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重症右心功能管理专家共识

Experts consensus on the management of the right heart function in critically ill patients

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关键词: Right ventricular function Intensive care unit Hemodynamic monitoring Echocardiography Consensus statement/guidelines

摘要:
To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE(Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle . (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion(TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. ( 25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

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收录情况: ◇统计源期刊 ◇北大核心 ◇CSCD-C ◇中华系列

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专家组成员:
刘大为 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 张宏民 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 隆云 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 赵华 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 丁欣 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 杜微 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 汤铂 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 何怀武 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 陈焕 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 柴文昭 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 周翔 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 崔娜 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 王郝 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 芮曦 (100730中国医学科学院北京协和医学院北京协和医院重症医学科) 管向东 (中山大学附属第一医院重症医学科) 欧阳彬 (中山大学附属第一医院重症医学科) 吴健峰 (中山大学附属第一医院重症医学科) 邱海波 (东南大学附属中大医院重症医学科) 杨毅 (东南大学附属中大医院重症医学科) 于凯江 (哈尔滨医科大学附属第四医院) 严静 (浙江医院) 汤耀卿 (上海交通大学医学院附属瑞金医院重症医学科) 陈德昌 (上海交通大学医学院附属瑞金医院重症医学科) 马晓春 (中国医科大学附属第一医院重症医学科) 康焰 (四川大学华西医院重症医学科) 尹万红 (四川大学华西医院重症医学科) 艾宇航 (中南大学湘雅医院重症医学科) 张丽娜 (中南大学湘雅医院重症医学科) 胡振杰 (河北医科大学第四医院重症医学科) 刘丽霞 (河北医科大学第四医院重症医学科) 李建国 (武汉大学中南医院重症医学科) 许媛 (北京清华长庚医院重症医学科) 谢志毅 (北京清华长庚医院重症医学科) 林洪远 (解放军总医院第一附属医院重症医学科) 黎毅敏 (广州医科大学第一附属医院) 万献尧 (大连医科大学附属第一医院重症医学科) 李素玮 (大连医科大学附属第一医院重症医学科) 杨荣利 (大连市中心医院重症医学科) 秦英智 (天津市第三中心医院重症医学科) 晁彦公 (清华大学第一附属医院重症医学科) 孙仁华 (浙江省人民医院重症医学科) 何振扬 (海南省人民医院重症医学科) 王迪芬 (贵阳医科大学附属医院重症医学科) 黄青青 (昆明医科大学第二附属医院重症医学科) 蒋东坡 (第三军医大学大坪医院重症医学科) 曹相原 (宁夏医科大学总医院重症医学科) 于荣国 (福建省立医院重症医学科) 王雪 (西安交通大学第一附属医院重症医学科) 陈秀凯 (美国匹兹堡医学中心) 陈祖君 (中国医学科学院国家心血管病中心北京阜外医院) 罗哲 (复旦大学附属中山医院重症医学科)
本院专家组成员:
胡振杰[10] (河北医科大学第四医院重症医学科) 刘丽霞[10] (河北医科大学第四医院重症医学科)
通讯作者:
刘大为 (dwliu98@163.com)
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