1、 指南解读：血流动力学监测与心脏超声（CUS）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 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 Five Specific Questions(1)What are the epidemiologic and
2、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 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 Consensus Recommended 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 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 M
4、ain differences Blood pressure statements ICM 2007 ICM 2014 Fluid responsiveness statements ICM 2007 ICM 2014 ICM 2007 Hemodynamic monitoring ICM 2014 Cecconi M,et al.Intensive Care Med.2014;40(12):1795-815.Main new statements(1)Statements on individualizing blood pressure targets;(2)Statements on t
5、he assessment and prediction of fluid responsiveness;(3)Statements on the use of echocardiography and hemodynamic monitoring.2014 Consensus Identification of the type of shock We recommend further hemodynamic assessment(such as assessing cardiac function)to determine the type of shock if the clinica
6、l examination does not lead to a clear diagnosis.Best practice We 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)Rationale:Context analysis(tra
7、uma,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 patient with chronic heart failure)in w
8、hich a diagnosis is more difficult.Vincent JL,et al.N Engl J Med.2013;369(18):1726-34.Manifestation on Echo 梗阻性 心包填塞 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 Care Med.2013;41(8):e179-81.IC-FoCUS 国际聚焦心脏超声循证建议 Via G,et al.Journal of the American Society of Echocardiograp
9、hy.2014;27(7):683 e1-e33.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。FoCUS statement Shock and Hemodynamic Instability 43.In the setting of shock,FoCUS accurately assesses global LV systolic function,when compared with comprehensive standard echocardiography.1A:Strong Recommendation,with Very Good Agreemen
10、t;Level A Evidence 44.In the setting of shock,FoCUS narrows the differential diagnosis.1A:Strong Recommendation,with Very Good Agreement;Level A Evidence 2014 Consensus Monitoring cardiac function and cardiac output Echocardiography can be used for the sequential evaluation of cardiac function in sh
11、ock.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 shock.Best practice Rationale:Echocardiography can help the ICU physician in three ways:(1)better characterization of the hemodyn
12、amic disorders;(2)selection of the best therapeutic options(intravenous fluids,inotropes and ultrafiltration);(3)assessment of the response of the hemodynamic disorders to therapy.VTI,LVEF,LVEDA,RVEDA,E/A ratio 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
13、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%的患者患PFO，4.5%的患者同时患ACP和PFO。FoCUS statement Shock and Hemodynamic Instability FoCUS statement Estimating CVP,Diagnosing Hypovolemia,and Predicting Fluid Responsiveness shock subject control subject Yanagawa Y,et al.J Trauma.2005;58(4):825-9.IVC的
14、直径与创伤患者的低血容量相关 FoCUS statement 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.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 expansion PP,radial pulse pressure;SV,stroke volume;VF,peak velocity of femoral artery flow FoCUS statement 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。Thank you for your attention!