床旁血流動(dòng)力學(xué)監(jiān)測(cè)

脈波連續(xù)心排血量(PiCCO)監(jiān)測(cè)

北京協(xié)和醫(yī)院ICU隆云基本理論容量反應(yīng)性-----動(dòng)態(tài)指標(biāo)器官平衡------EVLWI/PVPI治療終點(diǎn)----SvO2/ScvO2乳酸我才不管別人說(shuō)什么，我關(guān)心的是….心功能評(píng)價(jià)心輸出量心率前負(fù)荷后負(fù)荷心肌收縮力休克的血流動(dòng)力學(xué)分類低動(dòng)力型休克高動(dòng)力型休克MAP=CI*SVRIMAP=CI*SVRISVRICI一二三四休克的分類低血容量性心源性分布性梗阻性各種休克的血流動(dòng)力學(xué)特征分類低動(dòng)力性高動(dòng)力性低血容量性心源性梗阻性分布性前負(fù)荷↓↓↓↑→？？↑↑后負(fù)荷↑↑↑↑？？↓↓↓心肌收縮性↑↑↓↓↓？？↑↓順應(yīng)性→↓↓↓？？→↓AContinuumtoSevereDiseaseGoldenHourandSilverDayDetectionandCorrectionofOccultHypoperfusionwithin24HrsImprovesOutcomefromMajorTraumainEDsMorbidityandsurvivalversustimetocorrectocculthypoperfusion.BlowO,etal.GoldenHourandtheSilverDay:

DetectionandCorrectionofOccultHypoperfusionwithin24HrsImprovesOutcomefromMajorTrauma.JTrauma,1999,47:964血流動(dòng)力學(xué)支持低血容量性休克補(bǔ)充循環(huán)容量梗阻性休克解除梗阻心源性休克的ABC理論P(yáng)AWPCIABCD感染性休克的特征充足的液體負(fù)荷,仍不能糾正的休克,需要血管活性藥循環(huán)高動(dòng)力狀態(tài)與組織缺氧共存感染性休克的支持充足的液體復(fù)蘇充足的氧輸送血管收縮藥組織水平缺氧理想的血流動(dòng)力學(xué)監(jiān)測(cè)持續(xù)、可重復(fù)性簡(jiǎn)潔、微創(chuàng)人文---反應(yīng)性器官平衡CentralvenouscatheterThermodilutionfemoralarterialcatheter跨肺熱稀釋法+脈波輪廓分析法RALARVLV中心靜脈

冰水注射

股動(dòng)脈導(dǎo)管持續(xù)血溫監(jiān)測(cè)Pulmonar肺血容積PBV

EVLWTemperatureinjectiontimeSurface=Cal.xStrokevolumePICCO測(cè)定的參數(shù)脈波連續(xù)測(cè)定每次心臟搏動(dòng)的心輸出量(PCCO)及指數(shù)(PCCI)動(dòng)脈壓(AP)心率(HR)每搏量(SV)及指數(shù)(SVI)每搏量變化(SVV)外周血管阻力(SVR)及指數(shù)(SVRI)熱稀釋法心輸出量(CO)及指數(shù)(CI)胸腔內(nèi)血容量(ITBV)及指數(shù)(ITBI)全心舒張末期容量(GEDV)及指數(shù)(GEDI)血管外肺水(EVLW)及指數(shù)(ELWI)心功能指數(shù)(CFI)反映前負(fù)荷

----靜態(tài)與動(dòng)態(tài)指標(biāo)staticRAP/CVPPAOPRVEDVLVEDAdynamic

inspiratorydecreaseinRAP[RAP]expiratorydecreaseinarterialsystolicpressure[?down]respiratorychangesinpulsepressure[PP]respiratorychangesinaorticbloodvelocity[Vpeak]容量反應(yīng)性（FluidResponsiveness）SignificantSV/CO↑afterFluidchallengeVentricularPreloadSV/CO單次的右房壓不能預(yù)測(cè)容量反應(yīng)性，反應(yīng)者與無(wú)反應(yīng)者數(shù)值明顯交叉右房壓與容量反應(yīng)性右室舒張末期容積指數(shù)RVEDVI<90mL/m2ahighrateofresponseRVEDVindex>138mL/m2thelackofresponse肺動(dòng)脈楔壓所有上述研究都沒(méi)有發(fā)現(xiàn)PAOP作為評(píng)價(jià)容量反應(yīng)性的閾值影響靜態(tài)指標(biāo)的因素PEEP三尖瓣返流血管活性藥物右室功能不全心室順應(yīng)性液體分布無(wú)反應(yīng)組的原因高靜脈系統(tǒng)順應(yīng)性低心室順應(yīng)性心室功能障礙動(dòng)態(tài)指標(biāo)與容量反應(yīng)性

ArterialPressurePPmaxPPminAmJRespirCritCareMed2000;162:134-8

respondersn=16non-respondersn=24PPV(%)beforefluidinfusion13%13%血管外肺水與液體復(fù)蘇earlyresuscitationofhaemorrhagicshockwithNSorLRhaslittleimpactonoxygenationwhenresuscitationvolumeislessthan250ml/kg.評(píng)價(jià)肺水腫原因心源性、肺源性？肺毛細(xì)血管靜水壓腦利鈉肽（BNP）

肺血管通透性指數(shù)(PVPI)Pcishydrostaticpulmonarycapillarypressure….butisnotwedgepressure(PAOP)Chest2007;131;964-971Inflammatoryvscardiogenic

pulmonaryedemaPVPI=EVLWI/PBVAclinician,armedwiththesepsisbundles,attacksthethreeheadsofseveresepsis:hypotension,hypoperfusionandorgandysfunction.