机体氧供需平衡监测及临床意义精品.ppt

* 43 * * * 50 Epinephrine 通常当 dopamine/dobutamine无效时使用 Miran et al., 观察了18个感染性休克病人, 平均年龄 64. 剂量3-18 ? g/min, HR, MAP, CI, LVSWI, SVI, VO2, and DO2增加. Pcwp, mean PAP, and SVRI 没有明显变化 Crit Care Med 1993; 21(1): 70-77. McKenzie et al., 治疗13名低容量感染性休克病人，剂量为 0.005 - 0.42 (mean 0.16) ? g/kg/min，使 C.I. 4.5, and DO2 600 ml/min/m2. 结果MAP, CI, LVSWI, 和 DO2皆增加。 SVR, VO2 不变, O2ER下降。54% 的病人死亡。 Intensive Care Med 1991; 17:36-39. 在14名对dopamine、dobutamine、输液没有反应的病人, 以 PAC 诊断 RV衰竭, epinephrine (0.1 to 1 ? g/kg/min) 可以改善 RV 收缩性. MAP, CI, SVI 增加。 Pcwp, SVR, HR没有变化。死亡率为 64%。 Intensive Care Med 1997; 23: 664-670. 强心治疗 目标：增加心肌收缩力，但没有明显的心率增快和心律失常。 措施：1）扩容-Frank-Starling 2）dobutamine+dopamime(1-5 ? g/kg/min) Ne或Epi 3）硝普钠或硝酸甘油 4）磷酸二酯酶III抑制药 5）利尿药 THE END * * * * * * * * * * * * * * * * * * * * * * * 34 * 35 The heart mainly contains beta-1 receptors wihich increase chronotropy, inotropy and dromotropy. The heart also contains significant numbers of beta-2 receptors which likewise increase rate and inotropy through activation of adenylate cyclase and increased cyclic AMP. Postsynaptic alpha-1 receptors have likewise been recently found in the human heart. Stimulation causes a significant increase in contractility without an increase in rate. This effect is not mediated by cyclic AMP, andis more pronounced at lower rates. It also has a slower onset and increased duration when compared to the beta 1 mediated response. Lastly, presynaptic alpha-2 receptors form a negative feedback loop inhibiting further release of norepinephrine by the nerve terminalwhen stimulated. * 38 * 39 Dobutamine produces a larger increase in cardiac output and is less arrythmogenic than dopamine. Ruffalo showed that the Beta 1 and Beta 2 activity of dobutamine resides in its positive isomer and that the negative isomer directly stimulates alpha 1 receptors in the heart. Thus, the strong inotropic action of dobutamine is a function of the additive effects of alpha1 and beta1 activit