PiCCO

的臨床應(yīng)用內(nèi)容原理測定參數(shù)臨床操作臨床病例心排監(jiān)測探討PiCCO原理PiCCO

Pulsecontourcardiacoutputpulseindicatorcontinuecardiacoutput

PiCCO采用成熟的熱稀釋方法測量單次的心輸出量（CO），并通過分析動脈壓力波形曲線下面積與CO存在的一定關(guān)系，來獲得連續(xù)的心輸出量（CCO）

a.經(jīng)肺熱稀釋技術(shù)b.動脈脈搏輪廓分析技術(shù)Picco技術(shù)獲得連續(xù)CO的基本原理Wesseling提出的心搏量同主動脈壓力曲線的收縮面積成正比，壓力依賴于順應(yīng)性及其系統(tǒng)阻力，并作了壓力、心率、年齡等影響因素校正后，該方法才得到認(rèn)可。PiCCO

plussetupCentralvenouscatheterInjectatetemperaturesensorhousingPV4046Arterialthermodilutioncatheter

InjectatetemperaturesensorcablePC80109PULSIONdisposablepressuretransducerPV8115PCCIAP13.0316.28

TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625

DPTMonitorcablePMK-206InterfacecablePC80150ConnectioncabletobedsidemonitorPMK-XXXAUXadaptercablePC81200

A.axillaris

(A.brachialis)PV2014L08

4F8cm

A.

radialisPV2014L50LGWA4F50cm

A.femoralisPV2015L205F20cmPV2013L07*3F7cmPV2014L08*morethan10kgbodyweight*ForapplicationinpediatricpatientsApplicationsitesforthermodilutioncathetersTbinjectiontTranspulmonarythermodilution:CardiacOutputStewart-HamiltonmethodTb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫?Tb.

dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectateAreaunderpressure

curveShapeofpressure

curvePCCO=cal?HR?SystoleP(t)SVR+C(p)?dPdt()dtAorticcomplianceHeartratePatient-specificcalibrationfactor(determinedbythermodilution)t[s]P[mmHg]CalculationofPCCOModel

PCCOisdisplayedaslast12smeanMethodologyofvolumetricmonitoring(I)lnc(I)injectionAtrecirculationMTtte-1DStc(I)

MTt:Meantransittime ≈halfoftheindicatorpassedthepointofdetection

DSt:Downslopetime≈exponentialdownslopetimeofTDcurveITTV=CO*MTtTDaPTV=CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWCalculationofvolumesPiCCO測定的參數(shù)TranspulmonarythermodilutionparametersCardiacoutput CO（心排血量）

Intrathoracicbloodvolume ITBV（胸腔內(nèi)血容量）Extravascularlungwater EVLW（血管外肺水）Cardiacfunctionindex CFI（心功能指數(shù)） Globalejectionfraction

GEF(心臟腔室射血分?jǐn)?shù))經(jīng)肺熱稀釋測量的參數(shù)NewparametersGEF

=GEDV4xSVGlobalejectionfractionPVPI

=PBVEVLWEstimationofpulmonaryvascularpermeabilityPulsecontourparametersPulsecontourcardiacoutputPCCO（動脈連續(xù)心排血量）

HeartrateHR（心率）ArterialpressureAP（動脈壓）StrokevolumeSV（每搏心排量）StrokevolumevariationSVV（每搏量變異指數(shù)）SystemicvascularresistanceSVR（體循環(huán)阻力）IndexofleftventricularcontractilitydP/dtmax（左室收縮力指數(shù)）連續(xù)動脈波形測量的參數(shù)正常值范圍

Parameter Range

UnitCI 3.0–5.0 l/min/m2

ITBVI 850–1000 ml/m2EVLWI 3.0–7.0 ml/kgCFI 4.5–6.5 1/minHR 60–90 1/minMAP 70–90 mmHgSVRI 1200–2000 dyn*s*cm-5*m2SVI 40–60 ml/m2SVV 10 %dP/dtmax1200—2000mmHg/sGEDVI600—750ml/m2DecisionTreeforvolumetrichemodynamicmonitoringCI(l/min/m2)

ITBVI(ml/m2)

TherapyTargetITBVICFIEVLWI(slowly

responding)

<10

V+850-1000>4.5

>10

V+

Cattemporary750-850>5.5<10<10

Cat>4.5>3.0<3.0

>10

CatV-temporary750-850>5.5<10<10

V+850-1000<10>10

V+temporary750-850<10>850<850>850

<10

OK!

>10

V-temporary750-850<10<850EVLWI(ml/kg)V+=volumeloading(!=cautiously)V-=volumecontractionCat=catecholamines/cardiovascularagentsIndicationsEverypatientwhorequireacentralvenousandartericalcathetermonitoring.

ContraindicationsArterialaccessrestrictionduetofemoralarterygraftingorsevereburnsinareaswherethecatheterwouldnormallyhavebeenplaced.

ThePiCCOmethodmaygiveincorrectthermodilutionmeasurementsinpatientswithintracardiacshunts;aorticaneurysm;aorticstenosis;pneumonary;macrolungembolisnandextracorporealcirculation(ifbloodiseitherextractedfromorinfusedbackintothecardiopulmonary.)臨床操作1,按主設(shè)定2,收入/轉(zhuǎn)出3,ABP

1cm=0.393in1kg=2.2lb按enter收入病人主設(shè)定測量CO接通

心輸出量測量目錄InjVol選擇試驗保存再采樣CVPm1mmHg=1.33cmH2O進行計算PiCCO臨床病例病例一男患53歲診斷膿毒癥MODS處于鎮(zhèn)靜狀態(tài)，HR：90次／分，BP：160／70mmHg，SaO2：90％R：15次／分氣管插管，呼吸機輔助呼吸，SIMV模式，F(xiàn)IO2：60％PEEP：8cmH2O雙肺吸氣相呼吸音粗糙，呼氣相呼吸音弱。血常規(guī)：WBC：47.0×109NEUT％：95.6％PLT:25×109肝功：ALT:21U/LAST:14U/LALB：17g／L腎功：BUN：36.79mmol／LCrea：399umol／LT1吳國安T1T2BP140/73196/98HR8692CVP58CI1.662.68SI19.229.2SVRI43473933LCWI2.15.1LVSWI24.951.6EVLWI9.16.5ITBVI453540GEDVI362432PVPI3.72.1病例二女患74歲食物中毒感染性休克入室時意識朦朧，自主呼吸，生命體征：HR140bpm,BP94/52mmHg,(多巴胺維持）SpO298%FiO23L/min,RR31bpm8小時后，心肺復(fù)蘇后，行PiCCO監(jiān)測張亞敏T1T2T3T4T5T6T7T8BP71/4390/4873/4579/4783/5065/3869/4066/33HR138144127142138147130113CVP1411109791218CI3.383.942.743.382.933.513.833.23SI24.527.421.623.821.323.929.428.6SVRI9241075131411851526888836719LCWI2.43.422.72.52.32.72.1LVSWI17.623.816.119.118.215.620.818.2EVLWI6.45.37.67.97.27.974.9ITBVI7658988759638461020962917GEDVI612718701770677877770733心肺復(fù)蘇后2小時后850ml液體擴容后硝普鈉0.3ug/kg.min多巴酚18ug/kg.min付腎0.13ug/kg.min代入治療樹--OK病例三女患69歲擴張型心肌病心衰心功Ⅲ級氣管插管呼吸機輔助呼吸SPONT模式PS8cmH2OPEEP4cmH2OFiO250%多巴胺25ug/kg.min多巴酚丁胺25ug/kg.min

米力農(nóng)0.5ug/kg.minT1T2T3T4T5T6T7BP85/4593/53mmHg97/55mmHg111/57mmHg94/6299/52mmHg114/52HR9085bpm85bpm87bpm8366bpm81CVP99mmHg9mmHg10mmHg912mmHg15CI0.771.774.314.085.032.964.01SI9.319.950.746.960.644.849.5SVRI7718267011141254104814591116LCWI0.91.644.15.12.73.9LVSWI10.618.447.547.261.940.347.8EVLWI13.36.814.414.412.89.621.5ITBVI72471815631439189715631876GEDVI57957512511151151712511501CFI1.33.13.43.53.52.32.6停呼吸機多巴胺，多巴酚25ug/kg.min24小時后多巴胺，多巴酚20ug/kg.min硝普鈉0.1-0.3ug/kg.min24小時持續(xù)泵入加用米力農(nóng)，硝普鈉后停多巴胺，多巴酚停米力農(nóng)病例四女患23歲病毒性腦炎氣管插管呼吸機輔助呼吸PS13cmH2OPEEP3.0cmH2O多巴胺12ug/kg.min前24小時總?cè)肓?040ml前24小時總出量3750ml劉曉麗T1T2T3T4T5T5T6T7T8BP93/49108/5997/56120/76120/72133/78140/79142/81144/79HR156143106109140114133127132CVP668562001CI2.882.763.993.074.212.995.174.73.51SI18.519.337.628.231.626.338.93726.6SVRI158015641223224016912537154717512304LCWI2.52.33.73.85.53.976.64.9LVSWI15.815.835.334.941.334.652.951.936.8EVLWI6.25.55.565.36.57.38.14.7ITBVI568591752637713554813837522GEDVI455473602509570444651670417CFI6.35.86.667.37.978.4前24小時入量6040ml，出量3750ml24小時后入量9010ml出量5430ml48小時后前24小時入量6465出量5660CO監(jiān)測探討InvasivemethodsMinimallyinvasivemethodsNon-invasivemethodsThermodilutiontechniqueFick’scardiacoutputmeasurementDopplerultrasound---TranspulmonarythermodilutionPartialCO2rebreathingThanspulmonarythermodilutionPulsecontourcardiacoutputestimationwithoutexternalcaliberation

ElectricalimpedancecardiographyFick’scardiacoutputmeasurement以氧作為指示劑，是一種經(jīng)典的方法V2O2—theoxygencontentdifferencebetweeninspiredandexhaledgasCaO2---OxygencontentofarterialbloodCvO2---OxygencontentofmixedvenousbloodNICO是利用二氧化碳彌散能力強的特點作為指示劑，根據(jù)Fick原理來測定心排血量。基本公式為：Q＝VCO2/(CVCO2-CaCO2)。優(yōu)點NICO所測心排血量的重點在于CO的有效部分，即積極完成氣體交換的血流量，就此點的意義來說NICO大于經(jīng)典的溫度稀釋法。NICO的數(shù)值改變大多發(fā)生于溫度稀釋法測量值變化之前，即NICO對血流動力學(xué)改變的反映快于經(jīng)典的溫度稀釋法，這對某些關(guān)鍵時刻意義重大。缺點是任何影響混合靜脈血二氧化碳、解剖死腔/潮氣量及肺內(nèi)分流的因素均可影響結(jié)果的準(zhǔn)確性尤其要指出剛給完碳酸氫鈉后的測量結(jié)果也不可靠，NaHCO3可影響PETCO2。Electricalimpedancecardiography利用心動周期于胸部電阻抗的變化來測定左心室收縮時間間期并計算出每搏量，然后再演算出一系列心功能參數(shù)?；驹恚簹W姆定律（電阻＝電壓/電流）ρ---resistivityofbloodL---meandistancebetweentheinnerelectrodesVET---ventricularejectiontimedZ/dt---theabsoluteofthemaximumvalueofthefinstderivativeduringsystosleZ0---basalthoracicimpedance操作簡單、費用低、能動態(tài)觀察心排血量的變化趨勢抗干擾能力差測量結(jié)果略大于溫度稀釋法測定值缺點盡管阻抗法以阻抗變化反映CO,可無損傷快速測量CO,但多數(shù)人認(rèn)為阻抗法測定CO影響因素太多,如肥胖、放置胸腔引流管、機械通氣、發(fā)熱、水種、胸膜滲液、心律失常、嚴(yán)重的心瓣膜病、急性心肌梗死和血液動力學(xué)不穩(wěn)定等因素均會導(dǎo)致監(jiān)測結(jié)果準(zhǔn)確性的下降[3],因此測量誤差較大,臨床應(yīng)用有困難。尤其對危重病人,臨床應(yīng)用一直有爭議0200400600800100012002.55.07.510.0GEDVI(ml/m2)CI(l/min/m2)VolumeInotropicsnormalrangenormalcardiacfunctionCFI =CI/GEDVICardiacfunctionindex(CFI)EVLW包括細胞內(nèi)、組織間、肺泡內(nèi)馬麗T9T8BP101/55