容量负荷试验.ppt

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1、CVP(mmHg)CO(L/min)容量缺乏更为严重低容量表现低容量表现心动过速心动过速低血压低血压(严重者严重者)高乳酸高乳酸(严重者严重者)肢端温度降低肢端温度降低脱水表现脱水表现皮肤充盈下降皮肤充盈下降口渴口渴口干口干腋窝干燥腋窝干燥高血钠高血钠高蛋白血症高蛋白血症高血红蛋白高血红蛋白高血球压积高血球压积体位性低血压体位性低血压动脉血压或每动脉血压或每搏输出量的呼搏输出量的呼吸波动吸波动下肢被动抬高下肢被动抬高容量负荷试验容量负荷试验结果阳性结果阳性肾脏灌注减少肾脏灌注减少浓缩尿浓缩尿(低尿钠低尿钠,高尿渗高尿渗)BUN升高升高(与肌酐升高不与肌酐升高不成比例成比例)持续性代谢性持续性代

2、谢性酸中毒酸中毒动态指标动态指标静态指标静态指标容量状态评价容量状态评价Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-55301015191915100Predicted PAWP(mmHg)Observed PAWP(mmHg)No change in planned th

3、erapy after catheterizationChange in planned therapy after catheterization004.57.0Predicted CO(L/min)Observed CO(L/min)4.57.0Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;

4、12(7):549-553参数参数预测正确比例预测正确比例预测正确百分比预测正确百分比Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553心输出量PAWPConnors(NEJM 83)ICU pts44%42%Eisenberg(CCM 84)ICU pts50%33%Ba

5、yliss(BMJ 83)CCU pts71%62%RVEDV(ml)CVP(mmHg)Kumar A,Anel R,Bunnell E,Habet K,Zanotti S,Marshall S,Neumann A,Ali A,Cheang M,Kavinsky C,Parrillo JE.Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume,cardiac performance,or the response to volume i

6、nfusion in normal subjects.Crit Care Med 2004;32:691-699 Lichtwarck-Aschoff et al,Intensive Care Med 1992;18:142-14735-30-25-20-15-10-5-0-CO(l/min)-5 0 5 10 15 20 25 30 35 40CVP(mmHg)Notarius et al Am Heart J 1998PraQQPraPraQPraQ7Pra(mmHg)Q(L/min)705Pms干预或治疗干预或治疗对心功能曲对心功能曲线的影响线的影响对静脉回流对静脉回流曲线的影响曲线的影

7、响高动力或低动力高动力或低动力体循环平均充盈压体循环平均充盈压静脉回流阻力静脉回流阻力Pra(mmHg)Q(L/min)交感张力的改变应用正性肌力药心肌梗塞其他心脏病变如心肌病或心瓣膜病Pra(mmHg)Q(L/min)705Pms血容量增加(输血,液体潴留)血管容量减少(儿茶酚胺增加,骨骼肌张力增加,按压腹部)血容量减少(失血,脱水)血管容量增加Pms Pms Pra(mmHg)Q(L/min)705Pms血管扩张血液稀释(贫血)动静脉瘘血管收缩血液粘滞度增加(真红细胞增多症)Rvr Rvr PraPraQQPraQ静脉回流曲线心功能曲线PraQPraQ高心输出量正常容量正常回流功能正常心输

8、出量低容量低回流功能PraQPraQ低心输出量正常回流功能正常心输出量高容量高回流功能RVEDV(ml)CVP(mmHg)时间(hr)血管内容量Vincent JL,Weil MH.Fluid challenge revisited.Crit Care Med 2006;34Dellinger RP,Carlet JM,Masur H,et al:Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.Crit Care Med 2004;32:858-873Mateer JR,

9、et al.Rapid fluid resuscitation with central venous catheters.Ann Emerg Med 1983;12:149-52.外周静脉置管中心静脉插管每10分钟测定CVPnCVP 2 mmHg继续快速补液nCVP 2 5 mmHg暂停快速补液,等待10分钟后再次评估nCVP 5 mmHg停止快速补液每10分钟测定PAWPnPAWP 3 mmHg继续快速补液nPAWP 3 7 mmHg暂停快速补液,等待10分钟后再次评估nPAWP 7 mmHg停止快速补液Weil MH,Henning RJ:New concepts in the diag

10、nosis and fluid treatment of circulatory shock.Anesth Analg 1979;58:124132Weil MH,Henning RJ:New concepts in the diagnosis and fluid treatment of circulatory shock.Anesth Analg 1979;58:1241320105201073CVP2 5 rulePAWP3 7 rule血管内容量CVP(mmHg)5 mmHg10CVP(mmHg)时间(hr)容量不足容量足够容量过多每搏输出量每搏输出量心输出量心输出量Calvin SV 0%Reuse CO 0%Schneider SV 0%Diebel CO 10%Wagner SV 10%Michard CO 15%Tavernier SV 15%Feissel CO 15%Tousignant SV 20%Diebel CO 20%Magder CO 250 ml/min