1、ScvO2的臨床意義,內(nèi) 容,氧供與氧耗 SvO2與ScvO2 ScvO2的臨床應(yīng)用,氧供與氧耗,15vol%=15ml/dl,5vol%=5ml/dl,氧供DO2與氧耗VO2,DO2=CaO2CO =(1.34SaO2Hb+0.0031PaO2)CO =1.34SaO2HbCO VO2=(CaO2-CvO2)CO = (SaO2- SvO2) 1.34 HbCO SvO2=SaO2-VO2/(1.34HbCO),呼吸,血紅蛋白,循環(huán),(Fick方程),氧攝取EO2,EO2=VO2/DO2 EO2=(SaO2 - SvO2)/SaO2 當(dāng)SaO2=100%時(shí) ： EO2=1-SvO2 全身 E

2、O2=1 - 75% = 25% 各組織EO2不同，其相應(yīng)之靜脈氧飽和度不同 SvO2 = 1 - EO2,氧供氧耗失衡,SvO2降低或增加,無(wú)氧代謝 組織缺氧 乳酸生成,影響SvO2的因素,75%,-,+,DO2,應(yīng)激 發(fā)熱 寒戰(zhàn) 躁動(dòng) 疼痛 呼吸做功,VO2,CO (心衰、低容量） Hb （貧血、出血） SaO2 （缺氧、呼衰）,DO2,CO （液體復(fù)蘇、正性肌力） Hb （輸血） SaO2 （氧療）,VO2,低體溫 鎮(zhèn)靜 鎮(zhèn)痛 麻醉 機(jī)械通氣 氧攝取 （分流、 細(xì)胞死亡）,SvO2 的界值,Pinsky MR, Mancebo J, Applied physiology in inten

3、sive care.,ScvO2與SvO2,ScvO2與SvO2,ScvO2與SvO2,SvO2 由肺動(dòng)脈導(dǎo)管測(cè)得 反映全身的氧耗量 正常值：75% ScvO2 由中心靜脈（上腔靜脈）導(dǎo)管測(cè)得 反映腦及上半身的氧耗量 正常值：72%,測(cè)定方法,連續(xù)監(jiān)測(cè) 光纖導(dǎo)管或光纖中心靜脈導(dǎo)管 間斷測(cè)定 中心靜脈血?dú)?正常各組織器官的靜脈氧飽和度,Pinsky MR, Mancebo J, Applied physiology in intensive care.,休克時(shí)？,ScvO2與SvO2的相關(guān)性,Charalambos Ladakis Pavlos Myrianthefs Andreas Karab

4、inis et al.Central Venous and Mixed Venous Oxygen Saturation in Critically ill patients,Respairation,2001;68 279-285,Linear correlation of paired ScvO2 and SvO2 measurements for 296 paired samples ScvO2 increases by 0.87% for every unit increase in SvO2,ScvO2與SvO2的相關(guān)性,Dueck MH et al. Anesthesiology

5、2005; 103:249 57,Moina and Podbregar Critical Care2010,14:R42 th,Moina and Podbregar Critical Care2010,14:R42,Moina and Podbregar Critical Care2010,14:R42,Moina and Podbregar Critical Care2010,14:R42,SvO2與ScvO2的一致性,絕對(duì)值相差518%,ScvO2的臨床應(yīng)用,休克中的應(yīng)用,VO2,DO2,ScvO2/SvO2 乳酸,休克的本質(zhì)是組織缺氧和氧代謝障礙，最終結(jié)果是MODS。液體復(fù)蘇、及早糾

6、正氧供與氧耗的失衡、降低組織缺氧程度至關(guān)重要。,急診患者的復(fù)蘇,多數(shù)（31例/36例）存在休克的危重患者經(jīng)初期復(fù)蘇至正常生命體征后乳酸繼續(xù)升高(2mmol/L)，ScvO2仍低于正常(65%)，提示存在無(wú)氧酵解和氧債。 這些患者進(jìn)一步治療后乳酸下降（4.63.8 to 2.62.5, p0.05)，ScvO2升高（5218 to 6513%, p0.05) ScvO2能作為初期復(fù)蘇后指導(dǎo)休克治療的指標(biāo),Rady MY, Rivers EP, Novak RM: Resuscitation of the critically ill in the ED: responses of blood p

7、ressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med1996, 14:218-225.,重癥感染與感染性休克中的應(yīng)用,13681377 N Engl J Med, Vol. 345, No. 19 November 8, 2001,早期目標(biāo)指導(dǎo)治療（EGDT）,研究結(jié)果死亡率,低ScvO2的預(yù)后差,2012 “拯救膿毒癥運(yùn)動(dòng)”指南 早期復(fù)蘇目標(biāo),MAP 65mmHg CVP 812mmHg , 機(jī)械通氣1215mmHg 尿量0.5ml/kg/h ScvO2

8、70% or SvO2 65%,感染性休克高ScvO2的預(yù)后,單因素分析結(jié)果,存活組與死亡組的ScvO2,該研究共納入4家醫(yī)院急診科膿毒癥患者619名，按EDGT復(fù)蘇方案治療，據(jù)ScvO2水平分為三組：低ScvO2組(70%)、正常ScvO2組(7189%)、高組(90100%)。比較住院死亡率并進(jìn)行多因素分析,23%,25%,31%,初始ScvO2與死亡率,(81/351),(56/223),(14/45),25/62,96/465,31/92,ScvO2在ACS 中的應(yīng)用,該研究納入患者43名，為收住CCU的急性冠脈綜合征（ACS）并急性肺水腫或心源性休克患者，測(cè)定入室時(shí)、24h、48h的

9、中心靜脈和外周動(dòng)脈血?dú)猓饕K點(diǎn)為致死性事件，次要終點(diǎn)為住院全因死亡率,Acta Cardiol Sin 2008;24:12633,結(jié)果：存活組與死亡組ScvO2的差異有顯著性,Acta Cardiol Sin 2008;24:12633,所有患者ScvO2、SaO2的變化,存活患者ScvO2的變化,Acta Cardiol Sin 2008;24:12633,創(chuàng)傷患者的評(píng)估,Low central venous saturation predicts poor outcome in patients with brain injury after major trauma: a prosp

10、ective observational study Alessandro Di Filippo*1, Chiara Gonnelli1, Lucia Perretta1,Rosario pina1, Marco Chiostri2, Gian Franco Gensini2 and Adriano Peris1,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine2009, 17:23,Scandinavian Journal of Trauma, Resuscitation and Emergency Me

11、dicine2009, 17:23,ScvO265%的患者住院時(shí)間延長(zhǎng)，死亡率明顯增加,急診插管對(duì)重癥患者ScvO2的影響,15min,Hernandez et al. Critical Care2009, 13:R63,Hernandez et al. Critical Care2009, 13:R63,插管改善ScvO2的機(jī)制,插管前預(yù)充純氧，溶解氧增加，氧供提高 插管時(shí)鎮(zhèn)靜與肌松使氧攝取減少而降低氧耗 初始機(jī)械通氣減輕了過(guò)度通氣，使pH升高而使氧離曲線右移，利于氧釋放,圍術(shù)期ScvO2的應(yīng)用,患者資料,單因素分析,After multivariate analysis, mean Scv

12、O2 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,低ScvO2與術(shù)后并發(fā)癥相關(guān),P=0.004,The optimal value of mean ScvO2 for discriminatin

13、g between patients who did or did not develop complications was 73% (sensitivity72%, specificity 61%),ScvO2與乳酸在感染性休克中應(yīng)用比較,Jones的研究顯示：在感染性休克的早期目標(biāo)性治療中，乳酸清除率達(dá)標(biāo)與ScvO2達(dá)標(biāo)，兩組的住院死亡率無(wú)差別【25% （1730%）vs 17%（1124%）】。,Jones AE et al. JAMA. 2010 February 24; 303(8): 739746,ScvO2與容量反應(yīng)性,大循環(huán)指標(biāo)：血壓、心率、尿量、CVP CO、CI PPV

14、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

15、 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

16、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 abi

17、lity to distinguish R and NR,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsiveness,Giraud R, et al. J Trauma.2011;70: 802807,ScvO2 As a Marker to Define Fluid Responsivenes

18、s,Results: ScvO2 and SvO2 variations after VE (SvO2) were significantly correlated with CI changes (CI) after VE (r 0.67 and r= 0.49,p0.001, respectively). AScvO2 threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 5798%) and 81% specificity (95%CI; 5496%),Giraud R, et al. J Tra