动脉血气分析及高乳酸血症资料.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,动脉血气分析及高乳酸血症,北京协和医院,杜斌,病例摘要,男性，,45,岁，病历号,1612296,入院日期,2010/02/21,入,ICU,日期,2010/02/24,既往史,24,年前因感冒后颈部淋巴结肿大行左颈部淋巴结活检术，自述病理阴性,8,年前阑尾切除术,1,年前行鼻中隔弯曲矫正术,病例摘要,2009/12/30,大量饮酒后头昏、恶心，右胁肋部及后背部胀痛,胃镜：糜烂性胃炎伴胆汁返流,2010/01/18,生化检查：,ALT,、,AST,、,LDH,、,HBDH,、尿淀粉酶进行性升高,腹部超声检查提示胆囊炎,病例摘要,2010/01/24,静滴脂肪乳过程中出现气促、胸闷,抗过敏、改善循环、补液及对症处理后缓解,2010/01/28,胸闷、气促，深大呼吸伴酸碱平衡紊乱,无创通气,病例摘要,WCC2.46 6.26 x 10,9,/L,Plt30 115 x10,9,/L,ALT 137 U/L,AST 97 U/L,UA 680,mol/L,aPTT/PT,明显延长,纠正后,PT 13.6 sec,aPTT 48.0 sec,Fib 1.41 g/L,血淀粉酶,237 588 U/L,尿淀粉酶,839 3330 U/L,肿瘤指标未见异常,CA199,CEA,NSE,CA242,AFP,PSA,CA125,病例摘要,ABG7.435/6.2/116/4.1/-19.2,AG20 27,血乳酸,14.8 16.0,mmol,/L,血丙酮酸,6.62 mg/,dL,(0.3-0.9),0.83,mmol,/L,L/P17.8 19.3,病例摘要,胸部,CT,左下肺多发肺大疱,腹部增强,CT,肝左外叶及右后叶多发海绵状血管瘤,肝右后叶囊肿,脾稍大,胃十二指肠镜,胆汁返流性胃炎伴糜烂,重度胆汁返流,返流性食管炎,1,级,病理结果,胃窦两块粘膜组织,中度慢性炎症,另见小片炎性渗出物,胃底两块粘膜组织,重度慢性炎症,活动,+,另见小片炎性渗出物,病例摘要,诊断：重症胰腺炎,?,治疗,按胰腺炎治疗，恶心、呕吐症状缓解,输血浆及冷沉淀纠正,DIC,亚甲蓝中和乳酸,病例摘要,呼吸困难（深大呼吸）合并代谢性酸中毒,2010/02/12,血液透析,乳酸可短暂下降至,7 mmol/L,病例摘要,2010/02/21,转入北京协和医院内分泌科,ABG:7.496/8.7/142/6.6/-15.3,Na 137,Cl 95,K 3.7,血乳酸,19.6 mmol/L,血淀粉酶,241 U/L,，脂肪酶,2430 U/L,ALT 126 U/L,TBil 23.3,mol/L,Cr 157,mol/L,BUN 8.82 mmol/L,血气结果分析,Step 1,pH=7.496 7.45,原发性酸碱失衡应包括碱中毒,ABG,pH7.496,pCO,2,8.7,pO,2,142,HCO,3,6.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,血气结果分析,Step 2,判定碱中毒为呼吸性抑或代谢性,ABG,pH7.496,pCO,2,8.7,pO,2,142,HCO,3,6.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,血气结果分析,Step 3,AG=Na Cl HCO3,=137 95 6.6=35 20,高,AG,代酸,ABG,pH7.496,pCO28.7,pO2142,HCO36.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,血气结果分析,Step 4,AG=35 12=23,HCO3+AG=6.6+23,=29.6 26,代谢性碱中毒,ABG,pH7.496,pCO,2,8.7,pO,2,142,HCO,3,6.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,血气结果分析,Step 5,pCO2=1.5 x HCO3+8 2,=1.5 x 6.6+8 2,=9.9+8 2,=15.9 to 19.9,呼吸性碱中毒,ABG,pH7.496,pCO,2,8.7,pO,2,142,HCO,3,6.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,血气结果分析,诊断,高,AG,代谢性酸中毒,代谢性碱中毒,呼吸,性碱中毒,ABG,pH7.496,pCO,2,8.7,pO,2,142,HCO,3,6.6,BE-15.3,Lytes,Na137,Cl,95,K3.7,血乳酸,19.6,mmol,/L,高,AG,代酸的常见原因,甲醇,(methanol),中毒,尿毒症,酮症酸中毒,糖尿病,*,酒精性,饥饿性,三聚乙醛,(paraldehyde),中毒,异烟肼,乳酸酸中毒,*,乙醇,(ethanol),中毒,*,乙二醇,(ethylene glycol),中毒,*,水杨酸,(salicylic acid),中毒,*,高,AG,代酸最常见的原因,*,常伴渗透压间隙升高,病例诊断,高,AG,代酸,高乳酸血症,高乳酸血症的病因,?,病例摘要,2010/03/01,ABG 7.525/26.9/121/22.1/-0.5,Lac 9.6,血渗透压,312,Na 146,Cl 101,BUN 3.32,Glu 7.4,AG=22.9,Osm,calc,=146 x 2+3.32+7.4=302.7,Osmolarity gap=9.3,传统观点认为,缺氧可以导致无氧代谢,无氧代谢产生乳酸,无氧代谢是有害的,缺氧是有害的,现阶段临床思维认为，高乳酸血症是缺氧的后果,治疗上采取提高心输出量和氧输送的方法,因此，这是否意味着,?,高乳酸是有害的,?,高乳酸提示存在缺氧,?,高乳酸提示存在无氧代谢,高乳酸,=,预后不佳,乳酸是如何生成的,?,Glucose,Glycogen,Glucose 6-P,Fructose 6-P,Fructose-1,6-Bisphosphate,Triose Phosphates,Phosphoenolpyruvate,Pyruvate,Lactate,Oxidation In,Citric Acid Cycle,Phosphofructonase,Pyruvate kinase,PDH,Lactate dehydrogenase,Anaerobic Metabolism,乳酸基础生成率,肌肉,脑,RBC,WBC,血小板,肾脏,髓质,胃肠道,粘膜,皮肤,0.13 mmol/kg/hr,0.14 mmol/kg/hr,0.18 mmol/kg/hr,0.11 mmol/kg/hr,0.11 mmol/kg/hr,Total=1290 mmol/24 hours for 70 kg,乳酸的代谢,乳酸代谢,肝脏,60%,肌肉,10%,肾脏,30%,Excretion renal threshold=5-6 mmol/L,高乳酸血症,(2 mmol/L),生成,利用,/,排出,因此,一旦丙酮酸氧化过程受到影响,任何能够增加糖酵解的因素都能够导致高乳酸血症,不仅仅是无氧代谢,!,感染性休克时的高乳酸血症,Curtis SE,Cain SM.Regional and systemic oxygen delivery/uptake relations and lactate flux in hyperdynamic,endotoxin-treated dogs.Am Rev Respir Dis 1992;145:348-354,0,2,4,6,8,Serum Lactate(mEq/L),0,40,80,120,160,Time(min),输注内毒素,FiO,2,=12%,dichloroacetate,二氯乙酸,(dichloroacetate),仅在有氧情况下激活,PDH,乳酸,/,丙酮酸比值,Lactate/Pyruvate=K x(NADH/NAD)x H,+,缺氧能够阻断氧化磷酸化过程,组织,NADH,氧化为,NAD,增加,NADH/NAD,比值,增加乳酸,/,丙酮酸比值,正常值约为,10:1,心源性休克,L/P,比值,=,40:1,符合组织缺氧表现,经过复苏的感染性休克,L/P,比值,=,14:1,不符合组织缺氧表现,何时,乳酸,=,组织灌注不足,心源性休克,出血性休克,以下情况的感染性休克,儿茶酚胺抵抗,+,心输出量降低,未经过复苏,(,参见,Rivers),何时,乳酸,组织灌注不足,有氧糖酵解加速,碳水化合物代谢,线粒体氧化能力,儿茶酚胺,/,细胞因子刺激,e.g.,血液,/,肺的白细胞乳酸,(ARDS),丙酮酸,蓄积,全身性感染时,PDH,功能障碍,何时,乳酸,组织灌注不足,乳酸清除减少,结果相互矛盾：测定方法与初始乳酸水平的影响,可能导致轻度高乳酸血症,当乳酸生成率接近正常时通常并不重要,丙酮酸脱氢酶功能障碍,PDH,使丙酮酸进入,Kreb,循环,而不产生乳酸,全身性感染时肌肉中,PDH,水平低于正常,应用二氯乙酸可恢复功能,从而导致乳酸水平下降,蛋白质分解代谢,氨基酸转化为丙酮酸,随后产生乳酸,线粒体呼吸抑制,全身性感染,药物如,二甲双胍,(,罕见,),氰化物,抗逆转录病毒药物,乳酸酸中毒的分类,Type A Lactic Acidosis,Associated with,malperfusion,/,dysoxia,Type B Lactic Acidosis,In the absence of malperfusion/dysoxia,B1 Disease states e.g.DKA,leukaemia,lymphoma,thiamine deficiency,B2 Drugs e.g.metformin,cyanide,beta-agonists,HARRT,B3 inborn errors of metabolism,Classification of Lactic Acidosis,Tissue hypoperfusion,Abnormal vascular tone or permeability,left ventricular failure,decreased cardiac output,Reduced arterial oxygen content,Asphyxia,hypoxemia(PaO2 35),carbon monoxide poisoning,life-threatening anemia,B1(common disorders),Sepsis,Hepatic failure,Renal failure,Diabetes mellitus,Cancer,Malaria,Cholera,B2(drug or toxins),Vitamin deficiency,Acetaminophen,Ethanol,Methanol,Cocaine,Salicylates,Isoniazid,Catecholamines,Ethylene glycol,Papaverine,Cyanide,Parenteral nutrition,Nitroprusside,Lactulose,Theophylline,B3(other conditions),Strenuous muscle exercise,Grand mal seizures,D-lactic acidosis,Type A,Due to tissue hypoxia,Type B,Not due to tissue hypoxia,预后价值,来源并不重要,高乳酸仍然为严重生理应激和死亡危险的标志,高乳酸常与低氧无关,但仍提示严重应激下存在代谢改变,因此,我们应当,?,寻找组织灌注不足的证据,如果存在组织灌注不足,应提高,CO,和氧输送,但是,不应仅仅针对乳酸水平进行上述治疗,治疗组织灌注不足而非高乳酸,考虑导致高乳酸的其他原因,Lactate is the messengerdont shoot it!,病例诊断,全身血流动力学稳定,组织灌注无明显异常,意识清楚,皮肤无花斑,毛细血管再充盈时间正常,尿量正常,药物因素,患病前未使用任何药物,中毒,毒物监测未发现异常,先天性因素,Classification of Lactic Acidosis,Tissue hypoperfusion,Abnormal vascular tone or permeability,left ventricular failure,decreased cardiac output,Reduced arterial oxygen content,Asphyxia,hypoxemia(PaO2 35),carbon monoxide poisoning,life-threatening anemia,B1(common disorders),Sepsis,Hepatic failure,Renal failure,Diabetes mellitus,Cancer,Malaria,Cholera,B2(drug or toxins),Vitamin deficiency,Acetaminophen,Ethanol,Methanol,Cocaine,Salicylates,Isoniazid,Catecholamines,Ethylene glycol,Papaverine,Cyanide,Parenteral nutrition,Nitroprusside,Lactulose,Theophylline,B3(other conditions),Strenuous muscle exercise,Grand mal seizures,D-lactic acidosis,Type A,Due to tissue hypoxia,Type B,Not due to tissue hypoxia,病例诊断,骨髓活检,淋巴瘤骨髓侵犯,诊断,非霍杰金氏淋巴瘤,病例摘要,02/21,02/22,02/23,02/24,16:50,14:00,10:00,17:00,19:30,22:30,07:30,pH,7.496,7.473,7.424,7.303,7.362,7.518,7.341,PCO,2,8.7,14.7,8.9,6.8,7.5,14.9,8.1,PO,2,142,122,143,148,142,140,134,HCO,3,6.6,10.6,5.7,3.3,4.2,12.0,4.3,SBE,-17.1,-12.6,-19.0,-23.5,-21.6,-10.6,-21.7,Lac,20.0,14.6,14.0,16.0,14.3,11.1,20.0,病例摘要,应用碳酸氢钠与血气变化的关系,总结,动脉血气结果分析,-,基本技能,高乳酸血症的鉴别诊断,