Bughrara Nibras, Diaz-Gomez Jose L, Pustavoitau Aliaksei
Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA.
Cardiovascular Critical Care, Professional Development, Education, and Clinical Research, Critical Care Medicine, Division of Cardiovascular Anesthesia, Texas Heart Institute - Baylor St. Luke's Medical Center, 6720 Bertner Avenue, Suite 0-520, Houston, TX 77030, USA; Critical Care Echocardiography and Point of Care Ultrasound, Baylor College of Medicine, Houston, TX, USA.
Anesthesiol Clin. 2020 Mar;38(1):123-134. doi: 10.1016/j.anclin.2019.11.001.
Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.
床旁超声能够识别感染性休克患者血流动力学衰竭的确切原因。休克患者的循环表现出复杂的改变，包括负荷状态（前负荷和后负荷）、左右心室功能的变化以及梗阻性生理状态的发展，其中一些患者还患有潜在的心脏疾病。了解这种情况下潜在的血流动力学紊乱有助于进行有针对性的干预，即使用液体、血管活性药物和正性肌力药物，以优化患者的灌注。相互矛盾的目标的一个例子是患有肥厚性“厚”左心室（LV）的患者，使用床旁超声（POCUS）很容易识别。这类患者通常存在舒张功能障碍，通常需要更高的充盈压（主要是II级和III级舒张功能障碍）来维持足够的心输出量。他们易受低血容量的影响，有发生动态左心室流出道（LVOT）梗阻的可能性。在这种情况下使用正性肌力药物是有害的，可能会由于二尖瓣叶的收缩期前向运动和二尖瓣反流并迅速进展为心脏骤停而导致梗阻性生理状态恶化。认识到POCUS在围手术期领域日益重要的作用，在本综述中，我们强调POCUS如何使麻醉医生识别和管理脓毒症和感染性休克患者的血流动力学紊乱。我们提供了一种系统的方法，通过对心肌功能、液体反应性和液体耐受性的定性评估来评估这一患者群体。我们的方法基于有限数量的超声视图：快速连续获取肋下、下腔静脉（IVC）和肺部视图。这些视图中的发现组合被分为不同的血流动力学表型，每种表型都需要各自的管理方法。
