Putting the puzzle together-cn感染性休克和心脏收缩，液体治疗.ppt

Smith-Madigan Inotropy Index史密斯－麦迪根心脏收缩指数 Normal Controls正常值 1.6 – 2.2 W/m2 Left Ventricular Failure左心衰竭 0.4 – 1.1 W/m2 Septicaemic Shock 0.6 – 1.2 W/m2 Cardiogenic Shock心源性休克 74 year old man with STEMI74岁老年男性 BP 84/44, pulse 114, SpO2 84% on 10L/min O2 血压84/44, 心率 114, SpO2 84% on 10L/min O2 Pulmonary Oedema +++严重的肺水肿 No urine output 无尿 PaO2 64mmHg, PaCO2 28mmHg Lactate 8.4乳酸盐8.4 8 12 14 2.4 60-75 90 800-1200 0.62 0.97 1.13 1.38 SMII W/m2 Dobutamine mcg/kg/min Cardiac Output Stroke Volume Blood Pressure Preload Inotropy Afterload (Hb) SpO2 Oxygen Delivery – DO2 Heart Rate SVR Preload JVP / CVP - Only looking at the right side of the heart. - Tells us little about left heart preload. - Tricuspid valve integrity? Stenosis and regurgitation both lead to errors. - Arrythmias lead to error. - Even right ventricular pressure tells us little about right ventricular volume. 前负荷 JVP / CVP 颈静脉压/中心静脉压 - 只能反映右心功能。 - 很少地反映左心前负荷的情况。 - 三尖瓣是否完整? 狭窄和反流都会使数值偏差。 - 心律失常也会造成误差 - 甚至右心室压也很少能反映右心室容积的情况. Pulmonary artery catheter What pressure should we use? PA Diastolic Pressure (PADP)? PA Wedge Pressure (PAWP)? PA mean Pressure (PAPm)? Is the catheter in the right place? What about IPPV, PEEP, pulmonary vascular patency, vasoconstriction, shunts, arrythmias, mitral valve problems….etc. 肺动脉导管 应该用哪个压力更好呢? 肺动脉舒张压 (PADP)? 肺动脉楔压(PAWP)? 肺动脉平均压(PAPm)? 导管是在正确的位置吗? 如果有间歇正压通气、呼气末正压通气、 肺血管开放,、血管收缩 、分流, 、心律失常 、二尖瓣病变 ….等等情况怎么办呢？ PAC Attempts to measure left ventricular end diastolic pressure - LVEDP Left ventricular preload is strictly the left ventricular end diastolic volume – LVEDV Ventricular end diastolic pressure only acts as an acceptable surrogate if we know the ventricular compliance. 肺动脉导管 试图测出左心室舒张末期压- LVEDP 左心室前负荷就是左心室舒张末期压– LVEDV 如果我们知道心室顺应性心室舒张末期压可作为一个可用的指标. Can basic physiology help us? 基础生理学知识可以帮助我们吗？ Inotropy SV LVEDV Passive Leg Raising - ↑SV 被动抬腿试验-提高每搏量 Stroke volume increases from 26ml to 35