什么是PiCCO技術(shù)？

PulseindicatorContinousCardiacOutput1a.經(jīng)肺熱稀釋技術(shù)（TPTD）b.動(dòng)脈脈搏輪廓分析技術(shù)（PC）兩者的結(jié)合：PiCCO2中心靜脈導(dǎo)管頸內(nèi)靜脈鎖骨下靜脈溫度指示劑注射大部分血流動(dòng)力學(xué)不穩(wěn)定的病人都會(huì)做以下監(jiān)測(cè)?中心靜脈導(dǎo)管(用作補(bǔ)液，血管活性藥物的使用，中心靜脈壓的監(jiān)測(cè))?動(dòng)脈導(dǎo)管(持續(xù)監(jiān)測(cè)動(dòng)脈血壓、動(dòng)脈抽血等)動(dòng)脈導(dǎo)管股動(dòng)脈腋動(dòng)脈肱動(dòng)脈持續(xù)監(jiān)測(cè)動(dòng)脈血壓、波形、血溫監(jiān)測(cè)3PiCCO

plus

連接示意圖中心靜脈導(dǎo)管注射液溫度探頭容納管（T型管）動(dòng)脈熱稀釋導(dǎo)管注射液溫度電纜PULSION一次性壓力傳感器PCCIAP13.0316.28

TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625溫度測(cè)量電纜壓力電纜4彈丸注射肺PiCCO導(dǎo)管如：股動(dòng)脈

經(jīng)肺熱稀釋技術(shù)需要在中心靜脈注射冷鹽水(<8°C)或室溫鹽水(<24°C)A.熱稀釋參數(shù)左心右心RAPBVEVLWLALVEVLWRVA.熱稀釋參數(shù)的測(cè)量5

熱稀釋參數(shù)

心輸出量 CO

全心舒張末期容積 GEDV

胸腔內(nèi)血容積 ITBV

血管外肺水 EVLW

肺血管通透性指數(shù) PVPI

心功能指數(shù) CFI

全心射血分?jǐn)?shù) GEF6t[s]P[mmHg]B.脈搏輪廓分析78大家有疑問(wèn)的，可以詢問(wèn)和交流可以互相討論下，但要小聲點(diǎn)9大家有疑問(wèn)的，可以詢問(wèn)和交流可以互相討論下，但要小聲點(diǎn)10如何測(cè)量心輸出量（CO）傳統(tǒng)的漂浮導(dǎo)管（swan-ganz）采用熱稀釋法來(lái)測(cè)定CO12TbinjectiontFemoralarterycatheter股動(dòng)脈導(dǎo)管(e.g.PV2014L16)Axillaryarterycatheter腋動(dòng)脈導(dǎo)管(e.g.PV2014L08)Centralvenousinjection經(jīng)肺熱稀釋法:CardiacOutputStewart-Hamiltonmethod1.用經(jīng)肺熱稀釋法測(cè)量COTb=血液溫度Ti=注射液溫度Vi=注射液容積∫?Tb.

dt=熱稀釋曲線下面積K=校正系數(shù)，與體重、血溫和注射液溫度相關(guān)13經(jīng)肺熱稀釋法的驗(yàn)證14B.動(dòng)脈脈搏輪廓分析t[s]P[mmHg]壓力曲線下面積壓力曲線型狀PCCO=cal?HR?

SystoleP(t)SVR+C(p)?dPdt()dt動(dòng)脈順應(yīng)性心率病人相關(guān)的校正因子（通過(guò)熱稀釋法得到）2.用脈搏輪廓分析法測(cè)量CO15

通過(guò)對(duì)分析每一次心臟跳動(dòng)（beatbybeat）時(shí)的動(dòng)脈壓力波型，得到連續(xù)的參數(shù)t-?Tt-?T校正t[s]P[mmHg]SV脈搏輪廓分析－原理熱稀釋法測(cè)量得到CO測(cè)量血壓(P(t),MAP,CVP)

經(jīng)過(guò)經(jīng)肺熱稀釋校正后，可以測(cè)量每一次心臟跳動(dòng)的每搏量（SV）16脈搏輪廓分析驗(yàn)證Thesetablesareonlyanexcerptofpublications,intotaltherearemorethan200articlesaboutthePiCCOTechnology.17Goedjeetal,ThoracCardiovascSurg46:242-249,1998PiCCOvsCOTDPain30patientsaftercardiacsurgery18容量的監(jiān)測(cè)19目前判斷心臟前負(fù)荷的標(biāo)準(zhǔn)Centrolvenouspressure(CVP)Pulmonarycapillarywedgepressure

(PCWP)

但是?壓力=容量

?前負(fù)荷的量化值是LVEDV（左室舒張末的容積），是容量值而非壓力值。20

壓力數(shù)據(jù)并不是在任何時(shí)候都可以正確反映心臟前負(fù)荷和容量水平Erroneousreadingsofpressuretracings

Ibertietal.JAMA1990 Al-Kharratetal.AmJRespirCritCareMed1999Discrepancybetweenmeasuredandtransmuralpressures

Pinskyetal.AmRevRespirDis1992 Tebouletal.CritCareMed1999壓力和容量之間并不成線性關(guān)系21Lichtwarck-Aschoffetal,IntensiveCareMed18:142-147,199222Lichtwarck-Aschoffetal,IntensiveCareMed18:142-147,199223lnc(I)injectionAtrecirculationMTtte-1DStc(I)At: Appearancetime MTt: Meantransittime DSt: Downslopetime出現(xiàn)時(shí)間平均通過(guò)時(shí)間下斜時(shí)間PiCCO容量監(jiān)測(cè)的方法（一）24COxMTt=volumeofdistribution=1+2+3+4+53COxDst=largestmixingchamber=33IndicatorinjectionIndicatordilutioncurve1425325CVbolusinjectionArterialTDcatheter

(e.g.PV2014L16)ITTV =Intrathoracicthermalvolume PTV =PulmonarythermalvolumeGEDV =Globalend-diastolicvolume EVLW =ExtravascularlungwaterITBV =Intrathoracicbloodvolume EVLWEVLWPTVGEDVITTVITBVPiCCO容量監(jiān)測(cè)的方法（二）26ITTV=CO*MTtTDaPTV=CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPBVEVLWEVLWPBVEVLWEVLWEVLWEVLWPiCCO容量監(jiān)測(cè)的方法（三）27RAEDVRVEDVLAEDVLVEDV全心舒張末期容積GEDVGEDV=ITTV-PTVITTV=CO*MTtTDaPTV=CO*DStTDa28Changesinstrokevolumeindex(%)Changesinglobalend-diastolicvolumeindex(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM200229胸內(nèi)血容量ITBVRAEDVRVEDVLAEDVLVEDVPBVITBV=1.25*GEDV30RelationshipbetweenITBVandGEDVSakkaetal:IntensiveCareMed26:180-187,2000GEDVvs.ITBVin57intensivecarepatientsr=0.96ITBV=1.25*GEDV–28.4[ml]31

Lichtwarck-AschoffM.etal,IntensivCareMed18:142-147,1992ITBVasindicatorofcardiacpreload32GEF=GEDV4xSV心臟腔室射血分?jǐn)?shù)GlobalejectionfractionPiCCO所特有心肺功能指數(shù)臨床上常用的EF(射血分?jǐn)?shù))=ejectionfractionSvLVEDVGlobalEjectionFraction(GEF)(transpulmonarythermodilution)=GEFSVGEDV/433dPmax=壓力曲線上最快的變化速度dP/dtmax反映了左室內(nèi)壓力上升的加速度t[s]P[mmHg]PiCCO用于評(píng)價(jià)心肌收縮力的指數(shù)34血管外肺水EVLWEVLWEVLWEVLW=ITTV-ITBV35Sakkaetal:IntensiveCareMed26:180-187,2000Bias = -0.2ml/kg

SD = 1.4ml/kgn=209r=0.96EVLWISTvs.EVLWITDin209intensivecarepatients熱稀釋法和熱-染料稀釋法測(cè)量EVLW的相關(guān)性36PICCO測(cè)量的EVLW和動(dòng)物實(shí)驗(yàn)中活體肺重量的相關(guān)性Katzenelsonetal.SCCM2002EVLWPiCCOEVLWGrav.37Source Comparison CorrelationHalperinetal,1985

X-rayscorevs.

r=0,51Chest88:649

EVLWBaudendisteletal,1982

X-rayscorevs.EVLW

77%JTrauma22:983Sibbaldetal,1983

comparisoncardiacedema

r=0,66Chest83:725 comparisonnoncardiacedema

r=0,7Sivaketal,1983

X-rayscorevsEVLW

64%CritCareMed.11:498

X-rayscorevs.

EVLW

42%Laggneretal,1984

X-rayscorevs.EVLW

r=0,84IntensiveCareMed.10:309Halleretal,1985

X-rayscorevs.EVLW

66%Fortschr.R?ntgenstr.142:68Eisenbergetal,1987

X-rayscorevs.EVLW

76%AmRevRespDis136:662Takedaetal,1995

X-rayscorevs.EVLW X-rayinsensitive

J

VetMedSci57(3):481 ComparisonofEVLWandchestX-ray38PVPI=EVLW/PBVPVPI=EVLW/PBV>>>>PulmonaryVascularPermeabilityIndex=PVPIPBV血管通透性增高的肺水腫流體壓力增高的肺水腫EVLW*PBV=0.25xGEDV Sa