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Effectsoffluidadministrationonrenalperfusionincriticallyillpatients危重病人液体管理对肾灌注的影响ContentsIntroduction1Methods2Results3Conclusions4DiagramoxygendeliveryoxygendemandImbalanceIntroductionImbalanceinoxygendeliveryandoxygendemandiscommonincriticallyillpatients,especiallythosewithacutecirculatoryfailureofseptic,hypovolemicorcardiogenicorigin.Introduction•Acutekidneyinjury(AKI)isafrequentcomplicationofcirculatoryfailureandassociatedwithincreasedmorbidityandmortality.•急性肾损伤是循环衰竭状态下的常见并发症，它与发病率及死亡率的升高密切相关。Introduction•Fluidresuscitationisafirst-linetherapyusedtorestoreoxygendeliverytotheorgansandpreventAKIandyettherenaleffectsoffluidresuscitationarenoteasilyassessed.•液体复苏是恢复器官血氧输送及预防AKI的一线治疗方法，然而液体复苏对于肾脏的影响是不容易评估的。Introduction•Physiciansgenerallyevaluatetheeffectivenessoffluidtherapybylookingatsystemichemodynamicvariables,suchasmeanarterialpressure(MAP)orcardiacoutput,becausetheincreaseinurineoutputmaybedelayedorinconsistentandthedecreaseinserumcreatininemaybeevenslower.Adirectevaluationofrenalhemodynamicswouldbevaluable.•医师通常通过全身血流动力学变量来评估液体治疗的效果，比如：平均动脉压、心输出量，因为尿量增加可能会延迟或者与实际情况不一致，血肌酐的下降也非常慢，这些指标都不能及时有效的反应肾灌注情况。•一种可以直接评估肾脏血流动力学的方法将非常有价值。Introduction•WeusedDopplertechniquestoinvestigatetheeffectsoffluidadministrationonintrarenalhemodynamicsandtherelationshipbetweenchangesinrenalhemodynamicsandurineoutput.•我们用多普勒技术研究液体管理对肾内血流动力学的影响以及肾脏血流动力学与尿量的关系。Fig.1Summaryofthestudydesign.Theinterventionwasafluidchallengethatconsistedofinfusionofaminimumvolumeof500mlataminimumrateof1,000ml/hour.InterlobararteryDopplervariables,bloodpressure,heartrateandurineoutputwererecordedbeforeandafterthefluidchallengeandstabilizationofhemodynamicvariables.UO/3H:urineoutputvolumesmeasuredover3hours.肾脏血管的测量和正常值阻力指数（RI，ResistanceIndex）=（Vmax-Vmin）/Vmax正常肾各段肾动脉的阻力指数（RI）各段肾动脉RI主肾动脉段动脉叶间动脉弓状动脉小叶间动脉0.650.020.630.040.590.020.540.030.510.04Fig.2StudyConsortdiagram.SixpatientshadtwoDopplerwavesinsteadofthreeormore,twopatientshad>5%differenceinRIbetweenthekidneys.RIADrenalinterlobararteryDoppler.Criteria--ControlgroupThecontrolgroupsincludedICUpatientswithstablesystemichemodynamicsreceivingnospecificintervention.对照组包括全身血流动力学稳定且没有接受特殊干预的ICU病人。ControlgroupA评价观察者在测量肾叶间动脉RI自身偏差——测量3次（3个心动周期），每次间隔15min同一超声医师测量，RI计算由统计员负责。ControlgroupB评价多普勒变量的稳定性——测量2次，间隔60min由同一超声医师测量，RI计算由统计员负责。Criteria--Interventiongroup需要液体冲击治疗的急性循环衰竭患者：并且至少包含以下一条标准：a.神志改变b.四肢白斑c.动脉血乳酸>2mmol/Ld.ScvO2<70%e.或SvO2<65%a.低动脉压：收缩期动脉压<90mmHgorMAP<65mmHgb.需要升压药纠正低血压c.少尿（尿量<0.5ml/kg/hour）Diagram•age<18years•atrialfibrillation•frequentventriculararrhythmias•end-stagerenaldisease•unilateralkidney•historyofrenaltransplantationorstenosisofrenalarteries•pregnancy•bodymassindex>40kg/m2ExclusivecriteriaDiagramgivendiureticsExcludedfromthestudychangesinvasopressoradministrationduringthestudyperiod研究期间监测项目1.持续动态心电图监测2.心率3.有创平均动脉压、脉压（桡动脉or股动脉）4.血乳酸5.ScvO2及SvO2DiagramAddYourTextAddYourTextAddYourText停止液体管理0.9%Nacl500mlor6%羟乙基淀粉在动脉压指导下维持最低1000ml/h.www.themegallery.com补液要求MAP>65mmHgMAPstrokevolumeincrease>10-15%基础值CVP>15mmHgFig.3IndividualchangesinRIovertimeinthenon-interventiongroup(ControlgroupB).EachlinecorrespondstothechangeinRIinonestableICUpatient.Measurementswereperformedatbaselineand1hourlaterinstablehemodynamicconditionswithnointerventionResultsResults•FluidadministrationresultedinincreasesinMAPfrom75±15to80±14mmHg(p<0.01)•PPfrom49±19to55±19mmHg(p<0.01).•RIdecreasedconcurrentlyfrom0.73±0.09to0.71±0.09(p<0.01)•urineoutputincreasedfrom55±76to81±87ml/hour(p<0.01).ResultsFig.4Changesinhemodynamicvariablesbeforeandafterfluidchallenge.AChangesinresistivityindex(RI).BChangesinmeanarterialpressure(MAP)andinpulsepressure(PP).They-axesshowthemeanvalues±standarddeviation.MAP1,PP1,RI1arevaluesbeforefluidchallengeandMAP2,PP2,RI2arevaluesafterfluidchallenge.Atbaseline,RIpredictedanincreaseinurineoutputfollowingafluidchallengeatallthresholdsandMAPpredictedanincreaseatthresholdsof0.2ml/kg/hourand0.3ml/kg/hour,butnot0.1ml/kg/hour(Table3).Conclusions•WeshowedthatfluidadministrationreducesintrarenalvasoconstrictionandthatchangesinRIaremoreeffectivethanchangesinMAPandPPtopredictanincreaseinurineoutputafterfluidchallenge.DynamicanalysisofintrarenalhemodynamicsusingRIADcanidentifyrenalresponsivepatients.However,theuseofRItoguidefluidtherapyforrenalhemodynamicmanagementmaybelimitedbythesmallmagnitudeofthechangesandpotentialtechnicallimitations.•我们的研究显示液体管理降低肾内血管张力，RI的变化比MAP和PP更能预知快速输液后尿量的增加。•利用RIAD动态分析肾内血流动力学可以识别患者的肾脏反应性。然而RI指导肾脏血流动力学管理的液体治疗可能会受到变量太小以及潜在技术上的限制。•