《危重病微循环障碍》PPT课件

危重病与微循环佛山市中医院ＩＣＵ张斌KroghA．(1929)《毛细血管的解剖和生理》(TheAnatomyandPhysiologyofCapillaries)“毛细血管是血液和组织间物质交换的器官”(…anorganforinterchangeOfsubstancesbe—tweenthebloodandthetissues：thecapillaries)贝时璋教授：什么是生命活动?根据生物物理学的观点，无非是自然界三个量综合运动的表现，即物质、能量和信息在生命系统中无时无刻地在变化，这三个量有组织、有秩序的活动是生命的基础。田牛.微循环学杂志，1994.1直接参与组织、细胞的物质、信息、能量传递的血液、淋巴液、组织液的流动称之为微循环。微循环的本质属性SIRS的临床特征心输出量的增加、全身血管阻力的降低动静脉氧分压差缩小血乳酸水平增加反映细胞对氧(或底物)的利用障碍。用于产生细胞必需能量的氧和底物的输送或利用障碍可导致SIRS,并形成MODs微血管构型及其微细结构微循环障碍的监测血乳酸SVO2BEDO2，VO2near-infraredspectroscopy(NIRS),Creteur.CurrOpinCritCare.2008Jun;14(3):361-6.TheprognosticvalueofmuscleStO2incriticallyillpatientsSUMMARY:Near-infraredspectroscopyprovidesanoninvasivemeasureofmuscleoxygenmetabolismandmicrovasculardysfunctionincriticallyillpatients.ItmaybeusefultoguidethemanagementofPtCO2加热的氧电极直接置于患者胸骨旁2、3肋间正常皮肤上来测定PtC02。无创性、续监测组织氧合。Ptc02测定的是传感器下面皮肤组织的P02。组织氧张力除了受PaO2影响外，还受组织血液灌注量的影响。组织血液灌注量正常时，Ptc02与PaO2具有非常好的相关性。FifeCE;SmartDR;UnderseaHyperbMed.2009V36N1:43-53Transcutaneousoximetryinclinicalpractice:consensusstatementsfromanexpertpanelbasedonevidence.IntensiveCareMed.2009Jun;35(6):1106-9.Epub2009Jan29.Thenaroxygensaturationmeasuredbynearinfraredspectroscopyasanoninvasivepredictoroflowcentralvenousoxygensaturationinsepticpatients.MesquidaJ,MasipJ,GiliG,ArtigasA,BaigorriF.《2008年严重脓毒症与脓毒症休克治疗国际指南》建议仅在成年脓毒症休克患者对容量复苏和血管活性药物反应差时静脉给予氢化可的松(推荐级别2C)Theeffectofincreasingdosesofnorepinephrineontissueoxygenationandmicrovascularflowinpatientswithsepticshock*ShamanJhanji,CritCareMed2009Vol.37,No.6方法N=16cardiacoutputcutaneoustissuePtO2usingaClarkelectrodecutaneousredbloodcellfluxusinglaserDopplerflowmetry,Sublingualmicrovascularflowusingsidestreamdarkfieldimaging.ShamanJhanji,CritCareMed2009Vol.37,No.6ShamanJhanji,CritCareMed2009Vol.37,No.6ShamanJhanji,CritCareMed2009Vol.37,No.6ShamanJhanji,CritCareMed2009Vol.37,No.6Increasingarterialbloodpressurewithnorepinephrinedoesnotimprovemicrocirculatorybloodflow:aprospectivestudyArnaldoDubinCriticalCare2009,13:R92方法N=20Sublingualmicrocirculationwasevaluatedbysidestreamdarkfield(SDF)imagingDO2andVO2,lactate,albumin-correctedaniongap,gastricintramucosal-arterialPCO2difference(ΔPCO2).ArnaldoDubin.CriticalCare2009,13:R92ArnaldoDubin.CriticalCare2009,13:R92ArnaldoDubin.CriticalCare2009,13:R92ArnaldoDubin.CriticalCare2009,13:R92ArnaldoDubin.CriticalCare2009,13:R92《2008年严重脓毒症与脓毒症休克治疗国际指南》NE为纠正脓毒症休克低血压首选的一线血管升压药,1C级,无在脓毒症治疗中选择何种儿茶酚胺类药物的最终建议TheeffectsofdobutamineonmicrocirculatoryalterationsinpatientswithsepticshockareindependentofitssystemiceffectsDanielDeBacker,CritCareMed2006Vol.34,No.2方法Intravenousadministrationofdobutamine(5g/kg·min)for2hrs(n22)followedbytheadditionof102Macetylcholine(topicallyapplied,n10).Hemodynamicmeasurementssublingualmicrocirculationwasinvestigatedwithanorthogonalpolarizationspectralimagingtechniquebeforeandafterdobutamineadministrationandaftertopicalapplicationofacetylcholine.DobutamineDanielDeBacker,CritCareMed2006Vol.34,No.2DanielDeBacker,CritCareMed2006Vol.34,No.2DanielDeBacker,CritCareMed2006Vol.34,No.2不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较涂自智　孙庆华　GeorgeDimopoulos　SuzanaMLobo　DanielDeFigure1　Changesofarteriallactateconcentrationineachgroup不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较涂自智　孙庆华　GeorgeDimopoulos　SuzanaMLobo　DanielDe　ChinCritCareMed,Feb.2005,Vol.17,No12Figure2　ChangesofPtaCO2　gapineachgroup不同液体复苏条件下多巴酚丁胺对肠缺血再灌注休克的疗效比较涂自智　孙庆华　GeorgeDimopoulos　SuzanaMLobo　DanielDe　ChinCritCareMed,Feb.2005,Vol.17,No12Figure3　ChangesofintestinalintramucosalpHineachgroupEffectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshockGustavoLuizBuCritCareMed2009Vol.37,No.4EffectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshockGustavoLuizBuCritCareMed2009Vol.37,No.4orthogonalpolarizationspectraldevicewasusedtoinvestigatethesublingualmicrocirculationthefirstdose(50mg)ofhydrocortisoneand1,2,4,and24hourslaterGlobalhemodynamicvariablesweresimilaratallstudytimepoints.EffectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshockGustavoLuizBuCritCareMed2009Vol.37,No.4Effectsofhydrocortisoneonmicrocirculatoryalterationsinpatientswithsepticshock*GustavoLuizBu¨cheleCritCareMed2009Vol.37,No.4Figure2.Evolutionofmicrocirculationvariablesduringstudytimeperiods.Perfusedsmallvessels.Theeffectofstoragetimeofhumanredcellsonintestinalicrocirculatoryoxygenationinaratisovolemicexchangemodel*N.J.Raat,PhD;A.J.Verhoeven,PhD;E.G.Mik,MSc;C.W.IsovolemicexchangewithfreshandintermediateredbloodcellsmaintainedPO2whereasoldcellsdecreasedPO2with26%.Subsequenttransfusionwithredbloodcells(hematocrit60%)untilreachingahematocritof32.4%(n24)increasedintestinalPO2inallthreegroupstothesameextentbetween28%and32%.EffectsofpropofolonhumanmicrocirculationM.Koch1,BritishJournalofAnaesthesia101(4):473–8(2008)15patientsanaesthetizedbypropofolfortransvaginaloocyteretrieval.Thesublingualmicrocirculatorynetworkwasstudiedbefore,during,andafterpropofolinfusionusingorthogonalpolarizationspectralimaging.systemichaemodynamicandoxygenationvariablesEffectsofpropofolonhumanmicrocirculationM.Koch1,BritishJournalofAnaesthesia101(4):473–8(2008)谢谢