血流動力學(xué)監(jiān)測與心臟超聲課件

1、指南解讀：血流動力學(xué)監(jiān)測與心臟超聲（CUS）SLAX: 肋下長軸切面SIVC: 肋下下腔靜脈切面PLAX：胸骨旁長軸切面PSAX: 胸骨旁短軸切面A4CH: 心尖四腔心切面CUS最常用的五個切面Antonelli M, et al. Intensive Care Med. 2007;33(4):575-90.Cecconi M, et al. Intensive Care Med. 2014;40(12):1795-815. 25位專家組成的團隊12位專家組成的團隊Five Specific Questions(1) What are the epidemiologic and pathoph

2、ysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function

3、be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock?2014 ConsensusRecommended against常規(guī)使用: (1) the pulmonary artery catheter in shock 休克患者使用肺動脈導(dǎo)管(2) static preload measurements used alone to predict fluid responsiveness 僅僅使用靜態(tài)的前負荷測量方法來預(yù)測液體反應(yīng)性 Bl

4、ood pressure statementsICM 2007ICM 2014Fluid responsiveness statementsICM 2007ICM 2014Hemodynamic monitoringICM 2014Cecconi M, et al. Intensive Care Med. 2014;40(12):1795-815. Main new statements(1) Statements on individualizing blood pressure targets; (2) Statements on the assessment and prediction

5、 of fluid responsiveness; (3) Statements on the use of echocardiography and hemodynamic monitoring.Rationale:Context analysis (trauma, infection, chest pain, etc.) and clinical evaluation which focuses on skin perfusion and jugular vein distension usually orient diagnosis to the type of shock, but c

6、omplex situations may exist (e.g. cardiac tamponade in a patient with trauma or septic shock in a patient with chronic heart failure) in which a diagnosis is more difficult.Vincent JL, et al. N Engl J Med. 2013;369(18):1726-34. FOCUS的測量很迅速，即使是初學(xué)者，一般時間也小于3min；FOCUS應(yīng)當(dāng)被列入重癥培訓(xùn)的項目中去。Beraud AS, et al. Cri

7、t Care Med. 2013;41(8):e179-81.IC-FoCUS 國際聚焦心臟超聲循證建議Via G, et al. Journal of the American Society of Echocardiography. 2014;27(7):683 e1- e33.名稱確認：聚焦心臟超聲（FoCUS）重點用于生命支持的評估、復(fù)蘇的評估等。FoCUS statementShock and Hemodynamic Instability43. In the setting of shock, FoCUS accurately assesses global LV systolic

8、 function, when compared with comprehensive standard echocardiography.1A: Strong Recommendation, with Very Good Agreement; Level A Evidence44. In the setting of shock, FoCUS narrows the differential diagnosis.1A: Strong Recommendation, with Very Good Agreement; Level A Evidence2014 ConsensusMonitori

9、ng cardiac function and cardiac outputEchocardiography can be used for the sequential evaluation of cardiac function in shock. Statement of fact We recommend that less invasive devices are used, instead of more invasive devices, only when they have been validated in the context of patients with shoc

10、k. Best practiceRationale:Echocardiography can help the ICU physician in three ways: (1) better characterization of the hemodynamic disorders; (2) selection of the best therapeutic options (intravenous fluids, inotropes and ultrafiltration); (3) assessment of the response of the hemodynamic disorder

11、s to therapy.VTI, LVEF, LVEDA, RVEDA, E/A ratioFoCUS statementShock and Hemodynamic InstabilityFoCUS statementEstimating CVP, Diagnosing Hypovolemia, and Predicting Fluid ResponsivenessFoCUS statement在懷疑血容量不足的自主呼吸患者中，在PLR前后使用FoCUS測量心輸出量可以準確地識別出患者是否存在血容量不足以及能否獲益于補液Maizel J, et al. Intensive Care Med. 2007;33(7):1133-8. Preau S, et al. Crit Care Med. 2010;38(3):819-25. Change (%) =100%* (post-VE value baseline 2 value)/baseline 2 value. Respond: change 15%PLR, passive leg raising; VE, volume expansionPP, radial pulse pressure; SV, stroke volume; VF, peak velocity of femor