休克的组织灌注监测 从生理到临床
休克的组织灌注监测 从生理到临床
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本书系统阐述了休克监测指标的发展和相关理论的形成过程。从基础理论开始，以休克的生理学改变为主线，对位于不同生理位点的血流动力学监测指标进行了深入细致的讲解，包括压力指标、容积指标、流量指标及其衍生指标、大循环指标、微循环指标、细胞代谢指标等的测量、计算方法和临床应用特点，同时还对Guyton 理论、氧输送和机体反应性、心脏功能管理等系统理论进行了介绍。
本书系统阐述了休克监测指标的发展和相关理论的形成过程。从基础理论开始，以休克的生理学改变为主线，对位于不同生理位点的血流动力学监测指标进行了深入细致的讲解，包括压力指标、容积指标、流量指标及其衍生指标、大循环指标、微循环指标、细胞代谢指标等的测量、计算方法和临床应用特点，同时还对Guyton 理论、氧输送和机体反应性、心脏功能管理等系统理论进行了介绍。
本书引进自德国 Springer 出版社，旨在更新床旁组织监测的新进展，包括从全身和局部灌注的生理学原理到应用这些原理来指导临床休克复苏的整个过程。著者将血流动力学核心的知识精准地提炼出来，对从基础知识到临床应用、从全身监测到局部监测的各方面知识进行了全面梳理。全书分四部分共 14 章，以绪论开篇，然后分别介绍了氧输送和氧消耗原理、全身组织灌注测量、局部组织灌注测量的相关内容。本书内容实用，阐释简明，适合各层次的读者阅读参考。
于荣国，男，主任医师，福建医科大学副教授，福建省立医院重症外科（SICU）主任，主任医师，福建医科大学副教授，硕士生导师。专业方向：外科重症患者监测与治疗、临床麻醉与镇痛。1983年毕业于山东滨州医学院。1993年1月-1996年6月参加福建省第七批援博茨瓦纳医疗队，受聘于NYANGABGWE医院麻醉科。1998年5月-1999年5月在北京协和医科大学阜外医院麻醉研究室研究学者。2002年4月-2003年4月获*国家留学基金委员会公派留学基金资助，到加拿大西安大略大学医院麻醉科研究学者。2005年公派到美国纽约布鲁克林医学中心进修学习重症医学。曾在国际和国内核心期刊发表学术论文25篇。曾多次参加国内或国际麻醉与重症医学学术交流会。
第 1 章 脓毒性休克的整体监测与治疗 Holistic Monitoring and Treatment in Septic Shock
一、整体视角
二、以生理学为基础的灌注监测
三、初始循环功能障碍
四、持续性循环功能障碍
第二部分 氧输送和氧消耗原理Principles of Oxygen Transport and Consumption
第 2 章 氧的输送和组织利用Oxygen Transport and Tissue Utilization
一、氧的输送
二、临床意义
第 3 章 床旁Guyton理论Guyton at the Bedside
一、Guyton模型的构成
二、泵
三、血管 .
心源性休克是一种心输出量下降不足以维持组织氧供和细胞代谢的急性循环衰竭状态。急性心肌梗死及心梗后左心室功能不全是引起心源性休克常见的原因。心室壁破裂、急性二尖瓣反流、心脏瓣膜病、心律失常或心肌病等也都会引起心源
心源性休克患者的重症监护仍面临重大挑战，体现在合并急性心肌梗死的患者死亡率高达 50%[1]。通常用于提高心输出量、纠正组织灌注不足的药物会增加心肌氧耗，可能带来有害影响 [2]。因此，需要采用一种既能增加心输出量满足组织灌注，又不会进一步加剧心衰时氧供需不匹配的治疗策略。要达到上述的平衡点仍十分困难，而目前技术和生物标志物的内在不足进一步加大了这种困难。因此从根本上要求我们发展以组织灌注为核心的技术和治疗策略。
一、微循环分析在诊断及监测中的应用
心源性休克的临床诊断标准如下 [1]：①收缩压＜ 90mmHg，持续＞ 30min，或者需要血管活性药物才能维持收缩压≥ 90mmHg；②肺淤血或者左室充盈压升高；③有精神状态改变、皮肤湿冷、少尿、血乳酸升高等组织灌注不足表现中的任意一种。虽然以上标准无可争议地反映了心功能不全时的临床表现，但仍缺乏反映组织水平灌注不足的标志物。血乳酸水平可以与不良预后有很好的相关性，但是高乳酸血症可以由休克状态下的许多临床情况和病理过程所引起，包括线粒体功能紊乱、肝脏清除率下降以及儿茶酚胺类药物的直接效应。考虑到这些复杂因素，血乳酸水平不能作为组织缺氧和灌注不足的标志物，而应作为评估休克严重程度的有效替代指标 [3]。
目前已经有一些监测休克复杂病理生理状态的可靠方法，包括一些有创性方法，如肺动脉导管、指示剂稀释法及脉搏轮廓分析的心输出量监测，以及不同模式的超声心动图 [4]。只有肺动脉导管和中心静脉导管（分别监测 SvO2 和 ScvO）可以提供组织氧供及氧耗平衡的信息。虽然这些信息可以用于滴定治疗，但是这些指标不能直接或特异性地反映微循环状态，对预后的影响也仍存在争议 [5, 6]。超声造影使用微球造影剂，配合专用的超声对比成像方式，可实现床旁冠状动脉微循环的评估。该技术采用具有血流动力学惰性及与红细胞具有相似血管内流变学的微球（直径 1 ～ 8μm）。使用高强度的超声波来破坏这些微球，从而分析心肌循环中这些微球的“漏出 - 返回率”（seep-back rate）。
疾病状态下，微循环灌注紊乱的重要意义，以及微循环与大循环的失偶联，首先由 Freedlander 在 1922 年提出 [7]，并被一些心源性休克的研究所证实 [8-12]。
Shipping Overview:
• Shipping: Standard Domestic Shipping within the United States charges USD 4.99. Standard International Shipping from United Kingdom, Germany and Japan to the United States charges 14.99.
• Order Processing: Please allow 1-2 business days for order processing and preparation before shipment.
• Domestic Shipping: Orders within the U.S. are shipped via USPS or FedEx, depending on the origin of the product. The average transit time is 3-7 business days.
• International Shipping: Currently, we only ship within the USA.
• Tracking Information: Every order is trackable. You will receive a tracking number once your order has been shipped. Products may be shipped from various global fulfillment centers.
Shipping Delays:
Please note that shipping times may vary due to factors beyond our control, such as weather conditions, natural disasters, or peak holiday periods. While we strive to ensure timely delivery, the exact arrival time cannot be guaranteed and is managed by the shipping carrier.
Shipping Options:
-
Standard Delivery: Most orders are shipped within 3-7 business days. Larger items may utilize LTL shipping for safe handling.
-
Handling Time: We handle shipments on business days (Monday - Friday), with a preparation time of 1-2 days.
-
Additional Charges: Some items require additional shipping charges due to their size, weight, or special handling. These charges are specified on the product pages and are not eligible for shipping discounts.
-
Exclusions: Gift cards, packaging, taxes, and prior purchases do not count toward the minimum purchase requirement for free shipping. This offer is valid only for shipments to U.S. addresses, including Puerto Rico.
Delivery Details:
-
Estimates: Standard shipping within the US typically takes 3-7 business days. These are estimates and not guarantees.
-
Shipping Restrictions: We ship to all 50 states, Washington, DC, U.S. territories, and APO/FPO/DPO addresses. Shipping options vary based on the delivery address.
-
Remote Areas: Shipments to remote areas may incur additional charges or require pickup from a nearby shipping partner’s location.
Shipping Confirmation:
You will receive a shipping confirmation email with a tracking number as soon as your order is dispatched. If you do not receive this email immediately, please be assured that your items will arrive within the estimated delivery window provided at checkout.
Order Modifications:
If you need to cancel or modify your order, please contact our customer support immediately.
Issues with Delivery:
If your order shows as delivered but you have not received it, please contact the shipping carrier directly to resolve the issue. For persistent problems, contact our customer service at cs@everymarket.com.
Customer Support:
Our team is available 24/7 to assist you with any questions or concerns regarding your order. We are committed to ensuring a smooth shopping experience.
Return & Refund Policy Overview
Please review our return and refund policies below to ensure a smooth transaction process.
Return Policy
-
Duration: You have 30 days from receiving your item to initiate a return.
-
Condition: Items must be unworn, unwashed, with original tags and packaging intact.
-
Shipping Costs: Customers are responsible for return shipping costs.
-
Packaging: Ensure returned items are well-packaged to avoid damage during transit.
-
Tracking: Use a trackable and insured shipping method as we are not liable for items lost or damaged on return.
-
Initiating a Return: Contact us at cs@everymarket.com to start your return. We will provide a return shipping label and instructions upon approval. Returns without prior approval will not be accepted.
How to Return
-
Method: Returns must be sent back by mail to the address provided in the return instructions.
Return Label
-
Defective Products: Return labels are provided for defective items.
-
Non-Defective Returns: Customers are responsible for obtaining their return shipping label.
Product Conditions for Return
-
Eligible Products: Returns are only accepted for items in new condition.
Nonreturnable Items
Certain items are not eligible for return:
-
Electronic devices after 30 days (e.g., computers, laptops, Kindles)
-
Gift cards, prepaid game cards
-
Perishable goods, live insects, some jewelry, some health and personal care items
-
Customized or personalized products
-
Items with special shipping restrictions
Refund Policy
-
Window: Eligible products may be returned within 30 days of delivery for a refund.
-
Refund Method: Refunds are processed to the original payment method or as store credit for items purchased with gift cards.
-
Processing Time: Refunds are processed within 3-5 business days after we receive the return; please allow additional time for shipping and bank processing.
Claims
Inspect your order upon arrival and report any defects, damages, or incorrect items immediately to allow us to address the issue. For claims, contact our support team with details of the issue.
Exchange Policy
For the quickest service, return your original item and place a new order for the desired product once your return is accepted.
Return Address
EveryMarket Customer Service 2101 E Terra Ln, O'Fallon, MO 63366
Customer Support
Available 24/7 for any questions or assistance needed:
-
Phone: +1 636-312-5925
-
Email: cs@everymarket.com
本书系统阐述了休克监测指标的发展和相关理论的形成过程。从基础理论开始，以休克的生理学改变为主线，对位于不同生理位点的血流动力学监测指标进行了深入细致的讲解，包括压力指标、容积指标、流量指标及其衍生指标、大循环指标、微循环指标、细胞代谢指标等的测量、计算方法和临床应用特点，同时还对Guyton 理论、氧输送和机体反应性、心脏功能管理等系统理论进行了介绍。
本书引进自德国 Springer 出版社，旨在更新床旁组织监测的新进展，包括从全身和局部灌注的生理学原理到应用这些原理来指导临床休克复苏的整个过程。著者将血流动力学核心的知识精准地提炼出来，对从基础知识到临床应用、从全身监测到局部监测的各方面知识进行了全面梳理。全书分四部分共 14 章，以绪论开篇，然后分别介绍了氧输送和氧消耗原理、全身组织灌注测量、局部组织灌注测量的相关内容。本书内容实用，阐释简明，适合各层次的读者阅读参考。
于荣国，男，主任医师，福建医科大学副教授，福建省立医院重症外科（SICU）主任，主任医师，福建医科大学副教授，硕士生导师。专业方向：外科重症患者监测与治疗、临床麻醉与镇痛。1983年毕业于山东滨州医学院。1993年1月-1996年6月参加福建省第七批援博茨瓦纳医疗队，受聘于NYANGABGWE医院麻醉科。1998年5月-1999年5月在北京协和医科大学阜外医院麻醉研究室研究学者。2002年4月-2003年4月获*国家留学基金委员会公派留学基金资助，到加拿大西安大略大学医院麻醉科研究学者。2005年公派到美国纽约布鲁克林医学中心进修学习重症医学。曾在国际和国内核心期刊发表学术论文25篇。曾多次参加国内或国际麻醉与重症医学学术交流会。
第 1 章 脓毒性休克的整体监测与治疗 Holistic Monitoring and Treatment in Septic Shock
一、整体视角
二、以生理学为基础的灌注监测
三、初始循环功能障碍
四、持续性循环功能障碍
第二部分 氧输送和氧消耗原理Principles of Oxygen Transport and Consumption
第 2 章 氧的输送和组织利用Oxygen Transport and Tissue Utilization
一、氧的输送
二、临床意义
第 3 章 床旁Guyton理论Guyton at the Bedside
一、Guyton模型的构成
二、泵
三、血管 .
心源性休克是一种心输出量下降不足以维持组织氧供和细胞代谢的急性循环衰竭状态。急性心肌梗死及心梗后左心室功能不全是引起心源性休克常见的原因。心室壁破裂、急性二尖瓣反流、心脏瓣膜病、心律失常或心肌病等也都会引起心源
心源性休克患者的重症监护仍面临重大挑战，体现在合并急性心肌梗死的患者死亡率高达 50%[1]。通常用于提高心输出量、纠正组织灌注不足的药物会增加心肌氧耗，可能带来有害影响 [2]。因此，需要采用一种既能增加心输出量满足组织灌注，又不会进一步加剧心衰时氧供需不匹配的治疗策略。要达到上述的平衡点仍十分困难，而目前技术和生物标志物的内在不足进一步加大了这种困难。因此从根本上要求我们发展以组织灌注为核心的技术和治疗策略。
一、微循环分析在诊断及监测中的应用
心源性休克的临床诊断标准如下 [1]：①收缩压＜ 90mmHg，持续＞ 30min，或者需要血管活性药物才能维持收缩压≥ 90mmHg；②肺淤血或者左室充盈压升高；③有精神状态改变、皮肤湿冷、少尿、血乳酸升高等组织灌注不足表现中的任意一种。虽然以上标准无可争议地反映了心功能不全时的临床表现，但仍缺乏反映组织水平灌注不足的标志物。血乳酸水平可以与不良预后有很好的相关性，但是高乳酸血症可以由休克状态下的许多临床情况和病理过程所引起，包括线粒体功能紊乱、肝脏清除率下降以及儿茶酚胺类药物的直接效应。考虑到这些复杂因素，血乳酸水平不能作为组织缺氧和灌注不足的标志物，而应作为评估休克严重程度的有效替代指标 [3]。
目前已经有一些监测休克复杂病理生理状态的可靠方法，包括一些有创性方法，如肺动脉导管、指示剂稀释法及脉搏轮廓分析的心输出量监测，以及不同模式的超声心动图 [4]。只有肺动脉导管和中心静脉导管（分别监测 SvO2 和 ScvO）可以提供组织氧供及氧耗平衡的信息。虽然这些信息可以用于滴定治疗，但是这些指标不能直接或特异性地反映微循环状态，对预后的影响也仍存在争议 [5, 6]。超声造影使用微球造影剂，配合专用的超声对比成像方式，可实现床旁冠状动脉微循环的评估。该技术采用具有血流动力学惰性及与红细胞具有相似血管内流变学的微球（直径 1 ～ 8μm）。使用高强度的超声波来破坏这些微球，从而分析心肌循环中这些微球的“漏出 - 返回率”（seep-back rate）。
疾病状态下，微循环灌注紊乱的重要意义，以及微循环与大循环的失偶联，首先由 Freedlander 在 1922 年提出 [7]，并被一些心源性休克的研究所证实 [8-12]。
Shipping Overview:
• Shipping: Standard Domestic Shipping within the United States charges USD 4.99. Standard International Shipping from United Kingdom, Germany and Japan to the United States charges 14.99.
• Order Processing: Please allow 1-2 business days for order processing and preparation before shipment.
• Domestic Shipping: Orders within the U.S. are shipped via USPS or FedEx, depending on the origin of the product. The average transit time is 3-7 business days.
• International Shipping: Currently, we only ship within the USA.
• Tracking Information: Every order is trackable. You will receive a tracking number once your order has been shipped. Products may be shipped from various global fulfillment centers.
Shipping Delays:
Please note that shipping times may vary due to factors beyond our control, such as weather conditions, natural disasters, or peak holiday periods. While we strive to ensure timely delivery, the exact arrival time cannot be guaranteed and is managed by the shipping carrier.
Shipping Options:
-
Standard Delivery: Most orders are shipped within 3-7 business days. Larger items may utilize LTL shipping for safe handling.
-
Handling Time: We handle shipments on business days (Monday - Friday), with a preparation time of 1-2 days.
-
Additional Charges: Some items require additional shipping charges due to their size, weight, or special handling. These charges are specified on the product pages and are not eligible for shipping discounts.
-
Exclusions: Gift cards, packaging, taxes, and prior purchases do not count toward the minimum purchase requirement for free shipping. This offer is valid only for shipments to U.S. addresses, including Puerto Rico.
Delivery Details:
-
Estimates: Standard shipping within the US typically takes 3-7 business days. These are estimates and not guarantees.
-
Shipping Restrictions: We ship to all 50 states, Washington, DC, U.S. territories, and APO/FPO/DPO addresses. Shipping options vary based on the delivery address.
-
Remote Areas: Shipments to remote areas may incur additional charges or require pickup from a nearby shipping partner’s location.
Shipping Confirmation:
You will receive a shipping confirmation email with a tracking number as soon as your order is dispatched. If you do not receive this email immediately, please be assured that your items will arrive within the estimated delivery window provided at checkout.
Order Modifications:
If you need to cancel or modify your order, please contact our customer support immediately.
Issues with Delivery:
If your order shows as delivered but you have not received it, please contact the shipping carrier directly to resolve the issue. For persistent problems, contact our customer service at cs@everymarket.com.
Customer Support:
Our team is available 24/7 to assist you with any questions or concerns regarding your order. We are committed to ensuring a smooth shopping experience.
Return & Refund Policy Overview
Please review our return and refund policies below to ensure a smooth transaction process.
Return Policy
-
Duration: You have 30 days from receiving your item to initiate a return.
-
Condition: Items must be unworn, unwashed, with original tags and packaging intact.
-
Shipping Costs: Customers are responsible for return shipping costs.
-
Packaging: Ensure returned items are well-packaged to avoid damage during transit.
-
Tracking: Use a trackable and insured shipping method as we are not liable for items lost or damaged on return.
-
Initiating a Return: Contact us at cs@everymarket.com to start your return. We will provide a return shipping label and instructions upon approval. Returns without prior approval will not be accepted.
How to Return
-
Method: Returns must be sent back by mail to the address provided in the return instructions.
Return Label
-
Defective Products: Return labels are provided for defective items.
-
Non-Defective Returns: Customers are responsible for obtaining their return shipping label.
Product Conditions for Return
-
Eligible Products: Returns are only accepted for items in new condition.
Nonreturnable Items
Certain items are not eligible for return:
-
Electronic devices after 30 days (e.g., computers, laptops, Kindles)
-
Gift cards, prepaid game cards
-
Perishable goods, live insects, some jewelry, some health and personal care items
-
Customized or personalized products
-
Items with special shipping restrictions
Refund Policy
-
Window: Eligible products may be returned within 30 days of delivery for a refund.
-
Refund Method: Refunds are processed to the original payment method or as store credit for items purchased with gift cards.
-
Processing Time: Refunds are processed within 3-5 business days after we receive the return; please allow additional time for shipping and bank processing.
Claims
Inspect your order upon arrival and report any defects, damages, or incorrect items immediately to allow us to address the issue. For claims, contact our support team with details of the issue.
Exchange Policy
For the quickest service, return your original item and place a new order for the desired product once your return is accepted.
Return Address
EveryMarket Customer Service 2101 E Terra Ln, O'Fallon, MO 63366
Customer Support
Available 24/7 for any questions or assistance needed:
-
Phone: +1 636-312-5925
-
Email: cs@everymarket.com
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