指南解读：血流动力学监测与心脏超声（CUS）1.SLAX:肋下长轴切面2.SIVC:肋下下腔静脉切面3.PLAX：胸骨旁长轴切面4.PSAX:胸骨旁短轴切面5.A4CH:心尖四腔心切面CUS最常用的五个切面AntonelliM,etal.IntensiveCareMed.2007;33(4):575-90.CecconiM,etal.IntensiveCareMed.2014;40(12):1795-815.25位专家组成的团队12位专家组成的团队FiveSpecificQuestions(1)Whataretheepidemiologicandpathophysiologicfeaturesofshockintheintensivecareunit?(2)Shouldwemonitorpreloadandfluidresponsivenessinshock?(3)Howandwhenshouldwemonitorstrokevolumeorcardiacoutputinshock?(4)Whatmarkersoftheregionalandmicrocirculationcanbemonitored,andhowcancellularfunctionbeassessedinshock?(5)Whatistheevidenceforusinghemodynamicmonitoringtodirecttherapyinshock?2014ConsensusRecommendedagainst常规使用:(1)thepulmonaryarterycatheterinshock休克患者使用肺动脉导管(2)staticpreloadmeasurementsusedalonetopredictfluidresponsiveness仅仅使用静态的前负荷测量方法来预测液体反应性MaindifferencesBloodpressurestatementsICM2007ICM2014FluidresponsivenessstatementsICM2007ICM2014ICM2007HemodynamicmonitoringICM2014CecconiM,etal.IntensiveCareMed.2014;40(12):1795-815.Mainnewstatements(1)Statementsonindividualizingbloodpressuretargets;(2)Statementsontheassessmentandpredictionoffluidresponsiveness;(3)Statementsontheuseofechocardiographyandhemodynamicmonitoring.2014ConsensusIdentificationofthetypeofshock•Werecommendfurtherhemodynamicassessment(suchasassessingcardiacfunction)todeterminethetypeofshockiftheclinicalexaminationdoesnotleadtoacleardiagnosis.BestpracticeWesuggestthat,whenhemodynamicassessmentisneeded,echocardiographyisthepreferredmodalitytoinitiallyevaluatethetypeofshockasopposedtomoreinvasivetechnologies.Recommendation.Level2;QoE(B)Rationale:Contextanalysis(trauma,infection,chestpain,etc.)andclinicalevaluationwhichfocusesonskinperfusionandjugularveindistensionusuallyorientdiagnosistothetypeofshock,butcomplexsituationsmayexist(e.g.cardiactamponadeinapatientwithtraumaorsepticshockinapatientwithchronicheartfailure)inwhichadiagnosisismoredifficult.VincentJL,etal.NEnglJMed.2013;369(18):1726-34.ManifestationonEcho梗阻性心包填塞FOCUS的测量很迅速，即使是初学者，一般时间也小于3min；FOCUS应当被列入重症培训的项目中去。BeraudAS,etal.CritCareMed.2013;41(8):e179-81.IC-FoCUS国际聚焦心脏超声循证建议ViaG,etal.JournaloftheAmericanSocietyofEchocardiography.2014;27(7):683e1-e33.名称确认：聚焦心脏超声（FoCUS）重点用于生命支持的评估、复苏的评估等。。。FoCUSstatementShockandHemodynamicInstability43.Inthesettingofshock,FoCUSaccuratelyassessesglobalLVsystolicfunction,whencomparedwithcomprehensivestandardechocardiography.[1A:StrongRecommendation,withVeryGoodAgreement;LevelAEvidence]44.Inthesettingofshock,FoCUSnarrowsthedifferentialdiagnosis.[1A:StrongRecommendation,withVeryGoodAgreement;LevelAEvidence]2014ConsensusMonitoringcardiacfunctionandcardiacoutputEchocardiographycanbeusedforthesequentialevaluationofcardiacfunctioninshock.Statementoffact•Werecommendthatlessinvasivedevicesareused,insteadofmoreinvasivedevices,onlywhentheyhavebeenvalidatedinthecontextofpatientswithshock.BestpracticeRationale:EchocardiographycanhelptheICUphysicianinthreeways:(1)bettercharacterizationofthehemodynamicdisorders;(2)selectionofthebesttherapeuticoptions(intravenousfluids,inotropesandultrafiltration);(3)assessmentoftheresponseofthehemodynamicdisorderstotherapy.VTI,LVEF,LVEDA,RVEDA,E/Aratio…LheritierG,etal.IntensiveCareMed.2013;39(10):1734-42.急性肺心病ACP:RVEDA/LVEDA>0.6,左室短轴可见室间隔矛盾运动卵圆孔未闭PFO：左右心房之间可见右向左分流结果：22.5%的机械通气患者患ACP，15.5%的患者患PFO，4.5%的患者同时患ACP和PFO。FoCUSstatementShockandHemodynamicInstabilityFoCUSstatementEstimatingCVP,DiagnosingHypovolemia,andPredictingFluidResponsivenessshocksubjectcontrolsubjectYanagawaY,etal.JTrauma.2005;58(4):825-9.IVC的直径与创伤患者的低血容量相关FoCUSstatement在怀疑血容量不足的自主呼吸患者中，在PLR前后使用FoCUS测量心输出量可以准确地识别出患者是否存在血容量不足以及能否获益于补液MaizelJ,etal.IntensiveCareMed.2007;33(7):1133-8.PreauS,etal.CritCareMed.2010;38(3):819-25.Change(%)=100%*(post-VEvaluebaseline2value)/baseline2value.Respond:change>15%PLR,passivelegraising;VE,volumeexpansionPP,radialpulsepressure;SV,strokevolume;VF,peakvelocityoffemoralarteryflowFoCUSstatementSummary鉴于其无创性和便捷性，FoCUS在重症患者的评估和治疗中占据越来越重要的地位；近年来，FoCUS在一些非心脏疾病的鉴别与评估中也展现出价值，尤其是在血流动力学监测和休克类型的鉴别上;随着重症医学的发展，FoCUS应该成为每个重症医师的必备技能。Thankyouforyourattention!
