危重患儿血流动力学监测及临床意义

心血管疾病如心肌病、心肌炎、先天性心脏病危重时可引起血流动力学改变而导致心力衰竭 ,其他系统疾病如肺炎危重时也可影响血流动力学而导致心力衰竭。因此 ,对危重患儿进行血流动力学监测 ,及时发现异常 ,分析发生原因和病理生理改变 ,及早采取正确治疗措施极为必要。现就危重患儿血流动力学监测的临床意义、方法及存在问题介绍于下。1　临床意义血流动力学监测是了解心功能的主要方法 ,同时也受血容量、血管弹性和阻力的影响。血流动力学监测可精确、定量监测心功能改变以达到下列目的 :①早期发现轻型心功能不全病例。②正确了解病情变…     

脓毒性休克血流动力学监测及容量、心功能状态评估

血流动力学监测是对循环系统血液流动,心脏各腔室压力,体循环、肺循环的压力及阻力等一系列生理病理变化的指标进行监测.脓毒性休克传统血流动力学监测以中心静脉压、心脏指数、血乳酸和pH为重要参考依据.近年来发展的无创或有创监测技术包括中心静脉或混合静脉血氧饱和度、连续无创超声心输出量监测、脉搏指数连续心排血量监测等.宏观血流动力学、代谢指标和微循环参数构成新的血流动力学监测数据网络.临床需要通过对各个参数进行分析与整合,克服单一参数的局限性,才能正确评估患儿容量及循环功能状态.     

先天性心脏病围术期血流动力学监测方法

血流动力学监测是先天性心脏病围术期的重要监测手段,对于指导临床治疗非常重要.目前,监测血流动力学的方法有多种,有创性的方法包括直接Fick法、Swan-Ganz导管的热稀释法及脉搏波形法;无创性的方法包括部分二氧化碳重复吸收法、生物阻抗法等方法.本文将对几种监测方法各自的原理,优缺点进行综述.     

直接脉搏轮廓记录分析法在婴幼儿先天性心脏病术后监护的应用进展

先天性心脏病(congenital heart disease,CHD)术后重症监护的重要职责之一是维持血流动力学稳定以保证足够的组织氧供。目前,直接脉搏轮廓记录分析法(pressure recording analytical method,PRAM)作为新的微创血流动力学监测手段逐渐应用于婴幼儿CHD的围手术期,相比于其他血流动力学监测手段具有操作简单、创伤小、持续监测、准确性高的独特优势。本文将PRAM与其他血流动力学监测技术进行比较,阐述了PRAM的重要指标及应用前景,希望为婴幼儿CHD的术后监护提供指导。     

感染性休克的血流动力学监测

由于机体交感神经和副交感神经系统的作用,对于休克的判断不能只以“正常”的血流动力学参数来界定,而应注重循环血量是否满足组织的代谢需求;在关注临床症状和传统血流动力学指标的基础上,更应重视氧输送的足够和组织代谢的充分;分布性休克的特征是氧输送正常或增高状态下的组织缺氧。对感染性休克患者进行客观细致的、量化并动态连续的血流动力学监测对及时评估病情和指导治疗有着非常重要的价值。1感染性休克的一般监测临床上对休克的观察指标如下。(1)神志:休克早期主要是精神状态的改变,反映中枢神经系统缺血缺氧,小婴儿表现为哭闹或少…     

超声心动图在儿科急症的临床应用

近年来非侵入性心脏检查技术发展迅速,特别是超声心动图经过不断改进和创新,已由M 型、二维超声心动图(2-DE),二维多普勒实时超声心动图发展到80年代创制的彩色二维多普勒超声心动图(2-DCFI),加上对比超声心动图的应用,可做到定位、定时、定量地了解心脏精确的解剖结构和血流动力学及左右心功能等方面的资料。由于这种技术具有非创伤性,安全、简便、准确、可在床侧进行并重复使用等优点,故在儿科急症临床中已得到广泛应用,并成为一项重要的监测手段,其主要功用有以下两个方面。监测心功能和血流动力学的变化超声心动图可在床侧对危重患儿进行心功能和血     

感染性休克的循环评估

正确评估感染性休克患儿的循环状态是成功治疗的基础。临床工作中评估休克患儿循环状态的方法包括临床表现、血流动力学监测及反映组织氧合的检测指标。进行循环评估时应注意各项评估指标相结合,同时随病情进展进行动态监测。     

无创心输出量监测在新生儿中的应用

心输出量监测是危重新生儿尤其血流动力学不稳定患儿(如新生儿重症感染、败血症休克、多器官功能衰竭、先天性心脏病等)抢救管理中非常重要的内容,监测方法有有创测量、无创测量以及穿戴式或移动式动态测量等。目前临床上实时、连续无创监测新生儿心输出量多采用超声心输出量监测仪技术。通过监测心输出量,可较准确判断心功能及体循环灌注的情况,对评估病情、指导临床用药及判断预后有重要意义。     

正确理解氧动力学及氧代谢监测参数在休克诊治中的临床意义

血流动力学监测重要性体现在对监测结果的正确解读并同时根据正确的解读结果采取相应的处理策略.休克的实质为全身组织灌注不足导致组织缺氧和器官功能失调,血流动力学的本质是氧供和氧耗的失衡.因此休克液体复苏终点现越来越强调混合/中心静脉氧饱和度和血乳酸、乳酸清除率的监测.     

危重患儿血流动力学监测的研究进展

血流动力学不稳定是危重患儿死亡的主要原因之一,实时、动态地监测血流动力学变化是重症监护病房和手术室工作的重要组成部分。在过去的50年里,有创肺动脉导管热稀释法一直被公认为是监测血流动力学的"金标准"。由于该技术易对机体造成创伤、并发症多,且操作难度大,近年来在临床的使用率已经下降。因此,微创或完全无创、操作简单、且准确...     

Cardiac output monitoring in newborns

There is an increased interest in methods of objective cardiac output measurement in critically ill patients. Several techniques are available for measurement of cardiac output in children, although this remains very complex in newborns. Cardiac output monitoring could provide essential information to guide hemodynamic management. An overview is given of various methods of cardiac output monitoring with advantages and major limitations of each technology together with a short explanation of the basic principles.     

危重症患儿营养支持研究进展

危重症患儿多处于严重应激状态，易出现营养不良，导致机体对疾病的抵抗力和修复力下降，从而加重患儿病情。对患儿进行合理而有效的营养支持可改善患儿的营养状态，有利于疾病的预后，所以对危重症患儿进行营养支持是必要的。该文综述了目前国内外危重症患儿营养支持治疗的研究情况及其临床应用现状，同时主要介绍了营养支持的方式，包括肠内营养和肠外营养，并阐述了早期肠内营养、免疫肠内营养及补充肠外营养等新型营养支持方法，以期更好地为危重症患儿的营养支持提供参考。     

Noninvasive Measurement of Cardiac Output in Critically Ill Children

This study was performed to evaluate the hemodynamic status of children admitted to the intensive care unit, using suprasternal and transesophageal Doppler ultrasound, and to establish a suitable noninvasive technique to monitor trends in cardiac output in critically ill children. Twenty children were studied over a period of 6 months. The median age was 32.5 months and weight 14.5 kg. Minute distance (MD), which is a linear cardiac output parameter, was assessed. Seven simultaneous pairs of measurements of MD were made using transesophageal Doppler (TED) and suprasternal Doppler (SSD) by the same operator. Following a fluid challenge, seven repeat pairs of measurements were made. The mean percentage changes for MD by TED and SSD were 21.84 (SD 9.97) and 5.75 (SD 7.32). The average coefficients of variation for measurements of MD by TED and SSD were 2.34% and 15.98%, respectively. The mean difference in percentage change between MD, measured by TED and SSD, was 27.59 with a 95% confidence interval and wide limits of agreement. The repeatability of TED measurements was good, but the measurements by SSD were wide and erratic with poor reproducibility. Our study shows that TED is easy to use, reliable, and very useful for monitoring hemodynamic changes in critically ill children.     

无创经皮监测氧气和二氧化碳在新生儿的应用

无创经皮监测(transcutaneous monitoring,TCM)氧气和二氧化碳是新生儿重症监护室(neo-natal intensive care unit,NICU)的常用技术,具有连续性、无创性的特点,能直观反映危重新生儿呼吸和循环功能的变化,对新生儿监护意义重大.该文阐述TCM的使用方法,比较TCM与其他监测手段的优缺点,并介绍其在新生儿转运及NICU的应用.     

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??PaO2 and PaCO2 monitoring is the most important indicators of ventilation and oxygenation in the NICU. The results of PaO2 and PaCO2 are from blood gas obtained by collecting arterial or peripheral blood samples. Repeated blood sampling is frequently needed in critically ill neonates??which may increase the risk of neonatal infection, iatrogenic anemia and pain stress. TcPCO2 and TcPO2??as the noninvasive monitors??have been emerging as non-invasive blood gas monitoring in the clinical care of critically ill neonates??especially the VLBWandELBWinfants??during neonatal oxygentherapy??mechanical ventilation and shock requiring perfusion monitoring.     

Can near infrared spectroscopy of the liver monitor tissue oxygenation?

Measurement of the hepatic oxygenation index by near infrared spectroscopy is a suitable method to estimate the oxygenation and can be a non-invasive means to continuously monitor tissue perfusion and to detect early haemodynamic disturbances in critically ill children.     

PICU危重患儿临床营养管理调查结果分析

目的 了解目前我国PICU危重患儿临床营养的管理状况,为进一步促进儿科危重病临床营养的完善和发展提供数据.方法 对PICU专科骨干采用问卷调查的方式调查国内PICU的危重患儿营养评估、营养干预、营养管理状况.结果 共39家PICU的专科骨干参与调查.国内不同PICU中危重患儿常用营养评估和指南不统一.64.1%(25人)被调查者认为需要根据临床表现和量表作为共同决定危重患儿喂养的依据;所有被调查者均认为营养评估和干预时机需要根据病情来决定;58.9%(23人)被调查者所在科室仅以体重监测作为营养量化监测指标;71.8%(28人)被调查者认为经胃管喂养是危重患儿的首选喂养方式;51.3%(20人)被调查者认为危重患儿应该在24h内进行喂养,33.3%(12人)认为24~48h开始进行喂养,84.6%(33人)被调查者主张早期肠内营养;92.3%(36人)被调查者认为呕吐、腹胀、胃肠出血等临床表现之一是禁食的主要原因;71.8%(28人)被调查者认为需要根据胃肠功能评估结果来决定是否禁食;59.0%(23人)被调查者认为危重患儿的临床营养决定人应该是PICU专科医生;61.5%(24人)被调查者认为需要建立危重患儿营养管理常规.结论目前我国儿童危重病的营养评估、监测、早期肠内营养干预、管理等方面取得了一定成绩,但存在不同程度的认识不足,需要加强临床重症营养专科建设,在营养评估、营养干预模式上还有很大的研究和发展空间,建议建立中国相关指南或共识以提升危重患儿营养诊疗水平.     

A comparison of thermodilution and pulsed Doppler cardiac output measurement in critically ill children

To evaluate the pulsed Doppler cardiac output method as a noninvasive means for determining cardiac output in critically ill children, we performed paired pulsed Doppler and thermodilution cardiac output determinations in 17 critically ill children. Commercially available equipment, specifically designed for this purpose, was employed. Forty paired thermodilution and pulsed Doppler determinations were made. There was a significant correlation between the two measurements (pulsed Doppler = 0.84 thermodilution + 0.39; r = 0.79, p less than 0.01). The ranges of thermodilution measurements (1.02 to 6.26 L/min; median 2.77 L/min) and pulsed Doppler measurements (1.13 to 6.35 L/min; median 2.57 L/min) were not different (p = 0.25). However, differences between individual paired thermodilution and pulsed Doppler measurements were large (-3.13 to 2.03 L/min; median 0.12 L/min), and the percentage difference between individual paired thermodilution and pulsed Doppler measurements ranged from 0.41% to 102.5% (median 12.7%). A discrepancy of 15% or more between thermodilution and pulsed Doppler was encountered in 18 (45%) of 40 of paired measurements (95% confidence interval: 29% to 61%), and one fourth of the paired measurements differed by more than 25%. We conclude that, as employed in this study, pulsed Doppler cardiac output determination is not sufficiently representative of the thermodilution output to be employed for hemodynamic monitoring in critically ill children.     

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??Intra-hospital transport??IHT?? is an inevitable and important part of intensive care unit??ICU?? treatment. IHT is frequently required in order to perform diagnostic or therapeutic procedures for critically ill children. The incidence of adverse events??AEs??during IHT of critically ill children is very high. The decision to transport a critically ill child is based on an assessment of the potential benefits and risks. Specialized training?? perfect clinical evaluation??appropriate equipment??use of checklist and monitoring during transport may decrease adverse events and increase safety in IHT.     

Advanced hemodynamic monitoring in critically ill children

Circulatory shock is an important cause of pediatric morbidity and mortality and requires early recognition and prompt institution of adequate treatment protocols. Unfortunately, the hemodynamic status of the critically ill child is poorly reflected by physical examination, heart rate, blood pressure, or laboratory blood tests. Advanced hemodynamic monitoring consists, among others, of measuring cardiac output, predicting fluid responsiveness, calculating systemic oxygen delivery in relation to oxygen demand, and quantifying (pulmonary) edema. We discuss here the potential value of these hemodynamic monitoring technologies in relation to pediatric physiology.