ScvO2的临床意义.ppt

ScvO2的临床意义的临床意义内内￿￿￿￿￿￿容容￿ ￿[[氧供与氧耗[[SvO2与ScvO2[[ScvO2的临床应用氧供与氧耗氧供与氧耗15vol%=15ml/dl5vol%=5ml/dl氧供氧供DO2与氧耗与氧耗VO2[DO2=CaO2×CO[ =(1.34×SaO2×Hb+0.0031×PaO2)×CO[￿￿￿￿￿￿￿￿=1.34×SaO2×Hb×CO[VO2=(CaO2-CvO2)×CO[ = (SaO2- SvO2) ×1.34 × Hb×CO[SvO2=SaO2-VO2/(1.34×Hb×CO)￿ ￿呼吸呼吸血红蛋白血红蛋白循环循环(Fick方程方程)氧摄取氧摄取EO2[EO2=VO2/DO2[EO2=(SaO2 - SvO2)/SaO2[当SaO2=100%时￿：￿EO2=1-SvO2n全身￿￿EO2=1 - 75% = 25%n各组织EO2不同，其相应之静脉氧饱和度不同nSvO2 = 1 - EO2氧供氧耗失衡氧供氧耗失衡SvO2降低或增加降低或增加无氧代谢无氧代谢组织缺氧组织缺氧乳酸生成乳酸生成影响影响SvO2的因素的因素75%-+DO2应激应激发热发热寒战寒战躁动躁动疼痛疼痛呼吸做功呼吸做功VO2CO(心衰、低容量）心衰、低容量）Hb（贫血、出血）（贫血、出血）SaO2（缺氧、呼衰）（缺氧、呼衰）DO2CO（液体复苏、正性肌力）（液体复苏、正性肌力）Hb（输血）（输血）SaO2（氧疗）（氧疗）VO2低体温低体温镇静镇静镇痛镇痛麻醉麻醉机械通气机械通气氧摄取氧摄取（分流、（分流、细胞死亡）细胞死亡）SvO2 的界值的界值Pinsky MR, Mancebo J, Applied physiology in intensive care. ScvO2与与SvO2ScvO2与SvO2ScvO2与SvO2[[SvO2SvO2n n由肺动脉导管测得由肺动脉导管测得n n反映全身的氧耗量反映全身的氧耗量n n正常值：正常值：75%75%[[ScvO2ScvO2n n由中心静脉（上腔静脉）导管测得由中心静脉（上腔静脉）导管测得n n反映脑及上半身的氧耗量反映脑及上半身的氧耗量n n正常值：正常值：72%72%测定方法测定方法[连续监测n光纤导管或光纤中心静脉导管[间断测定n中心静脉血气正正常常各各组组织织器器官官的的静静脉脉氧氧饱饱和和度度Pinsky MR, Mancebo J, Applied physiology in intensive care. 休休克克时时？？ScvO2与与SvO2的相关性的相关性Charalambos Ladakis Pavlos Myrianthefs Andreas Karabinis et al.Central Venous and Mixed Venous Oxygen Saturation in Critically ill patients,Respairation,2001;68 279-285Linear correlation of paired ScvO2 and SvO2 measurements for 296 paired samples ScvO2 increases by 0.87% for every unit increase in SvO2ScvO2与与SvO2的相关性的相关性Dueck MH et al. Anesthesiology 2005; 103:249 –57Možina and Podbregar Critical Care2010,14:R42 thMožina and Podbregar Critical Care2010,14:R42Možina and Podbregar Critical Care2010,14:R42Možina and Podbregar Critical Care2010,14:R42SvO2与与ScvO2的一致性的一致性绝对值相差绝对值相差5~18%ScvO2的临床应用的临床应用休克中的应用休克中的应用VO2DO2ScvO2/SvO2乳酸乳酸休克的本质是组织缺氧和氧代谢障碍，最终结果是MODS。

液体复苏、及早纠正氧供与氧耗的失衡、降低组织缺氧程度至关重要急诊患者的复苏急诊患者的复苏[多数（31例/36例）存在休克的危重患者经初期复苏至正常生命体征后乳酸继续升高(>2mmol/L)，ScvO2仍低于正常(<65%)，提示存在无氧酵解和氧债[这些患者进一步治疗后乳酸下降（4.6±3.8 to 2.6±2.5, p<0.05)，ScvO2升高（52±18 to 65±13%, p<0.05)[ScvO2能作为初期复苏后指导休克治疗的指标Rady MY, Rivers EP, Novak RM: Resuscitation of the critically ill in the ED:responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med1996, 14:218-225.重症感染与感染性休克中的应用重症感染与感染性休克中的应用1368·1377 N Engl J Med, Vol. 345, No. 19· November 8, 2001早期目标指导治疗（早期目标指导治疗（EGDT））研究结果研究结果——死亡率死亡率Rivers E, Nguyen B, Havstad S, et a1．Early goal directed therapy in the treatment of severe sepsis and septic shock. N Eng J Med,2001,345:1368—1377.进行ScvO2监测，达到EGDT目标，可使患者病死率下降16%（46.5% vs 30.5%）。

低低ScvO2的的预后差预后差2012 “拯救脓毒症运动拯救脓毒症运动”指南指南——早期复苏目标早期复苏目标[[MAP ≥65mmHg[[CVP 8~12mmHg , 机械通气12~15mmHg[[尿量≥0.5ml/kg/h [[ScvO2 ≥ 70% or SvO2 ≥65%感染性休克高感染性休克高ScvO2的预后的预后单因素分析结果单因素分析结果存活组与存活组与死亡组的死亡组的ScvO2该研究共纳入4家医院急诊科脓毒症患者619名，按EDGT复苏方案治疗，据ScvO2水平分为三组：低ScvO2组(＜70%)、正常ScvO2组(71~89%)、高组(90~100%)比较住院死亡率并进行多因素分析23%25%31%初始初始ScvO2与死亡率与死亡率(81/351)(56/223)(14/45)25/6296/46531/92ScvO2在在ACS 中的应用中的应用该研究纳入患者43名，为收住CCU的急性冠脉综合征（ACS）并急性肺水肿或心源性休克患者，测定入室时、24h、48h的中心静脉和外周动脉血气，主要终点为致死性事件，次要终点为住院全因死亡率Acta Cardiol Sin 2008;24:12633结果：存活组与死亡组结果：存活组与死亡组ScvO2的差异有显著性的差异有显著性Acta Cardiol Sin 2008;24:12633所有患者所有患者ScvO2、、SaO2的变化的变化存活患者存活患者ScvO2的变化的变化Acta Cardiol Sin 2008;24:12633创伤患者的评估创伤患者的评估Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prospective observational studyAlessandro Di Filippo*1, Chiara Gonnelli1, Lucia Perretta1,Rosario pina1, Marco Chiostri2, Gian Franco Gensini2 and Adriano Peris1Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23ScvO2≤65%的患者住院时间延长，死亡率明显增加的患者住院时间延长，死亡率明显增加急诊插管对重症患者急诊插管对重症患者ScvO2的影响的影响15minHernandez et al. Critical Care2009, 13:R63 Hernandez et al. Critical Care2009, 13:R63 插管改善插管改善ScvO2的机制的机制[插管前预充纯氧，溶解氧增加，氧供提高[插管时镇静与肌松使氧摄取减少而降低氧耗[初始机械通气减轻了过度通气，使pH升高而使氧离曲线右移，利于氧释放围术期围术期ScvO2的应用的应用患者资料患者资料单因素分析单因素分析After multivariate analysis, mean ScvO2 value (OR 1.23 [95%CI 1.01 to 1.50], p = 0.037), hospital LOS (OR 0.75 [95% CI 0.59 to 0.94], p = 0.012), and SAPS II (OR 0.90 [95% CI 0.82 to 0.99], p = 0.029) were independently associated with postoperative complications.多因素分析多因素分析低低ScvO2与术后并发症相关与术后并发症相关P=0.004The optimal value of mean ScvO2 for discriminating between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%)ScvO2与乳酸在感染性休克中应用比较与乳酸在感染性休克中应用比较[Jones的研究显示：在感染性休克的早期目标性治疗中，乳酸清除率达标与ScvO2达标，两组的住院死亡率无差别【25% （17~30%）vs 17%（11~24%）】。

Jones AE et al. JAMA. 2010 February 24; 303(8): 739–746ScvO2与容量反应性与容量反应性[大循环指标：血压、心率、尿量、CVP[CO、CI[PPV[SVV[ScvO2?ScvO2 As a Marker to Define Fluid Responsiveness[[Methods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR[Methods:A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO2) and ScvO2 were measured before and after VE. CI, SvO2, and ScvO2changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR Giraud R, et al. J Trauma.2011;70: 802–807ScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 802–807ScvO2 As a Marker to Define Fluid Responsiveness Giraud R, et al. J Trauma.2011;70: 802–807ScvO2 As a Marker to Define Fluid Responsiveness[[Results: ScvO2 and SvO2 variations after VE (SvO2) were significantly correlated with CI changes (CI) after VE (r 0.67 and r= 0.49,p<0.001, respectively). AScvO2 threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 57–98%) and 81% specificity (95%CI; 54–96%) Giraud R, et al. J Trauma.2011;70: 802–807ScvO2的局限性的局限性争论：争论：ScvO2不能反映不能反映SvO2[Bias of difference was 4.2% and 95% limits of agreement ranged from –8.1% to 16.5%.[The central venous oxygen saturation overestimated the mixed venous oxygen saturation by a mean bias (or an absolute difference) of 6.9%, and the 95% limits of agreement were large (-5.0% to 18.8%). The difference between central and mixed venous oxygen saturation appeared to be more significant when mixed venous oxygen saturation was <70% Varpula M et al. Intensive Care Med (2006) 32:1336–1343Ho KM et al. J Cardiothorac Vasc Anesth. 2010 Jun;24(3):434-9. 56.7%36%7.3%ScvO2初始值差异大初始值差异大(351)(223)(45)Pope JV et al. Ann Emerg Med. 2010 January ; 55(1): 40–46总数总数619组织氧代谢指标组织氧代谢指标[胃粘膜pH[组织氧饱和度（StO2）[微透析测组织代谢[联合指标[……？SvO2/ScvO2不能很好反应组织氧代谢不能很好反应组织氧代谢微透析？微透析？ScvO2+CO2gap的意义的意义Kocsi S et al.Critical Care Research and PracticeVolume 2013, Article ID 583598,7pagesIn ICU resuscitated patients, targeting only ScvO2 may not be sufficient to guide therapy. When the 70% ScvO2 goal value is reached, the presence of aP(cv-a)CO2 larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.Intensive Care Med (2008) 34:2218-222550 consecutive septic shock patients with ScvO2＞70% ScvO2+CO2gap的意义的意义SvO2ScvO2DO2VO2氧利用氧利用 改善氧供改善氧供——改善氧耗？线粒体改善氧耗？线粒体Rampal T. Curr Opin Crit Care 16:244–249总总￿￿￿￿￿￿￿￿结结[ScvO2与SvO2 相关性较好，动态监测可反映机体的全身氧代谢状况[ScvO2可作为重症患者病情评估、预后判断的有效参考指标[ScvO2可用于重症患者的治疗指导[ScvO2存在其局限性存在其局限性，不能替代医师的临床综合判断[将来——细胞水平缺氧的判断与治疗？！谢谢 谢！谢！ScvO2与与P(cv-a)CO2对外科感对外科感染性休克液体复苏的临床研究染性休克液体复苏的临床研究昆明医科大学第二附属医院研究背景研究背景本研究是针对腹部外科术后感染性休克患者，监测入ICU最初6小时复苏前后ScvO2、 P(cv-a)CO2，探讨其变化是否能更好的指导患者早期复苏治疗，寻找最佳的复苏目标，以及是否能对病情和预后作出评估和判断。

 本研究共纳入2012年1月～2013年3月期间所有收入昆明医科大学第二附属医院重症医学科（ICU）外科术后感染性休克患者46例，其中住ICU死亡10例，28天死亡16例，住ICU病死率21.7%，28天病死率34.8%实验结果实验结果检测项目检测项目T0T0T6T6t t值值P P值值HRHR（次（次/ /分）分）113.43±22.113.43±22.4646106.96±21.106.96±21.63632.3732.3730.0220.022MAPMAP（（mmmmHgHg））75.11±17.375.11±17.375.11±13.375.11±13.32 20.0000.0001.0001.000CVPCVP（（cmHcmH2 2OO））14.58±5.8214.58±5.8214.47±5.4714.47±5.470.1710.1710.8600.860COCO（（L/minL/min））8.15±6.868.15±6.866.42±3.456.42±3.451.0681.0680.2960.296P(cv-a)COP(cv-a)CO2 2（（mmHgmmHg））7.93±6.167.93±6.165.87±3.105.87±3.101.8961.8960.0440.044* *ScvOScvO2 2（（%%））69.67±10.969.67±10.97 772.28±9.4272.28±9.42-2.002-2.0020.0490.049* *LacLac（（mmol/mmol/L L））4.47±2.694.47±2.693.40±2.583.40±2.584.5014.5010.0000.000* *BEBE（（mmol/mmol/L L））-6.32±4.33-6.32±4.33-4.19±4.58-4.19±4.58-2.970-2.9700.0050.005* *PaOPaO2 2/FiO/FiO2 2（（mmHg/%mmHg/%））207.02±74.207.02±74.5454199.11±83.199.11±83.79790.6820.6820.4990.499CrCr（（μmol/Lμmol/L））151.35±12151.35±129.489.48140.52±10140.52±105.655.651.1671.1670.3080.3086 6小时复苏前后参数资料比较小时复苏前后参数资料比较实验结果实验结果P=0.044P=0.005P=0.000实验结果实验结果　　　　　　　　laclac丨丨BEBE丨丨T0T0时时ScvOScvO2 2r r值值值值-0.169-0.1690.1070.107P P值值值值0.2610.2610.4800.480T6T6时时ScvOScvO2 2r r值值值值-0.342-0.342-0.299-0.299P P值值值值0.0200.0200.0440.044ScvOScvO2 2与与laclac、、BEBE相关性分析相关性分析laclac丨丨BEBE丨丨T0T0时时P(cv-a)COP(cv-a)CO2 2r r值值值值0.1710.171-0.111-0.111P P值值值值0.2570.2570.4610.461T6T6时时P(cv-a)COP(cv-a)CO2 2r r值值值值0.6520.652-0.495-0.495P P值值值值0.0000.0000.0000.000 P(cv-a)CO P(cv-a)CO2 2与与laclac、、BEBE相关性分析相关性分析实验结果实验结果ScvOScvO2 2与与COCO相关性分析相关性分析 P(cv-a)CO P(cv-a)CO2 2与与COCO相关性分析相关性分析COCOT0T0时时ScvOScvO2 2r r值值值值0.3910.391P P值值值值0.0480.048T6T6时时ScvOScvO2 2r r值值值值0.6640.664P P值值值值0.0390.039COCOT0T0时时P(cv-a)COP(cv-a)CO2 2r r值值值值-0.183-0.183P P值值值值0.0400.040T6T6时时P(cv-a)COP(cv-a)CO2 2r r值值值值-0.521-0.521P P值值值值0.0020.002实验结果实验结果ScvOScvO2 2与与P(cv-a)COP(cv-a)CO2 2的相关性分析的相关性分析T T0 0 P P( (c cv v- -a a) )C CO O2 2T0 ScvOT0 ScvO2 2T T6 6 P P( (c cv v- -a a) )C CO O2 2T6 ScvOT6 ScvO2 2T0时r=-0.358，P=0.011 T6时r=-0.425，P=0.003 T T0 0 P P( (c cv v- -a a) )C CO O2 2T6 ScvOT6 ScvO2 2实验结果实验结果检测项目检测项目生存组生存组(30(30例）例） 死亡组（死亡组（1616例）例）t t值值P P值值HRHR（次（次/ /分）分）103103．．．．23±21.3823±21.38113.94±21.02113.94±21.02-1.627-1.6270.1110.111MAPMAP（（mmHgmmHg））73.97±14.3073.97±14.3077.25±11.3777.25±11.37-0.793-0.7930.4320.432COCO（（L/minL/min））6.33±2.126.33±2.126.69±2.556.69±2.55-0.390-0.3900.7000.700CVPCVP（（mmHgmmHg））14.03±5.5914.03±5.5915.28±5.3015.28±5.30-0.733-0.7330.4670.467LacLac（（mmol/Lmmol/L））2.09±1.002.09±1.005.88±2.855.88±2.85-5.150-5.1500.0000.0006 6小小时时乳乳酸酸清清除除率率0.42±0.210.42±0.21-0.18±0.49-0.18±0.495.7395.7390.0000.000ScvOScvO2 2（（%%））74.43±6.0474.43±6.0469.69±13.4269.69±13.421.3441.3440.1040.104P(cv-a)COP(cv-a)CO2 24.54±2.064.54±2.068.63±2.968.63±2.96-5.488-5.4880.0000.000BEBE（（mmol/Lmmol/L））-2.46±3.83-2.46±3.83-7.41±4.18-7.41±4.184.0474.0470.0000.000PaOPaO2 2/FiO/FiO2 2（（mmHg/%mmHg/%））218.30±82.92218.30±82.92163.13±75.17163.13±75.172.2182.2180.0320.032CrCr（（μmol/Lμmol/L））118.07±90.66118.07±90.66182.63±121.22182.63±121.22-2.042-2.0420.0470.047生存组与死亡组生存组与死亡组各项指标比较各项指标比较实验结果实验结果T6 P(cv-a)CO2<6mmHg(26例)低ScvO2组（6例）高ScvO2组（20例）根据ScvO2是否>70%实验结果实验结果T6 ScvO2＞70%(30例)低P(cv-a)CO2组（20例）高P(cv-a)CO2组（10例）根据P(cv-a)CO2是否≥6mmHg实验结果实验结果T6 ScvO2（（46例）例）低低ScvO2组（＜组（＜70%））（（15例）例）存活存活8例例(17.4%)死亡死亡7例例(15.2%)中中ScvO2组（组（70～～80%））（（22例）例）存活存活18例例(39.1%)死亡死亡4例例(8.7%)高高ScvO2组（＞组（＞80%））（（9例）例）存活存活4例例(8.7%)死亡死亡5例例(10.9%)T6 ScvO2（（46例）例）低低ScvO2组（＜组（＜70%））（（15例）例）存活存活8例例(17.4%)死亡死亡7例例(15.2%)中中ScvO2组（组（70～～80%））（（22例）例）存活存活18例例(39.1%)死亡死亡4例例(8.7%)高高ScvO2组（＞组（＞80%））（（9例）例）存活存活4例例(8.7%)死亡死亡5例例(10.9%)χ2值=5.319，P=0.070＞0.05，差异无统计学意义0.00%5.00%10.00%15.00%20.00%低ScvO2组 中ScvO2组 高ScvO2组三组ScvO2的病死率比较图图7实验结果实验结果T6 P(cv-a)CO2AUROC曲线下面积0.758，与0.5相比差异有统计学意义（P=0.004），对预后有中等判断能力。