1、1,PiCCO容量監(jiān)護儀在ICU中的應(yīng)用,2,PiCCOTechnology,容量管理,IntroductiontothePiCCO-Technology,CO,Volumetricpreload,EVLW,Contractility,DifferentiatedVolumeManagement,static-dynamic,3,正確的監(jiān)測才能進行正確的治療,4,什么是PiCCO？,5,PiCCO是一種技術(shù)，是一種簡便、微創(chuàng)、高效費比的，對重癥病人主要血流動力學(xué)參數(shù)進行監(jiān)測的工具。,6,Centralvenouscatheterjugularsubclavianfemoral,大多數(shù)血流動力學(xué)

2、不穩(wěn)定的患者都會置中心靜脈導(dǎo)管(vasoactiveagentsadministration)動脈導(dǎo)管(monitoringofbloodpressure,bloodsamples),Thermodilutionarterialcatheterfemoralaxillarylongradial,連接,7,Centralvenouscatheterjugularsubclavianfemoral,8,PiCCO技術(shù)可以監(jiān)測心輸出量,9,PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysi

3、s,PrinciplesofMeasurement,LeftHeart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATHarterialthermodilutioncatheter,centralvenousbolusinjection,IntroductiontothePiCCO-TechnologyFunction,10,Transpulmonarythermodilutionmethod,ArterialTDcatheter動脈熱稀釋導(dǎo)管(e.g.PV201

4、4L16),CVbolusinjection中心靜脈一次注射,RAEDV右房舒張末容量,PBV肺血容量,EVLW,LAEDV左房舒張末容量,LVEDV左室舒張末容量,EVLW血管外肺水,RVEDV右室舒張末容量,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,-,D,T,Injection,s,Lungs,CVC,Aorta,V.cavasup.,RA,ArterialTDcatheter,11,Tb=BloodtemperatureTi=InjectatetemperatureVi=InjectatevolumeTb.dt=Areaunderthethermo

5、dilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate,心輸出量是利用Stewart-Hamilton公式對熱稀釋曲線進行分析所得,熱稀釋方法所得心輸出量的計算,12,TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.,36,5,37,5,10,Thermodilutioncurves,NormalCO:5.5l/min,IntroductiontothePiCCO-TechnologyTh

6、ermodilution,36,5,37,36,5,37,Time,lowCO:1.9l/min,HighCO:19l/min,Time,Time,Temperature,Temperature,Temperature,13,經(jīng)肺vs.肺動脈熱稀釋,Leftheart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATHarterialthermo-dilutioncatheter,centralvenousbolusinjection,RA,RV,PA,LA,LV,Aorta,TranspulmonaryTD(PiC

7、CO),PulmonaryArteryTD(PAC),這兩種方法所得CO都是準確的，因為熱稀釋方法關(guān)注的只是時間以及溫度改變！,14,TranspulmonarythermodilutionCOmeasurement(vsPAthermodilution),AuthorBias(L/min)SDrGodjeChest19980.160.350.96SakkaICM19990.680.620.97GoedjeCCM19990.290.600.93BindelsCC20000.490.780.95GoedjeChest20000.350.720.98DellaRoccaBJA20020.150.8

8、70.93SanderCC20050.000.700.95OstergaardAAS20060.460.55,15,Pulsecontouranalysis脈搏輪廓分析,Cal=calibrationfactorobtainedfromtranspulmonarythermodilution(coldbolusinjection)校準系數(shù)來自經(jīng)肺熱稀釋方法,Surface=Cal.xStrokevolume,16,P(mmHg),t(s),17,Validationofcontinuouscardiacoutputmeasurementbythepulsecontouranalysis(PiC

9、COsystem)PiCCO所得連續(xù)心排量數(shù)值準確性論證,RoedigGetal.BrJAnaesth1999;82:525-530GoedjeOetal.AnnThoracSurg1999;68:1532-1536BuhreWetal.JCardiothoracVascAnesth1999;13:437-440GoedjeOetal.CritCareMed1999;27:2407-2412ZollnerCetal.JCardiothoracVascAnesth2000;14:125-129GoedjeOetal.MedSciMonit2001;7:1344-1350FelbingerTWet

10、al.JClinAnaesth2002;14:296-301GoedjeOetal.CritCareMed2002;30:52-58RauchHetal.ActaAnaesthesiolScand2002;46:426-429Felbingeretal.JClinAnaesth2005;17:241-248Ostergaardetal.ActaAnaesthesiolScand2006;50:1044-1049,18,PiCCO不僅是心排量監(jiān)測儀,19,PiCCOtechnology,GEDV評估心臟前負荷容量,20,目前醫(yī)學(xué)界判斷心臟前負荷的標準,Centrolvenouspressure(

11、CVP)Pulmonarycapillarywedgepressure(PCWP)但是這是基於以下的假設(shè)“壓力=容量但這種假設(shè)並非完全正確,PULSIONMedicalSystems,21,Kumaretal.,CritCareMed2004;32:691-699,21,灌注壓CVP/PCWP反映前負荷,中心靜脈壓和每搏輸出量的關(guān)聯(lián),監(jiān)測前負荷,22,Kumaretal.,CritCareMed2004;32:691-699,22,肺動脈嵌壓和每搏輸出量的關(guān)聯(lián),MeasuringPreload,監(jiān)測前負荷,灌注壓CVP/PCWP反映前負荷,23,RaperRandSibbaldWJ.Chest

12、1986Misledbythewedge?TheSwan-Ganzcatheterandleftventricularpreload.,24,GEDV可以作為心臟前負荷的指標,GlobalEnd-DiastolicVolumeevaluatedbytranspulmonarythermodilution,GEDV,25,COxMTt=volumeofdistribution=1+2+3+4+5,3,Indicatorinjection,Indicatordilutioncurve,26,COxMTt=volumeofdistribution=1+2+3+4+5,3,COxDst=largest

13、mixingchamber=3,Indicatorinjection,Indicatordilutioncurve,27,COxMTt=volumeofdistribution=GEDV+PBV+EVLW,EVLW,Meieretal.JApplPhysiol1954,28,Changesinstrokevolumeindex(%),Changesinglobalend-diastolicvolumeindex(%),r=0.72p0.001,Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutec

14、irculatoryfailure.Michardetal.SCCM2002,29,治療指南SurvivingSepsisCampaignGuidelines2008:灌注壓在評估擴容治療中已經(jīng)被證實有局限性.使用血流量或者容量參數(shù)指導(dǎo)容量管理或許更有優(yōu)勢這些技術(shù)已經(jīng)能夠在ICU內(nèi)實現(xiàn),PiCCO技術(shù),30,IntrathoracicpressureVenousreturntoleftandrightventricleLeftventricularpreloadLeftventricularstrokevolumeSystolicarterialbloodpressure,Intrathora

15、cicpressureSqueezing“ofthepulmonarybloodLeftventricularpreloadLeftventricularstokevolumeSystolicarterialbloodpressure,PPmax,PPmin,PPmax,PPmin,吸氣,Reuteretal.,Ansthesist2003;52:1005-1013,容量反映值的生理學(xué)意義,呼氣,吸氣,呼氣,吸氣早期,吸氣晚期,呼吸周期中血壓的波動,監(jiān)測前負荷,31,SVmax,SVmin,SVmean,每搏量變異SVV,每搏量變異（StrokeVolumeVariation，SVV）反映了每

16、搏量隨通氣周期變化的情況。,SVV是.過去30秒的測量結(jié)果只適用于心律規(guī)律的完全機械通氣病人,32,SVV反映了心臟對因機械通氣導(dǎo)致的前負荷周期性變化的敏感性。1,15,18,19,20SVV可用于預(yù)測擴容治療對每搏量的提高程度。1,15,18,19,20,對于沒有心律失常的完全機械通氣病人而言，,每搏量變異-SVV,33,00.51,1-specificity,sensitivity,SVV,CVP,0,0.6,0.4,1,0.8,0.2,Strokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbra

17、insurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9,sensitivity=79%specificity=93%,34,心肌收縮狀況,FORCE-FREQUENCYRELATION,DIGITALIS,OTHERINONOTROPICAGENTS,ANOXIAHYPERCAPNIAACIDOSIS,CIRCULATINGCATECHOLAMINES,SYMPATHETICNERVEIMPULSES,LOSSOFMYOCARDIUM,PHARMACOLOGIC

18、DEPRESSANTS,INTRINSICDEPRESSION,VENTRICULAREDV,VENTRICULARSTROKEVOLUME,FromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,1976,35,CFI心臟收縮功能指數(shù),36,TEEFAC,PiCCOCFI,37,r=0.80,38,左心室收縮力指數(shù)dPmx=動脈壓力曲線的上升枝,PiCCO心肌收縮力參數(shù),39,PiCCO心肌收縮力參數(shù),dPmx反映了左心室最大壓力增加的速度，是心肌收縮力的參數(shù),

19、40,全心射血分數(shù)（GEF）（經(jīng)肺熱稀釋導(dǎo)管）,GEF=,GEDV,4xSV,右心室射血分數(shù)（RVEF）（肺動脈熱稀釋導(dǎo)管）,左心室射血分數(shù)（LVEF）（心臟超聲）,1,2,&,3,全心射血分數(shù)GEF,右心,左心,肺,PBV,EVLW,EVLW,RAEDV,RVEDV,LVEDV,每搏量（SV）,LAEDV,射血分數(shù)：與每搏量和舒張末期容積相關(guān),41,EVLW肺水腫指數(shù),42,Extravascularwatercontentofthelung,Pulmonarycirculation,LeftHeart,RightHeart,Lungs,血管外肺水EVLW在管理前負荷中的作用,EVLW=Ex

20、travascularLungWater,Bodycirculation,監(jiān)測前負荷,分辨以及量化肺水腫僅有的一個在床邊獲得肺水量化值的方法對容量過度補充有預(yù)警功能,43,44,45,COxMTtcold=coldindicatorvolumeofdistribution,EVLW,COxMTtICG=ICGvolumeofdistribution,RA,LA,RV,LV,PBV,46,47,EVLWmeasuredwiththePiCCOsystemcomparedwithgravimetricsindogswithcardiogenicandnon-cardiogenicpulmonary

21、edema,Katzenelsonetal.SCCM2002,EVLWPiCCO,EVLWGrav.,48,SourceComparisonCorrelationBaudendisteletal,1982,JTrauma22:983X-rayscorevs.EVLW*77%Sibbaldetal,1983,Chest83:725comparisoncardiacedemar=0,66comparisonnoncardiacedemar=0,7Sivaketal,1983,CritCareMed.11:498X-rayscorevsEVLW*64%X-rayscorevs.EVLW*42%Lag

22、gneretal,1984,IntensiveCareMed.10:309X-rayscorevs.EVLW*r=0,84no/low/highPE,estimatedbyradiologistsHalperinetal,1985,Chest88:649X-rayscorevs.EVLW*r=0,51Halleretal,1985,Fortschr.Rntgenstr.142:68X-rayscorevs.EVLW*66%Eisenbergetal,1987,AmRevRespDis136:662X-rayscorevs.EVLW*76%Takedaetal,1995,JVetMedSci57

23、(3):481X-rayscorevs.EVLW*X-rayinsensitive,EVLW和胸部X光片的對比,胸部X光片常受到胸腔內(nèi)滲出的影響，并受到床旁拍攝X光片技術(shù)方面的限制,49,監(jiān)測ELWI能夠發(fā)現(xiàn)肺水10-15%的增加X-ray只有在肺水100-300%增長時才能甄別,50,373位重癥ICU病人中EVLWI與死亡率的關(guān)系：其中193人感染，49人ARDS，48人頭部創(chuàng)傷，83人出血性休克。根據(jù)EVLW的數(shù)值病人分成四組。Sakkaetal,Chest2002,EVLW與死亡率2,ELWIml/kg,51,利用EVLW治療病人,101位肺水腫病人隨時分成肺動脈導(dǎo)管（PAC）組與血管

24、外肺水組（EVLW），分別依據(jù)PCWP和EVLW的測量結(jié)果進行治療。在EVLW組的病人在ICU的時間和機械通氣時間都顯著降低。Mitchelletal,AmRevRespDis145:990-998,1992,22天,15天,9天,7天,*,*,機械通氣天數(shù),住ICU天數(shù),n=101,EVLW組,PAC組,EVLW組,PAC組,52,Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫,Incaseofdoubtfuldiagnosisbasedonconventionalcriteri

25、a尤其當傳統(tǒng)的標準產(chǎn)生不確定診斷時,HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標？,53,Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫,Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema針對已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）,HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標？,5

26、4,PiCCO肺相關(guān)指標,肺血管通透性指數(shù)（PulmonaryVascularPermeabilityIndex，PVPI）=血管外肺水（EVLW）與肺血容積（PBV），反映了肺水腫的類型,PulmonarvBloodVolume,靜水壓肺水腫,通透性肺水腫,PVPI=,PBV,EVLW,正常,升高,升高,PVPI=,PBV,EVLW,升高,升高,正常,PVPI=,PBV,EVLW,正常,正常,正常,PBV,EVLW,PBV,EVLW,PBV,EVLW,正常,ExtraVascularLungWater,55,Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫,Inpatientswithpulmonaryedemafordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema針對已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）,InALI/ARDSpatientsforidentifyin