PEEP对心脏前负荷的影响__培训课件.pptVIP

PEEP对心脏前负荷的影响 北京协和医院 杜斌 病例摘要 WYG, M/51, 1629632 DOA: 2009/06/18 PMHx: HTN, DM CC: 发热, 皮疹2月, 憋气1月 Dx: 肺间质病变原因待查 急性呼吸功能衰竭 休克 病例摘要 入ICU时 循环功能 HR 88 bpm NBP 84/58 mmHg CVP 16 mmHg 呼吸机设置 FiO2 1.0 PS 15 cmH2O PEEP 20 cmH2O CVP = 16 mmHg 能否除外低血容量 是否需要输液提高前负荷 CVP与前负荷 RVEDV / RVEDP / RAP / CVP Cardiac Output 容量负荷反应组与无反应组的CVP PEEP对CVP的影响 Saner FH, Pavlakovic G, Gu Y, et al. Effects of positive end-expiratory pressure on systemic haemodynamics, with special interest to central venous and common iliac venous pressure in liver transplanted patients. Eur J Anaesth 2006; 23: 766-771 间断正压通气对心输出量的影响 Cournand A, Motley HL, Werko L, et al. Physiological studies of the effects of intermittent positive pressure breathing on cardiac output in man. Am J Physiol 1948; 152: 162-174. 心输出量下降 右心室 充盈受限 静脉 回流? 胸腔内压 (ITP) ? 正压 通气 PEEP诱导的CO改变 CO = HR x SV SV的影响因素 前负荷 心肌收缩力 后负荷 Viquerat CE, Righetti A, Suter PM: Biventricular volumes and function in patients with adult respiratory distress syndrome ventilated with PEEP. Chest 1983; 83: 509-514. 跨壁压的概念 5 cmH2O 20 cmH2O 跨壁压的概念 5 cmH2O 20 cmH2O 15 cmH2O 心脏的跨壁压 Thorax Venous Return LV Ejection Increasing ITP Decreases the pressure gradients for venous return and LV ejection Decreasing ITP Increases the pressure gradients for venous return and LV ejection PEEP对跨壁压的影响 PEEP对跨壁压的影响 胸腔内压(ITP) ─ 概念 … … Esophageal Pleural Cardiac fossa Cardiac surface Intrathoracic Pressure Scharf S: Ventilatory support in cardiac failure. In The Ill Cardiac Patient. Edited by Kvetan V, Dantzker DR. Philadelphia: Lippincott-Raven; 1996: 29-45. 正压通气对肺容积的影响 胸腔内压改变 肺容积改变 正压通气 气道阻力 呼吸系统顺应性 PEEP对CVP的影响 – 测定方法 短暂脱离呼吸机 CVP首先降低到谷值，然后因心室负荷改变而逐渐升高 约在去除PEEP 2-3秒内CVP达谷值 Pinsky MR, Vincent JL, De Smet JM. Estimating left ventricular filling pressure during positive end-expiratory pressure in humans. Am Rev Respir Dis 1991; 143:25–31 PEEP对CVP的影响 – 测定方法 Pinsky MR, Vincent JL, De Smet JM. Estimating left ventricular filling pressure during positive end-expiratory pressure in humans. A