英文文献报告PPT模板.ppt

Effectsoffluidadministrationonrenalperfusionincriticallyillpatients危重病人液体管理对肾灌注的影响 Contents Diagram oxygendelivery oxygendemand Imbalance Introduction Imbalanceinoxygendeliveryandoxygendemandiscommonincriticallyillpatients especiallythosewithacutecirculatoryfailureofseptic hypovolemicorcardiogenicorigin Introduction Acutekidneyinjury AKI isafrequentcomplicationofcirculatoryfailureandassociatedwithincreasedmorbidityandmortality 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 Fluidresuscitationisafirst linetherapyusedtorestoreoxygendeliverytotheorgansandpreventAKIandyettherenaleffectsoffluidresuscitationarenoteasilyassessed 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 Physiciansgenerallyevaluatetheeffectivenessoffluidtherapybylookingatsystemichemodynamicvariables suchasmeanarterialpressure MAP orcardiacoutput becausetheincreaseinurineoutputmaybedelayedorinconsistentandthedecreaseinserumcreatininemaybeevenslower Adirectevaluationofrenalhemodynamicswouldbevaluable 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 比如 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应肾灌注情况 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 WeusedDopplertechniquestoinvestigatetheeffectsoffluidadministrationonintrarenalhemodynamicsandtherelationshipbetweenchangesinrenalhemodynamicsandurineoutput 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 1Summaryofthestudydesign Theinterventionwasafluidchallengethatconsistedofinfusionofaminimumvolumeof500mlataminimumrateof1 000ml hour InterlobararteryDopplervariables bloodpressure heartrateandurineoutputwererecordedbeforeandafterthefluidchallengeandstabilizationofhemodynamicvariables UO 3H urineoutputvolumesmeasuredover3hours 肾脏血管的测量和正常值 正常肾各段肾动脉的阻力指数 RI 各段肾动脉RI 0 65 0 020 63 0 040 59 0 020 54 0 030 51 0 04 Fig 2StudyConsortdiagram SixpatientshadtwoDopplerwavesinsteadofthreeormore twopatientshad 5 differenceinRIbetweenthekidneys RIADrenalinterlobararteryDoppler Criteria Controlgroup ThecontrolgroupsincludedICUpatientswithstablesystemichemodynamicsreceivingnospecificintervention 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 ControlgroupA 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 ControlgroupB 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 Interventiongroup 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 LScvO2 70 或SvO2 65 低动脉压 收缩期动脉压 90mmHgorMAP 65mmHg需要升压药纠正低血压少尿 尿量 0 5ml kg hour Diagram age 18yearsatrialfibrillationfrequentventriculararrhythmiasend stagerenaldiseaseunilateralkidney historyofrenaltransplantationorstenosisofrenalarteriespregnancybodymassindex 40kg m2 Exclusivecriteria Diagram 研究期间监测项目 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 AddYourText AddYourText AddYourText 停止液体管理 0 9 Nacl500mlor6 羟乙基淀粉在动脉压指导下维持最低1000ml h 补液要求 MAP 65mmHg MAPstrokevolumeincrease 10 15 基础值 CVP 15mmHg Results Results FluidadministrationresultedinincreasesinMAPfrom75 15to80 14mmHg p 0 01 PPfrom49 19to55 19mmHg p 0 01 RIdecreasedconcurrentlyfrom0 73 0 09to0 71 0 09 p 0 01 urineoutputincreasedfrom55 76to81 87ml hour p 0 01 Results Fig 4Changesinhemodynamicvariablesbeforeandafterfluidchallenge AChangesinresistivityindex RI BChangesinmeanarterialpressure MAP andinpulsepressure PP They axesshowthemeanvalues standarddeviation MAP1 PP1 RI1arevaluesbeforefluidchallengeandMAP2 PP2 RI2arevaluesafterfluidchallenge Atbaseline RIpredictedanincreaseinurineoutputfollowingafluidchallengeatallthresholdsandMAPpredictedanincreaseatthresholdsof0 2ml kg hourand0 3ml kg hour butnot0 1ml kg hour Table3 Conclusions WeshowedthatfluidadministrationreducesintrarenalvasoconstrictionandthatchangesinRIaremoreeffectivethanchangesinMAPandPPtopredictanincreaseinurineoutputafterfluidchallenge DynamicanalysisofintrarenalhemodynamicsusingRIADcanidentifyrenalresponsivepatients However theuseofRItoguidefluidtherapyforrenalhemodynamicmanagementmaybelimitedbythesmallmagnitudeofthechangesandpotentialtechnicallimitations 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应性 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 Thankyou