ScvO2的临床意义ppt课件

1,ScvO2的临床意义,2,内 容,氧供与氧耗 SvO2与ScvO2 ScvO2的临床应用,3,氧供与氧耗,4,15vol%=15ml/dl,5vol%=5ml/dl,5,6,氧供DO2与氧耗VO2,DO2=CaO2CO=(1.34SaO2Hb+0.0031PaO2)CO=1.34SaO2HbCOVO2=(CaO2-CvO2)CO= (SaO2- SvO2) 1.34 HbCOSvO2=SaO2-VO2/(1.34HbCO),呼吸,血红蛋白,循环,(Fick方程),7,氧摄取EO2,EO2=VO2/DO2 EO2=(SaO2 - SvO2)/SaO2 当SaO2=100%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 - EO2,8,氧供氧耗失衡,SvO2降低或增加,无氧代谢 组织缺氧 乳酸生成,9,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）,10,SvO2 的界值,Pinsky MR, Mancebo J, Applied physiology in intensive care.,11,ScvO2与SvO2,12,ScvO2与SvO2,13,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%,14,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,15,16,正常各组织器官的静脉氧饱和度,Pinsky MR, Mancebo J, Applied physiology in intensive care.,17,休克时？,18,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 ScvO2 and SvO2 measurements for 296 paired samples ScvO2 increases by 0.87% for every unit increase in SvO2,19,ScvO2与SvO2的相关性,Dueck MH et al. Anesthesiology 2005; 103:249 57,20,Moina and Podbregar Critical Care2010,14:R42 th,21,Moina and Podbregar Critical Care2010,14:R42,22,Moina and Podbregar Critical Care2010,14:R42,23,Moina and Podbregar Critical Care2010,14:R42,24,SvO2与ScvO2的一致性,绝对值相差518%,25,ScvO2的临床应用,26,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。,27,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.,28,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）,29,30,研究结果死亡率,31,低ScvO2的预后差,32,2012 “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0.5ml/kg/h ScvO2 70% or SvO2 65%,33,感染性休克高ScvO2的预后,34,35,单因素分析结果,36,存活组与死亡组的ScvO2,37,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,38,23%,25%,31%,初始ScvO2与死亡率,(81/351),(56/223),(14/45),39,25/62,96/465,31/92,40,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;24:12633,41,结果：存活组与死亡组ScvO2的差异有显著性,Acta Cardiol Sin 2008;24:12633,42,所有患者ScvO2、SaO2的变化,存活患者ScvO2的变化,Acta Cardiol Sin 2008;24:12633,43,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 studyAlessandro 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, 17:23,44,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,45,急诊插管对重症患者ScvO2的影响,15min,Hernandez et al. Critical Care2009, 13:R63,46,Hernandez et al. Critical Care2009, 13:R63,47,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,48,围术期ScvO2的应用,49,患者资料,50,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,51,低ScvO2与术后并发症相关,P=0.004,The optimal value of mean ScvO2 for discriminating between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%),52,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): 739746,53,ScvO2与容量反应性,大循环指标：血压、心率、尿量、CVPCO、CI PPV SVV ScvO2,?,54,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: 802807,55,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,56,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,57,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; 5798%) and 81% specificity (95%CI; 5496%),Giraud R, et al. J Trauma.2011;70: 802807,58,ScvO2的局限性,59,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%,Varpula M et al. Intensive Care Med (2006) 32:13361343 Ho KM et al. J Cardiothorac Vasc Anesth. 2010 Jun;24(3):434-9.,60,56.7%,36%,7.3%,ScvO2初始值差异大,(351),(223),(45),Pope JV et al. Ann Emerg Med. 2010 January ; 55(1): 4046,总数619,61,组织氧代谢指标,胃粘膜pH 组织氧饱和度（StO2） 微透析测组织代谢 联合指标 ？,SvO2/ScvO2不能很好反应组织氧代谢,62,微透析？,63,64,ScvO2+CO2gap的意义,Kocsi S et al.Critical Care Research and Practice Volume 2013, Article ID 583598,7pages,65,50 consecutive septic shock patients with ScvO270%,ScvO2+CO2gap的意义,66,SvO2 ScvO2,DO2,VO2,氧利用,67,68,改善氧供改善氧耗？线粒体,Rampal T. Curr Opin Crit Care 16:244249,69,总 结,ScvO2与SvO2 相关性较好，动态监测可反映机体的全身氧代谢状况 ScvO2可作为重症患者病情评估、预后判断的有效参考指标 ScvO2可用于重症患者的治疗指导 ScvO2存在其局限性，不能替代医师的临床综合判断 将来细胞水平缺氧的判断与治疗？！,70,谢 谢！,71,ScvO2与P(cv-a)CO2对外科感染性休克液体复苏的临床研究,昆明医科大学第二附属医院,72,研究背景,本研究是针对腹部外科术后感染性休克患者，监测入ICU最初6小时复苏前后ScvO2、 P(cv-a)CO2，探讨其变化是否能更好的指导患者早期复苏治疗，寻找最佳的复苏目标，以及是否能对病情和预后作出评估和判断。,73,本研究共纳入2012年1月2013年3月期间所有收入昆明医科大学第二附属医院重症医学科（ICU）外科术后感染性休克患者46例，其中住ICU死亡10例，28天死亡16例，住ICU病死率21.7%，28天病死率34.8%。,实验结果,74,6小时复苏前后参数资料比较,实验结果,P=0.044,P=0.005,P=0.000,75,实验结果,ScvO2与lac、BE相关性分析,P(cv-a)CO2与lac、BE相关性分析,76,实验结果,ScvO2与CO相关性分析,P(cv-a)CO2与CO相关性分析,77,实验结果,ScvO2与P(cv-a)CO2的相关性分析,T0时r=-0.358，P=0.011,T6时r=-0.425，P=0.003,78,实验结果,生存组与死亡组各项指标比较,79,实验结果,根据ScvO2是否70%,80,实验结果,根据P(cv-a)CO2是否6mmHg,81,实验结果,2值=5.319，P=0.0700.05，差异无统计学意义,82,实验结果,T6 P(cv-a)CO2AUROC,曲线下面积0.758，与0.5相比差异有统计学意义（P=0.004），对预后有中等判断能力。,