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1、,休克患者血容量监测,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,休克的概念,感染、创伤、烧伤等 引起有效循环血量明显减少 组织器官的灌注不足 氧输送不能满足组织代谢需要 导致组织缺氧 代谢障碍和细胞受损 临床综合征,休克治疗的首要任务： 积极、合适补充血容量,休克发生的始动因素： 有效循环血量下降,合适的容量管理,容量管理的基本目标,保证容量合适的心脏前负荷,预防肺水肿,二者必须平衡,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,RVEDP
2、/LVEDP的测定,压力反映容量及肺水肿的局限性,心脏顺应性 瓣膜功能 肺毛细血管通透性 机械通气对循环的影响,PAC对容量监测的 有效性和可信性受到置疑？,许多文献：CVP/PAWP 不能准确反映容量状态,Principle of EVLW measurement,RAEDV,LAEDV,LVEDV,PBV,RVEDV,EVLW,Injection,Picco Thermo-dilution catheter,Swan-ganz catheter,呼吁容量指标的应用 来反映容量状态及肺水肿,内容简介,容量管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 E
3、VLW的应用 小结,A physiological system model,ITTV : Intrathoracic total volume,GEDV : Global end-diastolic volume,ITBV : Intrathoracic blood volume,PTV : Pulmonary total volume,EVLW : extra-pulmonary lung water,胸內总容量,全心舒张期血容量,胸內血液容量,肺部容积,血管外肺水,容量指标的应用,胸腔内血管容量(ITBV) 血管外肺水(EVLW) 搏出量变异率(SVV),胸腔内血管容量(ITBV),左心
4、舒张末期容量 右心舒张末期容量 肺血容量,搏出量变异率(SVV),SVV=(SVmax SVmin)/SVmean Svmax:mean value of four SVmax/30s SVmin :mean value of four SVmin/30s SVmean,血管外肺水组成(EVLW),细胞内液 间质液体 肺泡内液体,内容简介,管理的基本目标 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,ITBVvalid estimate of preload in ALI,Prospective animal study 15 sheep with
5、 ALI -saline washout MV(PEEP 0,7,14,21 respectively 60min) Measurement: LVEF,LVEDV-CT scan ITBV,RVEDV-PiCCO CVP,PAWP-PAC,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,Luecke T, et al. Intensive Care Med, 2004, 30: 119-126,ITBV and RVEDV
6、 Provide valid estimate of preload Even at high intrathoracic pressure,ITBV-indicator of preload in liver transplantation,60 patients undergoing Liver transplantation monitored with PiCCO and PAC the correlation between PAOP and ITBVI with respect to CI and SVI the correlation between ITBVI and PAOP
7、,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - more reliable indicator of preload than PAWP,Della Rocca G, et al. Eur J Anaesthesiol. 2002, 19: 868-75,ITBVI - valid indicator of preload in lung transplantation,50 patients during lung transplantation Time: 6 phase during operatio
8、n Correlation between PAWP and SVI Correlation between ITBVI and SVI Correlation between (Delta) ITBVI PAWP and Delta SVI Delta were calculated by subtracting the first from the second measurement Della RG, et al. Anesth Analg. 2002 , 95: 835-43,ITBV- superior than PAWP in preload,Della RG, et al. A
9、nesth Analg. 2002 , 95: 835-43,Correlation of ITBV - SV in 4 phases,No correlation of PAWP - SV in any phases,Prospective, controlled, clinical study 18 patients with ejection fraction 50% undergoing coronary artery bypass graft surgery A baseline measurement :after induction of anesthesia (T1) trea
10、ted by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) After 10 minutes, a second measurement (T2) was performed,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,ITBV correlated significantly with CI and SV IN CABG,ITBV has Good relationship between CI/SVI, CVP/ PCWP 与 CI/SV无相关性, IT
11、BV 与 CI的相关性r = 0.55, ITBV 与 SV的相关性为r = 0.62,Wiesenack C, et al. Cardiothorac Vasc Anesth. 2001, 15:584-8,前瞻性临床研究 40例心脏移植术后患者 男34例，女6例 观察术后3、6、12、24、36、48、72h ITBV/GEDV和CVP/PAWP与SV的相关性,ITBV/GEDV-good preload indicator in heart transplantation,Goedje O, et al. Chest, 2000, 118: 775-781,Goedje O, et al
12、. Chest, 2000, 118: 775-781,Goedje O, et al. Chest, 2000, 118: 775-781,GEDV-SV: R2=0.4016 ITBV-SV: R2=0.2979,Goedje O, et al. Chest, 2000, 118: 775-781,PAWP-SV: R2=0.0043 CVP-SV: R2=0.0552,ITBV的改变反映肺水含量,Prospectively study 16 patients with septic shock and pulmonary edema(ACCP/SCCM) SAPS II: 56 Moni
13、tor: Picco,PAC Optimal PAWP: CI no longer increased Monitor time: 0, 24h Intensive Care Med, 2002,28,712-18,From intensive Care Med, 2002,28,712-18,CVP与EVLW的相关性,PAWP与EVLW的相关性,Correlation between ITBV/TEDV and EVLW,From intensive Care Med, 2002,28,712-18,ITBV 与 EVLW有良好相关性 优于 CVP 与 PAWP,内容简介,容量管理的基本目标
14、 容量监测的现状及局限性 容量监测的进展 ITBV的应用 SVV的应用 EVLW的应用 小结,SVV可以反映机体前负荷,Prospective study 20 MV patients following cardiac surgery Volume loading(HES 20ml*BSA/10min) Measurement: CVP, PAWP-PAC LVEDAI-TEE ITBV, SVV-PiCCO,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,血流动力学监测,SVV may help to determine the
15、 preload condition,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,CVP/PAWP not correlated with CI,SVV may help to determine the preload condition,Reuter DA, et al. Intensive Care Med. 2002, 28: 392-8.,CVP not correlated,SVV反映机体对容量治疗的反应,15例脑外科手术患者 麻醉诱导后 容量负荷实验： 100 mL of 6% hydroxyethylstarch
16、 given for 2 min 分组：responsive: SV5% nonresponsive: SV5% A total of 140 VLSs were performed,Anesth Analg. 2001, 92: 984-9,两组负荷试验前血流动力学状态,Response(70) nonresponse(70) P HR 76 75 NS SBP 102 116 0.001 CVP 9.3 9.3 NS SVV 12.6 6.8 0.001,Anesth Analg. 2001, 92: 984-9,两组负荷试验后血流动力学改变,Response(70) nonresponse(70) P HR -1 -1 NS SBP 9 2 0.001 CVP 9.8 11.9 NS SVV -25.8 -10 0.001,
