ESICM循环休克与血流动力学监测.ppt

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1、ESICM循环休克与血流动力学监测最新共识 2014年年12月的月的Intensive Care Medicine杂杂志发表了欧洲危重病医学会有关休克及血志发表了欧洲危重病医学会有关休克及血流动力学监测的新共识。流动力学监测的新共识。第一部分介绍了共识中重要的推荐意见第一部分介绍了共识中重要的推荐意见No.说明说明/推荐意见推荐意见GRADE推荐级别推荐级别a;证据质量证据质量说明的种说明的种类类1循环休克定义为危及生命的急性循环功能衰竭，伴有细胞的氧利用障碍。We define circulatory as a life-threatening,generalized form of acu

2、te circulatory failure associated with inadequate oxygen utilization by the cells未分级定义2休克可以导致细胞缺氧，并伴有血乳酸升高。As a result,there is cellular dysoxia,associated with increased blood lactate levels未分级事实陈述3.休克可以表现为四种类型：其中三种为低血流状态（低血容量性，心源性，梗阻性），另一种为高动力状态（分布性）.Shock can be associated with four underlying pa

3、tterns:three associated with a low flow state(hypovolemic,cardiogenic,obstructive)and one associated with a hyperkinetic state(distributive)未分级事实陈述4.休克可以由多种过程共同导致。Shock can be due to a combination of processes未分级事实陈述5.体格检查时，休克通常伴随组织灌注不足的表现。常常对三个器官进行评估判断组织灌注情况皮肤（表皮灌注情况）；肾脏（尿量）；以及脑（意识状态）。Shock is typi

4、cally associated with evidence of inadequate tissue perfusion on physical examination.The three organs readily accessible to clinical assessment of tissue perfusion are the:-skin(degree of cutaneous perfusion);kidneys(urine output);and brain(mental status)未分级事实陈述6.对于病史以及临床表现提示存在休克的患者，我们推荐经常评估心率、血压、体

5、温和体格检查指标（包括低灌注的体征，尿量和意识状态）。We recommend frequent measurement of heart rate,blood pressure,body temperature and physical examination variables(including signs of hypoperfusion,urine output and mental status)in patients with a history and clinical findings suggestive of shock未分级最佳临床实践7.我们推荐不要根据单一的指标（诊

6、断和/或治疗休克）。We recommend not to use a single variable(for the diagnosis and/or management of shock未分级最佳临床实践8.我们推荐应当努力确定休克类型，以便更好地进行病因和支持治疗。We recommend efforts to identify the type of shock to better target causal and supportive therapies未分级最佳临床实践9.尽管休克时常常合并低血压（定义为收缩压 90 mmHg，或MAP 65 mmHg，或较基础值下降 40mm

7、Hg），但我们推荐不要将低血压作为诊断休克的标准。We recommend that the presence of arterial hypotension(defined as systolic blood pressure of90mmHg,or MAP of 2 mEq/L(mmol/L)。Lactate levels are typically2mEq/L(or mmol/L)in shock states未分级事实陈述13.如果临床检查不能明确诊断时，我们推荐进行进一步的血流动力学评估（如心功能评价）以确定休克类型。We recommend further hemodynamic

8、assessment(such as assessing cardiac function)to determine the type of shock if the clinical examination does not lead to a clear diagnosis未分级最佳临床实践14.当需要进一步血流动力学评估时，与其他有创技术相比，我们建议采用心脏超声作为初始评估休克类型的优先选择。We suggest that,when further hemodynamic assessment is needed,echocardiography is the preferred mo

9、dality to initially evaluate the type of shock as opposed to more invasive technologies推荐级别2;证据级别中等(B)推荐意见15.对于病情复杂的病例，我们建议应用肺动脉导管或经肺热稀释法确定休克类型。In complex patients,we suggest to additionally use pulmonary artery catheterization or transpulmonary thermodilution to determine the type of shock推荐级别2;证据级

10、别低(C)推荐意见16.我们推荐进行早期治疗，包括（通过输液及必要时使用升压药物）维持血流动力学稳定，并治疗休克病因，同时频繁评估治疗反应。We recommend early treatment,including hemodynamic stabilization(with fluids and vasopressors if needed)and treatment of the shock etiology,with frequent reassessment of response未分级最佳临床实践17.对于初始治疗无反应和（或）需要输注升压药物的休克患者，我们推荐留置动脉和中心静脉

11、导管。We recommend arterial and central venous catheter insertion in shock not responsive to initial therapy and/or requiring vasopressor infusion未分级最佳临床实践18.如果患者留置中心静脉导管，我们建议测定中心静脉血氧饱和度(ScvO2)和静脉动脉PCO2差值(V-ApCO2)，以帮助评估休克类型和心输出量是否足够，并指导治疗。In patients with a central venous catheter,we suggest measuremen

12、ts of ScvO2)and V-ApCO2to help assess the underlying pattern and the adequacy of cardiac output as well as to guide therapy推荐级别2;证据级别中等(B)推荐意见19.我们推荐连续测定血乳酸水平以进行指导、监测和评估。We recommend serial measurements of blood lactate to guide,monitor,and assess推荐级别1;证据级别低(C)推荐意见20.我们建议评估局部循环或微循环的技术仅用于研究目的。We sugg

13、est the techniques to assess regional circulation or microcirculation for research purposes only推荐级别2;证据级别低(C)推荐意见21.我们推荐休克复苏时对目标血压进行个体化。We recommend individualizing the target blood pressure during shock resuscitation推荐级别1;证据级别中等(B)推荐意见22.我们推荐初始血压目标为MAP 65mmHg。We recommend to initially target a MAP

14、 of65mmHg推荐级别1;证据级别低(C)推荐意见23.对于未能控制的出血患者，如没有重度颅脑损伤（即创伤患者），我们建议采用较低的目标血压。We suggest to tolerate a lower level of blood pressure in patients with uncontrolled bleeding(i.e.in patients with trauma)without severe head injury推荐级别2;证据级别(C)推荐意见24.对于有高血压病史的感染患者，以及升高血压后病情改善的患者，我们建议采用较高的MAP。We suggest a high

15、er MAP in septic patients with history of hypertension and in patients that show clinical improvement with higher blood pressure推荐级别2;证据级别中等(B)推荐意见25.适当的液体管理能够改善患者预后；低血容量和血容量过多都是有害的。Optimal fluid management does improve patient outcome;hypovolemia and hypervolemia are harmful未分级事实陈述26.我们推荐评估容量状态及容量反

16、应性。We recommend to assess volume status and volume responsiveness未分级最佳临床实践27如果休克患者通常使用的前负荷指标处于非常低的状态，我们推荐立即进行液体复苏。We recommend that immediate fluid resuscitation should be started in shock states associated with very low values of commonly used preload parameters未分级最佳临床实践28.我们推荐不应单纯根据常用的前负荷指标（如CVP或PAOP或舒张末面积或全心舒张末容积）指导液体复苏治疗。We recommend that commonly used preload measures(such as CVP or PAOP or end diastolic area or global end diastolic volume)alone should not be used to guide fluid resuscitati