery and oxygen demand is common in critically ill patients,especially those with acute circulatory failure of septic,hypovolemic or cardiogenic origin.,Introduction,Acute kidney injury(AKI)is a frequent complication of circulatory failure and associated with increased morbidity and mortality.,急性肾损伤是循环衰竭状态下的常见并发症，它与发病率及死亡率的升高密切相关。,Introduction,Fluid resuscitation is a first-line therapy used to restore oxygen delivery,to the organs and prevent AKI and yet the renal effects of fluid resuscitation are not easily assessed.,液体复苏是恢复器官血氧输送及预防,AKI,的一线治疗方法，然而液体复苏对于肾脏的影响是不容易评估的。,Introduction,Physicians generally evaluate the effectiveness of fluid therapy by looking at systemic hemodynamic variables,such as mean arterial pressure(MAP)or cardiac output,because the increase in urine output may be delayed or inconsistent and the decrease in serum creatinine may be even slower.A direct evaluation of renal hemodynamics would be valuable.,医师通常通过全身血流动力学变量来评估液体治疗的效果，比方：平均动脉压、心输出量，因为尿量增加可能会延迟或者与实际情况不一致，血肌酐的下降也非常慢，这些指标都不能及时有效的反响肾灌注情况。,一种可以直接评估肾脏血流动力学的方法将非常有价值。,Introduction,We used Doppler techniques to investigate the effects of fluid administration on intrarenal hemodynamics and the relationship between changes in renal hemodynamics and urine output.,我们用多普勒技术研究液体管理对肾内血流动力学的影响以及肾脏血流动力学与尿量的关系。,Fig.1 Summary of the study design.The intervention was a fluid challenge that consisted of infusion of a minimum volume of 500 ml at a minimum rate of 1,000 ml/hour.,Interlobar artery Doppler variables,blood pressure,heart rate and urine output,were recorded,before and after,the fluid challenge and stabilization of hemodynamic variables.UO/3H:urine output volumes measured over 3 hours,.,肾脏血管的测量和正常值,阻力指数,（,RI,，,Resistance Index,）,=,（,Vmax-Vmin,）,/Vmax,正常肾各段肾动脉的阻力指数RI,各段肾动脉,RI,主肾动脉 段动脉 叶间动脉 弓状动脉 小叶间动脉,0.65,0.02 0.630.04 0.590.02 0.54 0.03 0.510.04,Fig.2 Study Consort diagram.*Six patients had two Doppler waves instead of three or more,two patients had 5%difference in RI between the kidneys.RIAD renal interlobar artery Doppler,.,Criteria-Control group,The control groups included ICU patients with stable systemic hemodynamics receiving no specific intervention.,对照组包括全身血流动力学稳定且没有接受特殊干预的,ICU,病人。,Control group A,评价观察者在测量肾叶间动脉RI自身偏差,测量3次3个心动周期，每次间隔15min,同一超声医师测量，RI计算由统计员负责。,Control group B,评价多普勒变量的稳定性,测量,2,次，间隔,60min,由同一超声医师测量，,RI,计算由统计员负责。,Criteria-Intervention group,需要液体冲击治疗的急性循环衰竭患者：,并且至少包含以下一条标准：,神志改变,四肢白斑,动脉血乳酸,2mmol/L,ScvO,2,70%,或,SvO,2,65%,低动脉压：收缩期动脉压90mmHg or MAP65mmHg,需要升压药纠正低血压,少尿尿量0.5ml/kg/hour,Diagram,age 40 kg/m,2,Exclusive criteria,Diagram,given diuretics,Excluded from the study,changes in vasopressor administration,during the study period,研究期间监测工程,持续动态心电图监测,心率,有创平均动脉压、脉压桡动脉or股动脉,血乳酸,ScvO2 及SvO2,Diagram,Add Your Text,Add Your Text,Add Your Text,停止液体管理,0.9%Nacl 500ml or 6%,羟乙基淀粉,在动脉压指导下维持最低,1000ml/h.,补液要求,MAP65mmHg,MAP stroke volume,increase10-15%根底值,CVP15mmHg,Fig.3,Individual changes in RI over time in the non-intervention group(Control group B).Each line corresponds to the change in RI in one stable ICU patient.Measurements were performed at baseline and 1 hour later in stable hemodynamic conditions with no intervention,Results,Results,Fluid administration resulted in increases in MAP from 75 15 to 80 14 mmHg(p 0.01),PP from 49 19 to 55 19 mmHg(p 0.01).,RI decreased concurrently from 0.73 0.09 to 0.71 0.09(p 0.01),urine output increased from 55 76 to 81 87 ml/hour(p 0.01).,Results,Fig.4 Changes in hemodynamic variables before and after fluid challenge.,A,Changes in resistivity index(RI).,B,Changes in mean arterial pressure(MAP)and in pulse pressure(PP).The y-axes show the mean values standard deviation.MAP,1,PP,1,RI,1,are values before fluid challenge and MAP,2,PP,2,RI,2,are values after fluid challenge,.,At baseline,RI predicted an increase in urine output following a fluid challenge at all thresholds and MAP predicted an increase at thresholds of 0.2 ml/kg/hour and 0.3 ml/kg/hour,but not 0.1 ml/kg/hour(Table 3).,Conclusions,We showed that fluid administration reduces intrarenal vasoconstriction and that changes in RI are more effective than changes in MAP and PP to predict an increase in urine output after fluid challenge.Dynamic analysis of intrarenal hemodynamics using RIAD can identify renal responsive patients.However,the use of RI to guide fluid therapy for renal hemodynamic management may be limited by the small magnitude of the changes and potential technical limitations.,我们的研究显示液体管理降低肾内血管张力，RI的变化比MAP和PP更能预知快速输液后尿量的增加。,利用RIAD动态分析肾内血流动力学可以识别患者的肾脏反响性。然而RI指导肾脏血流动力学管理的液体治疗可能会受到变量太小以及潜在技术上的限制。,Thank you!,