邱海波外伤致ALIMV治疗策略课件.ppt

* * * * * * * * * * * * * * * * 内毒素吸附与血浆交换 5月31日 21：30 血浆交换一次 5月31日 内毒素吸附治疗一次 6月 1日 内毒素吸附治疗一次 6月 2日 内毒素吸附治疗一次 体温改变 HVHF--- As salvage therapyin severe septic shock Objectives: To evaluate the effect PHVHF (12-h) in reversing progressive refractory hypotension in pats with sshock N=20 sshock pats with NE 0.3 μg/kg.min and and lactic acidosis Responders vs Non-R (NE and lactate levels at 6h after PHVHF) Intensive Care Med (2006) 32:713–722 控制液体平衡 摄入： 出量/CRTT 监测容量状态与器官灌注情况 (2)降低毛细血管静水压 Univariate and multivariate analysis:risk of death Intensive Care Med, 2002, 28: 1073 Hydrostatic forces in ARDS The majority of ALI pats have at least intermittent PCWP 18 mmHg (80%) Mortality in ALI is predicted by PCWP Diuresis improves physiology +/-survival ICM 2002, 28: 1073-1077 AJRCCM 1999, 159, A716 Chest 1990, 97, 1176 CCM 1978, 6: 136 ARRD 1992, 145 990 降低PCWP---改善ARDS预后 ARDS pas n=40 PAWP与ARDS病死率正相关 PAWP12 mmHg：病死率明显增高 根据治疗后PAWP改变 ARDS分为两组： 降低25%为反应组 Chest 1990, 97: 1176 ARDS的液体管理策略 问题：是否应该限制液体，限制性的液体管理是否影响其他器官功能 Randomized study n=1000 pats with ALI Conservative vs liberal strategy of fluid management N Engl J Med 2006;354 Fluid Balance From Day 1 to 7 限制性液体管理－不改善预后，但改善呼吸功能 限制性液体管理对肺外器官功能的影响 CRRT—调节液体平衡 Balance study Randomized, double-blind, placebo-controlled trial of furosmide + albumin or furosmide + placebo ALI or ARDS pats 3 day treatment period Study protocol Furosemide: Continuous infusion Titrated to achieve negative fluid balance weight loss Suspended for hypotension, K+, Na+, alkalosis Albumin 25g of 25% sulution (100ml) q8h Placebo substituted if serum total protein 8g/dL Crit Care Med 2005; 33:1681–1687 (3)提高血浆胶体渗透压 BALANCE studyDemographics 40 pats (20/group) Demographics: Male 47% Caucasian 72% African-Amer 28% Age = 48 years APACHE II = 13.7 LIS =2.8 Crit Care Med 2005; 33:1681–1687 Colloid Osmotic Pressure Crit Care Med 2005; 33:1681–1687 Fluid balance Oxygenation Clinic