杜微;王小亭;刘大为;
DU Wei;WANG Xiaoting;LIU Dawei;Department of Intensive Care Unit, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College;

• 1:中国医学科学院北京协和医院重症医学科

摘要(Abstract)：

人类对重症认知的重要里程碑是从对休克的血流动力学精细化理解开始。经过几十年的发展，血流动力学治疗理念更加完善，休克的治疗既有依托于指南的群体化治疗，又有具体到床旁每一位患者的个体化策略。血流的龙头效应早已深入人心，而血流中的氧流更是休克血流动力学复苏的目的性指标。本文对血流及血流中的氧流进行进一步追踪探讨，并将血流与氧流的影响因素、监测与复苏导向治疗进行拆分，提出基于血流-氧流的休克新分型，以期在器官化血流动力学治疗理念之下开启更精准的血流动力学治疗时代。
An important milestone in human cognition of severe diseases began with a refined understanding of the hemodynamics of shock. After decades of development, the concept of hemodynamic therapy has become more perfect. The treatment of shock involves not only guided group therapy, but also bedside individualized strategies. The leading effect of blood flow has long been well understood, and the oxygen flux in the blood flow is the target index of hemodynamic resuscitation of shock. In this paper, we aim to further explore blood flow and blood oxygen flux, separate the influence factors of blood flow and oxygen flux, monitoring and recovery-guided treatment, and propose four subtypes based on blood flow and oxygen flux shock, with the hope of ushering in an era of more precise hemodynamic treatment for organ hemodynamic therapy.

关键词(KeyWords)： 休克;血流动力学;血流;氧流;复苏
shock;hemodynamics;blood flow;oxygen flux;resuscitation

Abstract:

Keywords:

基金项目(Foundation): 中国医学科学院中央级公益性研究院所基本科研业务费专项资金(2020-RW320-001)~~

作者(Authors): 杜微;王小亭;刘大为;
DU Wei;WANG Xiaoting;LIU Dawei;Department of Intensive Care Unit, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College;

参考文献(References)：

• [1] Lamontagne F,Richards-Belle A,Thomas K,et al.Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ⅲ Patients With Vasodilatory Hypotension:A Randomized Clinical Trial[J].JAMA,2020,323:938- 949.
• [2] Hernández G,Ospina-Tascón GA,Damiani LP,et al.Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock:The ANDROMEDA-SHOCK Randomized Clinical Trial[J].JAMA,2019,21:654- 664.
• [3] Massey MJ,Larochelle E,Najarro G,et al.The microcirculation image quality score:development and preliminary evaluation of a proposed approach to grading quality of image acquisition for bedside videomicroscopy[J].J Crit Care,2013,28:913- 917.
• [4] De Backer D,Donadello K,Sakr Y,et al.Microcirculatory alterations in patients with severe sepsis:impact of time of assessment and relationship with outcome[J].Crit Care Med,2013,41:791- 799.
• [5] Ait-Oufella H,Lemoinne S,Boelle PY,et al.Mottling score predicts survival in septic shock[J].Intensive Care Med,2011,37:801- 807.
• [6] Ospina-Tascon G,Neves AP,Occhipinti G,et al.Effects of fluids on microvascular perfusion in patients with severe sepsis[J].Intensive Care Med,2010,36:949- 955.
• [7] Edul VS,Ince C,Navarro N,et al.Dissociation between sublingual and gut microcirculation in the response to a fluid challenge in postoperative patients with abdominal sepsis[J].Ann Intensive Care,2014,4:39.
• [8] Aldecoa C,Llau JV,Nuvials X,et al.Role of albumin in the preservation of endothelial glycocalyx integrity and the microcirculation:a review[J].Ann Intensive Care,2020,10:85.
• [9] Nascente A,Freitas F,Bakker J,et al.Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline[J].Clinics (Sao Paulo),2017,72:750- 757.
• [10] Du W,Liu D,Long Y,et al.The β-Blocker Esmolol Restores the Vascular Waterfall Phenomenon After Acute Endotoxemia[J].Crit Care Med,2017,45:e1247-e1253.
• [11] Modun D,Krnic M,Vukovic J,et al.Plasma nitrite concentration decreases after hyperoxia-induced oxidative stress in healthy humans[J].Clin Physiol Funct Imaging,2012,32:404- 408.
• [12] Helmerhorst H,de Wilde R,Lee DH,et al.Hemodynamic effects of short-term hyperoxia after coronary artery bypass grafting[J].Ann Intensive Care,2017,7:20.
• [13] Wei HS,Kang H,Rasheed ID,et al.Erythrocytes Are Oxygen-Sensing Regulators of the Cerebral Microcirculation[J].Neuron,2016,91:851- 862.
• [14] Uchimido R,Schmidt EP,Shapiro NI.The glycocalyx:a novel diagnostic and therapeutic target in sepsis[J].Crit Care,2019,23:16.
• [15] Preau S,Vodovar D,Jung B,et al.Energetic dysfunction in sepsis:a narrative review[J].Ann Intensive Care,2021,11:104.
• [16] Scheuzger J,Zehnder A,Meier V,et al.Sublingual microcirculation does not reflect red blood cell transfusion thresholds in the intensive care unit-a prospective observational study in the intensive care unit[J].Crit Care,2020,24:18.
• [17] Bateman RM,Tokunaga C,Kareco T,et al.Myocardial hypoxia-inducible HIF- 1alpha,VEGF,and GLUT1 gene expression is associated with microvascular and ICAM- 1 heterogeneity during endotoxemia[J].Am J Physiol Heart Circ Physiol,2007,293:H448- H456.
• [18] Ospina-Tascón GA,García Marin AF,Echeverri GJ,et al.Effects of dobutamine on intestinal microvascular blood flow heterogeneity and O(2) extraction during septic shock[J].J Appl Physiol (1985),2017,122:1406- 1417.
• [19] Kirkman MA,Smith M.Brain Oxygenation Monitoring[J].Anesthesiol Clin,2016,34:537- 556.
• [20] R?mers LH,Bakker C,Dollée N,et al.Cutaneous Mitochondrial PO2,but Not Tissue Oxygen Saturation,Is an Early Indicator of the Physiologic Limit of Hemodilution in the Pig[J].Anesthesiology,2016,125:124- 132.