血流动力学监测与支持：可圈、可点(讨论).ppt
从休克临床病例说起血流动力学监测与支持：可圈、可点您期望获得哪些信息？监测与支持的目标导向实现目标的过程与理解结论：共性基础上的个性治疗病 史患者李XX，女性，71岁，体重55 Kg主诉：肛门停止排气排便4天，腹痛1+天现病史：n入院前4天患者无明显诱因出现肛门停止排气排便，逐渐出现腹胀，不伴腹痛，无畏寒发热等不适n1+天前患者进食后出现腹痛腹胀，伴发热，恶心、呕吐，至当地医院就诊，行腹部CT示肠梗阻可能，给予胃肠减压等对症支持治疗，病情未好转，尿少n为进一步治疗来院急诊，以“腹痛待查：肠梗阻”收住入院病史与体检既往史：有高血压病史，不规则用药，余未提供特殊病史家族史：无特殊入院查体：nT 38.6，P 139次/分，R 30次/分，BP 141/92mmHgn神志清楚，急性病容，心肺听诊未见明显异常n腹部查体：腹部膨隆，全腹肌紧张，压痛及反跳痛明显实验室检查急诊血常规：WBC 17.8*109/L，N%93.8%，Hb 112g/L生化：TBIL 42.7 umol/L DBIL 22.4 umol/L ALT 42 IU/L AST 80 IU/L BUN 11.01mmol/L Cr 137umol/L PT 21.5 s，APTT 44.3 s，FIB 3.43 g/L ABG：PiO2 5 L/min，PaO2 65 mmHg，PaCO2 35 mmHg PH 7.29，LAC 3.1 mmol/L问 题如你为接诊医师或邀请你会诊，此时，除病因诊断外，n什么状态是你最关注的？n作为ICU大夫你应该做什么？辅助检查：CT阑尾肿胀，根部见高密度粪石，远端形态失常，升结肠及末段回肠明显肿胀，周围多发积液、积气，盆腔散在游离积液、积气，腹腔积液，腹盆腔脂肪间隙及肠系膜广泛肿胀，腹膜及盆底筋膜增厚考虑急性阑尾炎伴穿孔，脓肿形成可能，弥漫性腹膜炎急诊手术急诊行“剖腹探查术”术中见：腹腔内脓性粪样液 1600 ml，腹腔污染极重，小肠表面覆有多量脓苔，阑尾中部坏疽穿孔，可见粪石溢出麻醉达成后，出现血压下降，NBP 80/50 mmHg，术中（3小时）补液3500ml，小便80 ml，并使用去甲肾上腺素术后转入ICU，转入时大剂量血管活性药物维持血压转入ICU情况住院医师初步处理n晶体液600mln去甲肾上腺素 2.22 ug/kg.min1小时后：nT 37.6，HR 123 次/分；ABP 103/61 mmHg；UO/hr 40 ml；CVP 11 mmHg nRR 12次/分，SPO2 90%uPEEP 12 mmHg uFIO2 100%而且，还有如此的Chest-X-line，为什么？实验室检查血常规：WBC 21.89*109/L N%93.8%，Hb 112g/LCRP 200 mg/L，PCT 10.5gL生化：TBIL 32.7 umol/L，DBIL 26.4 umol/L，ALT 42 IU/L AST 68 IU/L，Alb3.24 g/L BUN 12.1mmol/L，Cr 297umol/L PT 23.5 s，APTT 54.3 s，FIB 3.24 g/L ABG：PiO2 100%，PaO2 61 mmHg，PaCO2 45 mmHg PH 7.29，LAC 15.5mmol/L，SvO2 72%pro-BNP 11689pg/mlAPACHE II 28 分此时，你如何评估病情，进一步处理？感染性休克急性弥漫性腹膜炎急性阑尾炎伴穿孔诊断与鉴别感染：明确的感染灶全身性感染休克：麻醉术中已充分补液，休克未纠正血管活性药物维持血压器官功能受损组织灌注不足其他类型的休克？共性：感染性休克原则：严重全身性感染与感染性休克治疗指南SSC2012下一步诊治？对症：支持SSC2012：推荐尽快寻找确诊或排除需要采取紧急感染控制措施的感染灶（如坏死性软组织感染、腹膜炎、胆管炎或肠坏死），如有可能应在确诊后12小时内进行处理以控制感染灶（推荐级别仍维持1C）SSC2012：推荐尽早开始静脉抗生素治疗，应当在确诊感染性休克（推荐级别仍维持1B）或不伴有休克的严重全身性感染（推荐级别由1D提高到1C）后一小时内应用抗生素对因：原发病下一步治疗SSC2012：对于全身性感染诱发的组织低灌注患者（表现为初始液体复苏治疗后仍持续低血压或血乳酸水平4 mmol/L），推荐采用定量复苏方案进行治疗（推荐级别仍维持1C）对症：支持对因：原发病Surviving Sepsis Campaign 2012CVP=8-12mmHg平均动脉压 65mmHgScvO2 70%尿量 0.5ml/kg/h目标意义何在？RR 12次/分 SPO2 90%nPEEP 15 mmHg nFIO2 100%下一步：限液利尿？HR 123 次/分Pro-BNP 11689 pg/mlCVPABPSvO2 U.O./hr11103/617240下一步：限液利尿？什么是目标？血管活性药物n去甲肾上腺素 2.22 ug/kg.min乳酸：11.811.4 mmol/L转入ICU情况严重全身性感染与感染性休克治疗指南2012：对于乳酸水平升高的患者，建议复苏治疗以乳酸恢复正常为目标（推荐级别为2C）个性：假象达标血管活性药物n去甲肾上腺素 2.22 ug/kg.min乳酸：11.811.4 mmol/L如何实现目标？组织灌注与氧合评估n前负荷，容量反应性n心脏功能n后负荷n组织灌注我们还能做什么？n还有些什么评估指标？n获得这些指标，能够采取哪些监测手段？血流动力学监测分级监测回到共性：增加容量及反应性指标HR123ABP103/61MAP75CVP11GEDI639SVV31CI2.58SVI16GEF11%SVRI2457ELWI15个性：心功能？u71岁，GEF 11%，Pro-BNP 11689 pg/mluTn-I阳性；CK 959，CK-MB 40 IU/L共性：容量不足继续液体复苏1835M ateri al s and m ethodsPat i ent sW e st udi ed 39 m echani cal l y vent i l at ed pat i ent s wi t h sept i c shock.Thi sgroup com pri sed 22 m en and 17 wom en,aged bet ween 20 and80 years(m ean age 65 15 years).Incl usi on cri t eri a were sept i cshock asdefi ned by t heInt ernat i onalSepsi sDefi ni t i onsConference10,and t he cl i ni cal requi rem ent for a rapi d vol um e chal l enge(8 m L/kg of6%hydroxyet hyl st arch over20 m i n)accordi ng t o t heat t endi ng physi ci an.The physi ci an s deci si on was based on t hepresence of cl i ni cal si gns of acut e ci rcul at ory fai l ure(l ow bl oodpressure or uri ne out put,t achycardi a,m ot t l i ng),or/and bi ol ogi calsi gns of organ dysfunct i on(renal or hepat i c dysfunct i on,hyper-l act aci dem i a)and on t he absence of cont rai ndi cat i on t o a fl ui dchal l enge(l i fe-t hreat eni ng hypoxem i a,echocardi ographi c evi denceofri ghtvent ri cul arfai l ure).The i nst i t ut i onalrevi ew board forhu-m an subj ect sconsi dered t he prot ocolt o beapartofrout i ne cl i ni calpract i ce so t hatno wri t t en i nform ed consentwasobt ai ned from t hepat i ent s nextofki n.M easurem ent sA t wo-di m ensi onal echographi c sect or was used t o vi sual i ze t hei nferi orvena cava(sub-xyphoi dall ong axi svi ew),and i t sM-m odecursor was used t o generat e a t i m e-m ot i on record of t he i nferi orvena cava di am et er(DIVC)approxi m at el y 3 cm from t he ri ghtat ri um(Fi g.1).M axi m um and m i ni m um DIVCval uesovera si ngl erespi rat ory cycl e were col l ect ed and t he DIVCvari at i on(DDIVC)cal cul at ed as t he di fference bet ween t he m axi m um and t he m i ni-m um DIVCval ue,norm al i zed by t he m ean oft he t wo val ues andexpressed asa percent age.Cardi ac out put was eval uat ed usi ng echocardi ography bym easuri ng t he di am et eroft he aort i c ori fi ce and t he vel oci t y t i m ei nt egral of aort i c bl ood fl ow duri ng end-expi rat i on as previ ousl ydescri bed 7.Al lm easurem ent s were perform ed i n t ri pl i cat e by asi ngl e experi enced operat or(M.F.).The reproduci bi l i t y ofDDIVCand cardi ac out putm easurem ent sst andard devi at i on(SD)di vi ded by t he m ean of t he t hree m ea-surem ent swas 3 4%and 9 5%,respect i vel y.St udy prot ocolAl lpat i ent swere sedat ed and m echani cal l y vent i l at ed i n a vol um e-cont rol l ed m ode wi t h a t i dalvol um e of8 10 m L/kg.Two set s ofm easurem ent swere perform ed:t he fi rstpri ort o vol um e expansi onand t he s
