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1、危重病患者的血流动力学监测与危重病患者的血流动力学监测与治疗治疗血流动力学监测与治疗COMAPSVR=xSVHRx后负荷后负荷前负荷前负荷心肌收缩力心肌收缩力脱水: 临床表现体格检查发现敏感性/特异性, %+LR (95%CI)-LR (95%CI)体位性脉搏加快 30 bpm43/751.7 (0.7 4.0)0.8 (0.5 1.3)体位性低血压29/811.5 (0.5 4.6)0.9 (0.6 1.3)粘膜干燥85/582.0 (1.0 4.0)0.3 (0.1 0.6)舌干59/732.1 (0.8 5.8)0.6 (0.3 1.0)舌体皱缩85/582.0 (1.0 4.0)0.3
2、 (0.1 0.6)眼睛凹陷62/823.4 (1.0 12.2)0.5 (0.3 0.7)意识模糊57/732.1 (0.8 5.7)0.6 (0.4 1.0)肢体无力43/822.3 (0.6 8.6)0.7 (0.5 1.0)言语不流利56/823.1 (1.2 14.9)0.7 (0.5 0.9)前负荷的维持: 指南建议复苏目标 (1C)中心静脉压(CVP) 8 12 mmHg*平均动脉压 65 mmHg尿量 0.5 ml/kg/hr中心静脉(上腔静脉)血氧饱和度 70%，或混合静脉血氧饱和度 65%Dellinger RP, Levy MM, Carlet JM, et al. Su
3、rviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.中心静脉压: 影响因素基础水平出血420 ml(310 470 ml)NE0.001 g/kg/minHR (bpm)167 (35)210 (44)*153 (56)*MAP (mmHg)144 (42)85 (46
4、)*153 (36)*CVP (mmHg)5.5 (4.2)3.0 (4.2)2.0 (4.0)PAOP (mmHg)6.0 (5.1)4.5 (4.0)3.5 (5.1)CO (lpm)4.68 (3.30)1.98 (0.86)*3.08 (1.72)*,*SVR (dyne.sec/cm5)2367 (1475)3313 (1900)*3922 (2744)*,*PVR (dyne.sec.cm-5)213 (182)303 (245)*428 (310)PPV (%)12 (9)28 (11.5)*14.5 (6.2)*SPV (mmHg)12.5 (6.5)21 (8.2)*15.5
5、 (4.5)*Nouira S, Elatrous S, Dimassi S, et al. Effects of norepinephrine on static and dynamic preload indicators in experimental hemorrhagic shock. Crit Care Med 2005; 33: 2339-2343容量负荷试验: 判断标准每10分钟测定CVPCVP 2 mmHg继续快速补液CVP 2 5 mmHg暂停快速补液, 等待10分钟后再次评估CVP 5 mmHg停止快速补液每10分钟测定PAWPPAWP 3 mmHg继续快速补液PAWP
6、3 7 mmHg暂停快速补液, 等待10分钟后再次评估PAWP 7 mmHg停止快速补液Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124132病例1: 现病史男性, 70岁, 2001年1月9日入院咳嗽, 咳痰12天, 发热4天, 呼吸困难1天12天前咳嗽, 咳黄粘痰, 伴全身乏力4天前寒战高热, 体温39.5CCXR：肺部感染, 右上肺膨胀不全头孢呋肟治疗无效1天前呼吸困难, 紫绀, 伴血压下降(50/20
7、 mmHg)病例1: 入院情况入入ICU时时BT 37.2CHR 130 bpmBP 84/40 mmHg (DA 10 g/kg/min)SpO2 78%双肺散在湿双肺散在湿罗罗音音病例1: 入院诊断诊断重度社区获得性肺炎急性呼吸功能衰竭感染性休克病例1: 支持治疗呼吸功能支持(SIMV + PSV)FiO2 100%, PEEP 10 cmH2OSpO2 92%循环支持羟基淀粉500 ml扩容无效DA 13 g/kg/min NE 1.2 g/kg/minBP 110/70 mmHg病例1: 血流动力学监测放置肺动脉漂浮导管HR130MAP71CVP9PAWP9CI1.96SVRI2524
8、PVRI529NE1.0病例1: 血流动力学监测扩容3000 ml后HR103MAP118CVP12PAWP18CI3.63SVRI2182PVRI331NE1.0白蛋白 vs. 晶体液: SAFE研究多中心, 随机, 双盲, 对照试验澳大利亚和新西兰16个ICU的7000名患者2001/11至2003/6入选标准: 需要输液治疗 + 1项低血容量的客观指标排除标准: 肝脏移植, 心脏手术, 烧伤4%白蛋白(n = 3499) vs. 生理盐水(n = 3501)The SAFE Stuy Investigators. A comparison of albumin and saline fo
9、r fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.白蛋白 vs. 晶体液: SAFE研究白蛋白白蛋白生理盐水生理盐水28天病死率天病死率(%)20.921.1ICU住院日住院日(d)6.5
10、6.66.2 6.2机械通气时间机械通气时间(d)4.5 6.14.3 5.7肾脏替代治疗时间肾脏替代治疗时间(d)0.48 2.280.39 2.00新发器官功能衰竭新发器官功能衰竭无无52.753.31个器官个器官30.029.82个器官个器官13.913.53个器官个器官2.62.84个器官个器官0.70.65个器官个器官0.10The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 20
11、04;350:2247-56The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.白蛋白 vs. 晶体液: SAFE研究The SAFE Stuy Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit.
12、N Engl J Med 2004;350:2247-56The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256.乳酸林格液 vs 羟乙基淀粉: VISEP强化胰岛素治疗强化胰岛素治疗传统胰岛素治疗传统胰岛素治疗羟乙基淀粉羟乙基淀粉247290乳酸林格液乳酸林格液Brunkhorst FM, Engel C, Bloos F, et al. Inten
13、sive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳酸林格液 vs 羟乙基淀粉: VISEP强化胰岛素治疗强化胰岛素治疗传统胰岛素治疗传统胰岛素治疗羟乙基淀粉羟乙基淀粉262乳酸林格液乳酸林格液275Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J M
14、ed 2008; 358: 125-139.乳酸林格液 vs 羟乙基淀粉: VISEP乳酸林格液(n = 275)HES (n = 262)P28天病死率n/N66/27470/2620.48%24.1 (19.0 29.2)26.7 (21.4 32.1)90天病死率n/N93/274107/2610.09%33.9 (28.3 39.6)41.0 (35.0 47.0)凝血系统SOFA评分0.11 (0 0.83)0.46 (0 1.30) 0.001肾脏SOFA评分0.42 (0 1.33)0.67 (0 1.94)0.02急性肾功能衰竭n/N62/27291/2610.002%22.8
15、 (17.8 27.8)34.9 (29.1 40.7)肾脏替代治疗n/N51/27281/2610.001%18.8 (14.1 23.4)31.0 (25.4 36.7)输注RBC单位4 (2 8)6 (4 12) 0.001Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.乳酸林格液 vs 羟乙基淀粉: VISEPBrunkhorst FM, Eng
16、el C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139.血流动力学监测: 前负荷前负荷不足危重病人中非常普遍临床表现缺乏特异性可能需要试验性治疗不同种类液体有差异血流动力学监测: 基本内容1前负荷前负荷Preload3组织灌注组织灌注Tissue Perfusion2灌注压灌注压MAP血流动力学中的欧姆定律R = P / flowPinPoutflowR器官灌注压肾脏灌注RPP = MAP IAP
17、FG = GFP PTP = MAP IAP x 2脑灌注CPP = MAP ICP健康与疾病时的自身调节015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope疾病时的自身调节机制015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)control3 weeks1 week升压药物: 指南建议维持MAP
18、65 mmHg (1C)首选升压药物应为去甲肾上腺素或多巴胺, 并经中心静脉输注(1C)肾上腺素, 苯肾上腺素或血管加压素不应作为感染性休克的一线用药(2C)在去甲肾上腺素基础上加用血管加压素0.03 U/min, 可能与单纯应用去甲肾上腺素效果相等感染性休克时如血压对去甲肾上腺素反应不佳, 可首选肾上腺素或多巴胺(2B)不应使用小剂量多巴胺进行肾脏保护(1A)需要升压药的患者应留置动脉导管(1D)Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for ma
19、nagement of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Care Med 2008; 36(4): 1394-1396.平均动脉压应当多少?无创血压不准确高血压时读数低低血压时读数高有创血压与无创血压经常不一致血流动力学监测: 技巧确认患者的平均动脉压家属病历记录检查患者平均动脉压的测定方法无创 vs. 有创确定无创血压与有创血压的差值病例2: 基本情况男性, 74岁, 病历号既往史I型糖尿病18年糖尿病肾病高血压病史5年口服络活喜, 倍他乐克等
20、药物平素BP 160 180 / 70 90 mmHg病例2: 现病史2007年7月25日入院主因发现恶心, 呕吐1周, 伴心前区疼痛及少尿3天1周前出现恶心, 呕吐, 予对症治疗3天前出现心前区疼痛, 憋闷, 尿量减少静脉泵入NG 100 g/min, 控制BP 134/56 mmHg血Cr 861 mol/L, UO 500 ml/d (速尿400 mg/d)血液透析, 透析过程中出现心绞痛, 持续不缓解病例2: 体格检查GCSE4V5M6BT36.2CHR70 bpmRR20 bpmBP103/45 mmHgSpO298 100% (鼻导管吸氧5 lpm)病例2: 实验室检查CBC: W
21、CC 14.79, Hb 102, plt 215Chemistry (8 2):Na140mmol/LCl 97mmol/LK 4.2mmol/LCr745mol/LBUN 31.14mmol/LCK-MB 6.8u/LcTnI 11.56g/LGLU 21.5mmol/L病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6导联ST段压低0.1 0.2 mv病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6导联ST段压低0.1 0.2 mv病例2: MAP与组织灌注心绞痛*发作时EKG: V3-6导联ST段压低0.1 0.2 mv感染性休克: NE + DB vs. Epi满足
22、以下标准 7 d感染证据SIRS标准 2/4组织低灌注或器官功能不全( 2)PaO2/FiO2 280UO 2 mmol/LPlt 100 x 109/L满足以下标准 24 hSBP 90 mmHg或MAP 1000 ml或PCWP 12 18 mmHg血管活性药物多巴胺 15 g/kg/minEpi或NE: 任何剂量Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised t
23、rial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. EpiAnnane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. Epi总计(n = 330)Epi (n = 161)NE + DB (n = 169)年龄(岁)63 (50 7
24、3)65 (53 75)60 (47 72)男性(%)202 (61%)103 (64%)99 (59%)SAPS II53 (40 65)54 (42 67)52 (38 - 64)SOFA11 (9 14)11 (9 13)11 (9 14)MAP (mmHg)69 (19)70 (19)68 (19)DA 15 g/kg/min63 (19%)38 (24%)25 (15%)Epi137 (42%)61 (38%)76 (45%)NE102 (31%)48 (30%)54 (32%)早期适当抗生素(%)250 (76%)119 (74%)131 (78%)RRT (%)31 (9%)15
25、 (9%)16 (10%)皮质激素(%)263 (80%)133 (83%)130 (77%)APC (%)25 (21%)11 (19%)14 (23%)Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. EpiEpi (n = 161)NE + DB (n = 169
26、)P值7天病死率(%)40 (25%)34 (20%)0.3014天病死率(%)56 (35%)44 (26%)0.0828天病死率(%)64 (40%)58 (34%)0.31ICU病死率(%)75 (47%)75 (44%)0.69住院病死率(%)84 (52%)82 (49%)0.5190天病死率(%)84 (52%)85 (50%)0.73ORHR所有变量(n = 308)0.90 (0.54 1.49)0.87 (0.59 1.28)除适当抗生素外的所有变量(n = 319)0.82 (0.51 1.34)0.84 (0.58 1.22)除适当抗生素及乳酸外的所有变量(n = 330
27、)0.82 (0.51 1.31)0.87 (0.61 1.24)Annane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: NE + DB vs. EpiAnnane D, Vignon P, Renault A, et al. Norepinephrine plus dobutamine versu
28、s epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.感染性休克感染性休克需要血管活性药物需要血管活性药物(NE 5 g/min) (n
29、= 779)起始剂量0.01 U/min增加剂量0.005 U/min最大剂量0.03 U/min (n = 397)起始剂量5 g/min增加剂量2.5 g/min最大剂量15 g/min) (n = 382)血管加压素(VP)(0.12 U/ml) (n = 397)去甲肾上腺素(NE)(60 g/ml) (n = 382)感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Eng
30、l J Med 2008; 358: 877-87.NE (n = 382)VP (n = 397)P值年龄(岁)61.8 1659.3 16.40.03男性(%)229 (59.9)246 (62.0)0.56APACHE II27.1 6.927.0 7.70.84MAP (mmHg)73 1072 90.23LA (mmol/L)3.5 3.03.5 3.20.96DA (g/kg/min)7.3 5.37.6 6.40.88DB (g/kg/min)5.1 3.76.4 5.20.18Epi (g/kg/min)0.12 0.150.20 0.290.12NE (g/kg/min)0.
31、28 0.260.26 0.270.97 2种升压药物111 (29.1)124 (31.2)0.51皮质激素(%)293 (76.7)296 (74.6)0.49APC (%)56 (14.7)61 (15.4)0.78感染性休克: VP vs. NENE组组(n = 382)VP组组(n = 396)PARR(95% CI)RR(95% CI)校正校正OR28天病死率150/382(39.3)140/396(35.4)0.263.9(-2.9 to 10.7)0.90(0.75 1.08)0.88(0.62 1.26)90天病死率188/379(49.6)172/392(43.9)0.11
32、5.7(-1.3 to 12.8)0.88(0.76 1.03)0.81(0.57 1.16)Russell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med 2008; 358: 877-87.感染性休克: VP vs. NERussell JA, Walley KR, Singer J, et al. Vasopressin versus Norepinephrine Infusion in Patien
33、ts with Septic Shock. N Engl J Med 2008; 358: 877-87.Parrillo JE. Septic shock vasopressin, norepinephrine, and urgency. N Engl J Med 2008; 358: 954-956血流动力学监测: 灌注压灌注压不足灌注压没有固定数值注意有创及无创血压的差异根据患者情况确定目标血压排除低血容量时应用升压药具有受体激动作用的药物(多巴胺, 去甲肾上腺素等)血流动力学监测: 基本内容1前负荷前负荷Preload3组织灌注组织灌注Tissue Perfusion2灌注压灌注压MA
34、P病例3一名25岁体重70 kg肺炎患者, BP 100/50 (65) mmHg, CVP 0 mmHg, 尿量50 ml/hr, pH 7.4. 患者神志清楚, 四肢温暖. 最适宜的血流动力学处理措施为:1.IV输注胶体液250 ml2.无需任何处理3.IV输注5%葡萄糖250 ml4.小剂量多巴胺输注5.多巴酚丁胺输注组织灌注不足的表现皮肤花斑四肢冰冷毛细血管再充盈时间延长尿量减少意识障碍代谢性酸中毒乳酸酸中毒ScvO2 4.5 L/min/m2DO2I 600 ml/min/m2VO2I 170 ml/min/m2 Velmahos GC, Demetriades D, Shoemak
35、er WC, et al.: Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial. Ann Surg 2000, 232: 409-418.Boyd O, Hayes M. The oxygen trial: the goal. Br Med Bull 1999; 55(1): 125-1391101000.10.01Tuschmidt26 (50)25 (72)0.39 (0.12 1.24)Yu, 199335 (34
36、)32 (34)1.00 (0.36 2.73)Hayes50 (54)50 (34)2.28 (1.02 5.11)Gattinoni252 (48)253 (49)0.99 (0.70 1.41)Yu, 199545 (38)44 (41)0.88 (0.37 2.05)Yu, 1998 ( 75 yo) 21 (57)18 (61)0.85 (0.24 3.06)Yu, 1998 (50 75 yo) 43 (21)23 (52)0.24 (0.08 1.18)TrialProtocol ControlOR (95%CI)Mortality n(%)Favor ProtocolFavor
37、 Control超正常值与患者预后循环支持治疗: 指南建议正性肌力药物治疗心肌功能障碍(心脏充盈压力升高及心输出量降低)时使用多巴酚丁胺(1C)不应使心脏指数增加到预先确定的超正常水平(1B)Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1): 296-327. Erratum in: Crit Ca
38、re Med 2008; 36(4): 1394-1396.隐性低灌注与创伤预后The Golden Hour and the Silver Day入选标准:成年创伤患者存活时间 24小时ISS 20血流动力学稳定SBP 100HR 1 mL/kg/h乳酸 2.5 mmol/L或其他灌注不足表现Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours
39、Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964隐性低灌注与创伤预后严重创伤患者两次严重创伤患者两次LA 2.5输注液体或血液制品输注液体或血液制品重复重复LA 2.5Swan-Ganz, 动脉插管动脉插管, 肾脏剂量多巴胺肾脏剂量多巴胺将将PCWP提高到提高到12 15将将Hct提高到提高到30%重复重复LA 2.5升压药物升压药物(多巴酚丁胺多巴酚丁胺)心脏超声检查心脏超声检查若若LA仍仍 2.5Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden
40、 Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964隐性低灌注与创伤预后Blow O, Magliore L, Claridge J, Butler K, Young J. The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion wi
41、thin 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964感染性休克的EGDTRivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377感染性休克的EGDTRivers E, Nguyen B, Havstad S, et al: Early goal-direc
42、ted therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377感染性休克的EGDT血流动力学目标前负荷CVP灌注压MAP组织灌注UOScvO2Rivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377血流动力学监测: 组织灌
43、注组织灌注不足多种指标用于评估组织灌注各种指标间的优劣缺乏评估往往需要进行整体评价急性肾功能衰竭: BE, 尿量急性肝功能衰竭: 乳酸原发神经系统疾病: 意识状态血流动力学监测: 组织灌注组织灌注不足排除前负荷及灌注压的因素应用强心药物具有受体兴奋作用的药物(多巴酚丁胺, 肾上腺素等)洋地黄类药物很少有效血管扩张药物缺乏临床证据血流动力学监测: 总结1前负荷前负荷(Preload)中心静脉压(CVP)肺动脉楔压(PAWP)输液治疗输液治疗3组织灌注组织灌注(Tissue Perfusion)尿量(UO), 心指数(CI)混合静脉血氧(MVO2)中心静脉血氧(ScvO2)强心药物强心药物2灌注压灌注压(Perfusion Pressure)平均动脉压(MAP)升压药物升压药物
