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1、指南解读：血流动力学监测与心脏超声（CUS）12021/7/27 星期二星期二1.SLAX:肋下长轴切面2.SIVC:肋下下腔静脉切面3.PLAX：胸骨旁长轴切面4.PSAX:胸骨旁短轴切面5.A4CH:心尖四腔心切面CUS最常用的五个切面2 22021/7/27 2021/7/27 星期二星期二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位专家组成的团队12位专家组成的团队32021/7/27 星期二星期二Fiv
2、e Specific Questions(1)What are the epidemiologic and pathophysiologic 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 microcircu
3、lation can be monitored,and how can cellular function be assessed in shock?(5)What is the evidence for using hemodynamic monitoring to direct therapy in shock?4 42021/7/27 2021/7/27 星期二星期二2014 ConsensusRecommended against常规使用常规使用:(1)the pulmonary artery catheter in shock 休克患者使用肺动脉导管(2)static preload
4、 measurements used alone to predict fluid responsiveness 仅仅使用静态的前负荷测量方法来预测液体反应性 5 52021/7/27 2021/7/27 星期二星期二Main differences6 62021/7/27 2021/7/27 星期二星期二Blood pressure statementsICM 2007ICM 20147 72021/7/27 2021/7/27 星期二星期二Fluid responsiveness statementsICM 2007ICM 20148 82021/7/27 2021/7/27 星期二星期二
5、ICM 20079 92021/7/27 2021/7/27 星期二星期二Hemodynamic monitoringICM 201410102021/7/27 2021/7/27 星期二星期二Cecconi M,et al.Intensive Care Med.2014;40(12):1795-815.11112021/7/27 2021/7/27 星期二星期二Main new statements(1)Statements on individualizing blood pressure targets;(2)Statements on the assessment and predic
6、tion of fluid responsiveness;(3)Statements on the use of echocardiography and hemodynamic monitoring.12122021/7/27 2021/7/27 星期二星期二2014 ConsensusIdentification of the type of shock We recommend further hemodynamic assessment(such as assessing cardiac function)to determine the type of shock if the cl
7、inical examination does not lead to a clear diagnosis.Best practiceWe suggest that,when hemodynamic assessment is needed,echocardiography is the preferred modality to initially evaluate the type of shock as opposed to more invasive technologies.Recommendation.Level 2;QoE(B)13132021/7/27 2021/7/27 星期
8、二星期二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 complex situations may exist(e.g.cardiac tamponade in a patient with trauma or septic shock in a patie
9、nt with chronic heart failure)in which a diagnosis is more difficult.14142021/7/27 2021/7/27 星期二星期二Vincent JL,et al.N Engl J Med.2013;369(18):1726-34.152021/7/27 星期二星期二Manifestation on Echo梗阻性心包填塞16162021/7/27 2021/7/27 星期二星期二FOCUS的测量很迅速，即使是初学者，一般时间也小于3min；FOCUS应当被列入重症培训的项目中去。Beraud AS,et al.Crit Ca
10、re Med.2013;41(8):e179-81.172021/7/27 星期二星期二IC-FoCUS 国际聚焦心脏超声循证建议Via G,et al.Journal of the American Society of Echocardiography.2014;27(7):683 e1-e33.182021/7/27 星期二星期二名称确认：聚焦心脏超声（FoCUS）重点用于生命支持的评估、复苏的评估等。192021/7/27 星期二星期二FoCUS statementShock and Hemodynamic Instability43.In the setting of shock,F
11、oCUS accurately assesses global LV systolic 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;Leve
12、l A Evidence20202021/7/27 2021/7/27 星期二星期二2014 ConsensusMonitoring 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
13、they have been validated in the context of patients with shock.Best practice21212021/7/27 2021/7/27 星期二星期二Rationale: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,inotro
14、pes and ultrafiltration);(3)assessment of the response of the hemodynamic disorders to therapy.VTI,LVEF,LVEDA,RVEDA,E/A ratio22222021/7/27 2021/7/27 星期二星期二Lheritier G,et al.Intensive Care Med.2013;39(10):1734-42.急性肺心病 ACP:RVEDA/LVEDA 0.6,左室短轴可见室间隔矛盾运动卵圆孔未闭 PFO：左右心房之间可见右向左分流 结果：22.5%的机械通气患者患ACP，15.5%
15、的患者患PFO，4.5%的患者同时患ACP和PFO。232021/7/27 星期二星期二FoCUS statementShock and Hemodynamic Instability24242021/7/27 2021/7/27 星期二星期二FoCUS statementEstimating CVP,Diagnosing Hypovolemia,and Predicting Fluid Responsiveness25252021/7/27 2021/7/27 星期二星期二shock subjectcontrol subject Yanagawa Y,et al.J Trauma.2005;
16、58(4):825-9.IVC的直径与创伤患者的低血容量相关262021/7/27 星期二星期二FoCUS statement27272021/7/27 2021/7/27 星期二星期二在怀疑血容量不足的自主呼吸患者中，在PLR前后使用FoCUS测量心输出量可以准确地识别出患者是否存在血容量不足以及能否获益于补液Maizel J,et al.Intensive Care Med.2007;33(7):1133-8.282021/7/27 星期二星期二Preau S,et al.Crit Care Med.2010;38(3):819-25.Change(%)=100%*(post-VE val
17、ue 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 femoral artery flow292021/7/27 星期二星期二302021/7/27 星期二星期二FoCUS statement31312021/7/27 2021/7/27 星期二星期二Summary 鉴于其无创性和便捷性，FoCUS在重症患者的评估和治疗中占据越来越重要的地位；近年来，FoCUS在一些非心脏疾病的鉴别与评估中也展现出价值，尤其是在血流动力学监测和休克类型的鉴别上;随着重症医学的发展，FoCUS应该成为每个重症医师的必备技能。32322021/7/27 2021/7/27 星期二星期二Thank you for your attention!332021/7/27 星期二星期二