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1、危重病与微循环危重病与微循环佛山市中医院佛山市中医院 张斌张斌 Krogh A(1929)毛细血管的解剖和生理(The Anatomy and Physiology of Capillaries) “毛细血管是血液和组织间物质交换的器官”(an organ for interchange Of substances between the blood and the tissues：the capillaries) 贝时璋教授：贝时璋教授： 什么是生命活动什么是生命活动?根据生物物理学的观点，根据生物物理学的观点，无非是自然界三个量综合运动的表现，即无非是自然界三个量综合运动的表现，即物质、能
2、量和信息在生命系统中无时无刻物质、能量和信息在生命系统中无时无刻地在变化，这三个量有组织、有秩序的活地在变化，这三个量有组织、有秩序的活动是生命的基础。动是生命的基础。田牛田牛.微循环学杂志，微循环学杂志，1994.1 直接参与组织、细胞的直接参与组织、细胞的物质、信息、能物质、信息、能量量传递的血液、淋巴液、组织液的流动称传递的血液、淋巴液、组织液的流动称之为微循环。之为微循环。微循环的本质属性SIRS的临床特征心输出量的增加、全身血管阻力的降低心输出量的增加、全身血管阻力的降低动静脉氧分压差缩小动静脉氧分压差缩小血乳酸水平增加血乳酸水平增加 反映细胞对氧反映细胞对氧(或底物或底物)的利用障
3、碍。用于产生细的利用障碍。用于产生细胞必需能量的氧和底物的输送或利用障碍可导致胞必需能量的氧和底物的输送或利用障碍可导致SIRS,并形成并形成MODs微血管构型及其微细结构微循环障碍的监测血乳酸SVO2BEDO2，VO2near-infrared spectroscopy (NIRS),Creteur.Curr Opin Crit Care. 2008 Jun;14(3):361-6.The prognostic value of muscle StO2 in critically ill patients SUMMARY: Near-infrared spectroscopy provide
4、s a noninvasive measure of muscle oxygen metabolism and microvascular dysfunction in critically ill patients. It may be useful to guide the management ofPtCO2加热的氧电极直接置于患者胸骨旁2、3肋间正常皮肤上来测定PtC02。无创性、续监测组织氧合。Ptc02测定的是传感器下面皮肤组织的P02。组织氧张力除了受PaO2影响外，还受组织血液灌注量的影响。组织血液灌注量正常时，Ptc02与PaO2具有非常好的相关性。Fife CE; Smar
5、t DR; Undersea Hyperb Med. 2009V36N1:43-53 Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence. Intensive Care Med. 2009 Jun;35(6):1106-9. Epub 2009 Jan 29.Thenar oxygen saturation measured by near infrared spectroscopy as a noninvasive predictor
6、 of low central venous oxygen saturation in septic patients.Mesquida J, Masip J, Gili G, Artigas A, Baigorri F.2008年严重脓毒症与脓毒症休克治疗国际指南 建议仅在成年脓毒症休克患者对容量复苏和血管活性药物反应差时静脉给予氢化可的松(推荐级别2C) The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic s
7、hock* Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6方法N=16cardiac outputcutaneous tissue PtO2 using a Clark electrodecutaneous red blood cell flux using laser Doppler flowmetry, Sublingual microvascular flow using sidestream darkfield imaging. Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Shama
8、n Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6Shaman Jhanji, Crit Care Med 2009 Vol. 37, No. 6 Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective studyArnaldo Dubin Critical Care 2009, 13:R9
9、2方法N=20Sublingual microcirculation was evaluated by sidestream darkfield (SDF) imagingDO2 and VO2, lactate, albumin-corrected anion gap, gastric intramucosal-arterial PCO2 difference (PCO2).Arnaldo Dubin .Critical Care 2009, 13:R92 Arnaldo Dubin. Critical Care 2009, 13:R92 Arnaldo Dubin .Critical Ca
10、re 2009, 13:R92Arnaldo Dubin .Critical Care 2009, 13:R92 Arnaldo Dubin. Critical Care 2009, 13:R92 2008年严重脓毒症与脓毒症休克治疗国际指南 NE 为纠正脓毒症休克低血压首选的一线血为纠正脓毒症休克低血压首选的一线血管升压药管升压药, 1C级级, 无在脓毒症治疗中选择何种儿茶酚胺类药无在脓毒症治疗中选择何种儿茶酚胺类药 物的最终建议物的最终建议The effects of dobutamine on microcirculatory alterations inpatients with se
11、ptic shock are independent of its systemic effectsDaniel De Backer,Crit Care Med 2006 Vol. 34, No. 2方法方法Intravenous administration of dobutamine (5 g/kgmin) for 2 hrs (n 22) followed by the addition of 102M acetylcholine (topically applied, n 10).Hemodynamic measurementssublingual microcirculation w
12、as investigated with an orthogonal polarization spectral imaging technique before and after dobutamine administration and after topical application of acetylcholine. DobutamineDaniel De Daniel De Backer,Backer,CritCrit Care Med 2006 Vol. 34, No. 2 Care Med 2006 Vol. 34, No. 2Daniel De Backer,Crit Ca
13、re Med 2006 Vol. 34, No. 2Daniel De Backer,Crit Care Med 2006 Vol. 34, No. 2不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较涂自智孙庆华Geo rge D imopou lo sSuzanaM LoboDan ielDeFigure 1Changes of arter ial lactate concentration in each group不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较克的疗效比较涂自智孙庆华Geo rge D imopou lo sS
14、uzanaM LoboDan ielDeCh in Crit CareM ed, Feb. 2005,Vo l. 17,No12Figure 2Changes of Pt aCO2gap in each group不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较克的疗效比较涂自智孙庆华Geo rge D imopou lo sSuzanaM LoboDan ielDeCh in Crit CareM ed, Feb. 2005,Vo l. 17,No12Figure 3Changes of intestinal intramucosal pH
15、 in each groupEffects of hydrocortisone on microcirculatory alterations in patients with septic shockGustavo Luiz Bu Crit Care Med 2009 Vol. 37, No. 4Effects of hydrocortisone on microcirculatory alterations in patients with septic shockGustavo Luiz Bu Crit Care Med 2009 Vol. 37, No. 4orthogonal pol
16、arization spectral device was used to investigate the sublingual microcirculationthe first dose (50 mg) of hydrocortisoneand 1, 2, 4, and 24 hours laterGlobal hemodynamic variables were similar at allstudy time points.Effects of hydrocortisone on microcirculatory alterations in patients with septic
17、shockGustavo Luiz Bu Crit Care Med 2009 Vol. 37, No. 4Effects of hydrocortisone on microcirculatory alterations inpatients with septic shock*Gustavo Luiz Bu cheleCrit Care Med 2009 Vol. 37, No. 4Figure 2. Evolution of microcirculation variables during study time periods. Perfused small vessels.The e
18、ffect of storage time of human red cells on intestinalicrocirculatory oxygenation in a rat isovolemic exchange model*N. J. Raat, PhD; A. J. Verhoeven, PhD; E. G. Mik, MSc; C. W. Isovolemic exchange with fresh and intermediate red blood cells maintained PO2 whereas old cells decreased PO2 with 26%. S
19、ubsequent transfusion with red blood cells (hematocrit 60%) until reaching a hematocrit of 32.4 % (n 24) increased intestinal PO2 in all three groups to the same extent between 28% and 32%. Effects of propofol on human microcirculationM. Koch1, British Journal of Anaesthesia 101 (4): 4738 (2008)15 p
20、atients anaesthetized by propofol for transvaginal oocyte retrieval. The sublingual microcirculatory network was studiedbefore, during, and after propofol infusion using orthogonal polarization spectral imaging.systemic haemodynamic and oxygenation variablesEffects of propofol on human microcirculationM. Koch1, British Journal of Anaesthesia 101 (4): 4738 (2008) 谢谢 谢谢
