PiCCO原理以及计算过程.ppt

,IntroductiontoPiCCOTechnologyPiCCO技术的介绍,Principlesoffunction理论知识Thermodilution热稀释法Pulsecontouranalysis脉搏轮廓分析法Contractilityparameters收缩力参数Afterloadparameters后负荷参数Extravascularlungwater血管外肺水Pulmonarypermeability肺通透性指数,血流动力学监测,TheoryandPractice,PiCCOTechnology,Parametersforguidingvolumetherapy,IntroductiontothePiCCO-Technology,CO心排量,Volumetricpreload容量负荷,EVLW肺水,Contractility收缩力,DifferentiatedVolumeManagement,-static-dynamic-,PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysisPiCCO技术是经肺热稀释法和脉搏轮廓分析法的结合,PrinciplesofMeasurement,LeftHeart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATHarterialthermodilutioncatheter,centralvenousbolusinjection,IntroductiontothePiCCO-TechnologyFunction,Bolusinjection,concentrationchangesovertime(Thermodilutioncurve),Aftercentralvenousinjectionthecoldbolussequentiallypassesthroughthevariousintrathoraciccompartments中心静脉弹丸注射后，冰盐水会通过胸腔内的各个腔室。,Thetemperaturechangeovertimeisregisteredbyasensoratthetipofthearterialcatheter动脉导管尖端的感受器探测到注射液温度的改变。,IntroductiontothePiCCO-TechnologyFunction,Leftheart,Rightheart,Lungs,PrinciplesofMeasurement,IntrathoracicCompartments(mixingchambers),IntroductiontothePiCCO-TechnologyFunction,PulmonaryThermalVolume(PTV)肺内热稀释容积,IntrathoracicThermalVolume(ITTV)胸腔内热容积,Totalofmixingchambers所有的混合腔室,Largestsinglemixingchamber最大的单一混合腔室,HaemodynamicMonitoring,E.IntroductiontoPiCCOTechnology,PrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability,Tbxdt,(Tb-Ti)xVixK,Tb,Injection,t,D,=,COTDa,Tb=BloodtemperatureTi=InjectatetemperatureVi=InjectatevolumeTb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate,TheCOiscalculatedbyanalysisofthethermodilutioncurveusingthemodifiedStewart-Hamiltonalgorithm心排量是通过分析热稀释曲线得来的，应用Stewart-Hamilton定律。,CalculationoftheCardiacOutput,IntroductiontothePiCCO-TechnologyThermodilution,TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.热稀释曲线下的面积是与CO呈反比的。,36,5,37,5,10,Thermodilutioncurves,NormalCO:5.5l/min,IntroductiontothePiCCO-TechnologyThermodilution,36,5,37,36,5,37,Time,lowCO:1.9l/min,HighCO:19l/min,Time,Time,Temperature,Temperature,Temperature,Transpulmonaryvs.PulmonaryArteryThermodilution,Leftheart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATHarterialthermo-dilutioncatheter,centralvenousbolusinjection,RA,RV,PA,LA,LV,Aorta,TranspulmonaryTD(PiCCO),PulmonaryArteryTD(PAC),Inbothproceduresonlypartoftheinjectedindicatorpassesthethermistor.在这两种方式中只有一部分注射液会通过热敏感受器。NonethelessthedeterminationofCOiscorrect,asitisnottheamountofthedetectedindicatorbutthedifferenceintemperatureovertimethatisrelevant!但是CO正确与否的决定性因素，并不是指示剂的量，而是随着时间变化导致的温度变化，这两者相关的。,IntroductiontothePiCCOTechnologyThermodilution,ComparisonwiththeFickMethod,0,97,0,680,62,37/449,SakkaSGetal.,IntensiveCareMed25,1999,-/-,0,190,21,9/27,McLuckieA.eta.,ActaPaediatr85,1996,0,96,0,160,31,30/150,GdjeOetal.,Chest113(4),1998,0.98,0,320,29,23/218,HolmCetal.,Burns27,2001,0,93,0,130,52,60/180,DellaRoccaGetal.,EurJAnaest14,2002,0,95,-0,040,41,17/102,FriedmanZetal.,EurJAnaest,2002,0,95,0,490,45,45/283,BindelsAJGHetal.,CritCare4,2000,0,98,0,030,17,18/54,PauliC.etal.,IntensiveCareMed28,2002,24/120,n(Pts/Measurements),0,99,0,030,24,TibbyS.etal.,IntensiveCareMed23,1997,r,biasSD(l/min),ComparisonwithPulmonaryArteryThermodilution,ValidationoftheTranspulmonaryThermodilution,IntroductiontothePiCCOTechnologyThermodilution,MTt:MeanTransittimethemeantimerequiredfortheindicatortoreachthedetectionpoint,DSt:DownSlopetimetheexponentialdownslopetimeofthethermodilutioncurve,Recirculation,t,e-1,Tb,Fromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters从热稀释曲线的特点来看，它是可以决定某些时间参数的。,Extendedanalysisofthethermodilutioncurve,IntroductiontothePiCCO-TechnologyThermodilution,Injection,InTb,MTt,DSt,Tb=bloodtemperature;lnTb=logarithmicbloodtemperature;t=time,PulmonaryThermalVolumePTV=DstxCO,ByusingthetimeparametersfromthethermodilutioncurveandtheCOITTVandPTVcanbecalculated通过热稀释曲线的时间参数，可以计算出ITTV和PTV.,CalculationofITTVandPTV,IntroductiontothePiCCO-TechnologyThermodilution,Recirculation,t,e-1,Tb,Injection,InTb,IntrathoracicThermalVolumeITTV=MTtxCO,MTt,DSt,PulmonaryThermalVolume(PTV),IntrathoracicThermalVolume(ITTV),CalculationofITTVandPTV,EinfhrungindiePiCCO-TechnologieThermodilution,ITTV=MTtxCO,PTV=DstxCO,GEDVisthedifferencebetweenintrathoracicandpulmonarythermalvolumes.GEDV就是胸腔内热容积和肺内热容积的差值。,GlobalEnd-diastolicVolume(GEDV),VolumetricpreloadparametersGEDV,ITTV,GEDV,PTV,IntroductiontothePiCCOTechnologyThermodilution,VolumetricpreloadparametersITBV,IntrathoracicBloodVolume(ITBV),GEDV,ITBV,PBV,IntroductiontothePiCCOTechnologyThermodilution,ITBVisthetotaloftheGlobalEnd-DiastolicVolumeandthebloodvolumeinthepulmonaryvessels(PBV),ITBVTD(ml),ITBV=1.25*GEDV28.4ml,GEDVvs.ITBVin57IntensiveCarePatients,IntrathoracicBloodVolume(ITBV),VolumetricpreloadparametersITBV,IntroductiontothePiCCO-TechnologyThermodilution,ITBViscalculatedfromtheGEDVbythePiCCOTechnology,GEDV(ml),Sakkaetal,IntensiveCareMed26:180-187,2000,SummaryandKeyPoints-Thermodilution,PiCCOTechnologyisalessinvasivemethodformonitoringthevolumestatusandcardiovascularfunction.PiCCO技术是一种监测容量状态和心肌功能的微创技术。Transpulmonarythermodilutionallowscalculationofvariousvolumetricparameters.经肺热稀释法可以计算各种容量参数。TheCOiscalculatedfromtheshapeofthethermodilutioncurve.CO是通过热稀释曲线的面积计算而得的。Thevolumetricparametersofcardiacpreloadcanbecalculatedthroughadvancedanalysisofthethermodilutioncurve.心脏前负荷的容量参数是通过进一步分析热稀释曲线获得的。Forthethermodilutionmeasurementonlyafractionofthetotalinjectedindicatorneedstopassthedetectionsite,asitisonlythechangeintemperatureovertimethatisrelevant.对于热稀释测量来讲，只需要一部分的指示剂通过监测点，同样只需要在相关的时间里面温度有所改变即可。,IntroductiontothePiCCO-Technology,HaemodynamicMonitoring,E.IntroductiontoPiCCOTechnology,PrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability,TranspulmonaryThermodilution,Thepulsecontouranalysisiscalibratedthroughthetranspulmonarythermodilutionandisabeattobeatrealtimeanalysisofthearterialpressurecurve.脉搏轮廓分析法是通过经肺热稀释法计算，同时也是实时分析动脉压力曲线得出的。,CalibrationofthePulseContourAnalysis,IntroductiontothePiCCO-TechnologyPulsecontouranalysis,Injection,PulseContourAnalysis,T=bloodtemperaturet=timeP=bloodpressure,COTPD,=SVTD,HR,PCCO=calHR,P(t),SVR,+C(p),dP,dt,(,),dt,CardiacOutput,Heartrate,Systole,IntroductiontothePiCCO-TechnologyPulsecontouranalysis,ParametersofPulseContourAnalysis,n(Pts/Measurements),0,94,0,030,63,12/36,BuhreWetal.,JCardiothoracVascAnesth13(4),1999,19/76,24/517,62/186,20/360,25/380,22/96,-/-,-0,401,3,Mielcketal.,JCardiothoracVascAnesth17(2),2003,0,88,0,311,25,ZllnerCetal.,JCardiothoracVascAnesth14(2),2000,0,88,-0,21,15,GdjeOetal.,CritCareMed30(1),2002,0,94,-0,020,74,DellaRoccaGetal.,BrJAnaesth88(3),2002,0,93,-0,140,33,FelbingerTWetal.,JClinAnesth46,2002,-/-,0,140,58,RauchHetal.,ActaAnaesthScand46,2002,r,biasSD(l/min),Comparisonwithpulmonaryarterythermodilution,ValidationofPulseContourAnalysis,IntroductiontothePiCCO-TechnologyPulsecontouranalysis,SVmaxSVmin,SVV=,SVmean,TheStrokeVolumeVariationisthevariationinstrokevolumeovertheventilatorycycle,measuredovertheprevious30secondperiod.每博量变异是每博量在一个呼吸周期中的变异，它所测量的是之前30秒的值。,ParametersofPulseContourAnalysis,IntroductiontothePiCCO-TechnologyPulseContourAnalysis,DynamicparametersofvolumeresponsivenessStrokeVolumeVariation,PPmaxPPmin,PPV=,PPmean,Thepulsepressurevariationisthevariationinpulsepressureovertheventilatorycycle,measuredovertheprevious30secondperiod.脉压变异是在一个呼吸周期里面脉搏压力的变异，它测得的是之前30秒的值。,ParametersofPulseContourAnalysis,IntroductiontothePiCCO-TechnologyPulseContourAnalysis,DynamicparametersofvolumeresponsivenessPulsePressureVariation,PPmax,PPmean,PPmin,Summarypulsecontouranalysis-COandvolumeresponsiveness,ThePiCCOtechnologypulsecontouranalysisiscalibratedbytranspulmonarythermodilutionPiCCO技术脉搏轮廓分析基于热稀释法来计算的PiCCOtechnologyanalysesthearterialpressurecurvebeatbybeattherebyprovidingrealtimeparameters.PiCCO技术分析实时动脉压力曲线，因此它提供了实时的监测数据。Besidescardiacoutput,thedynamicparametersofvolumeresponsivenessSVV(strokevolumevariation)andPPV(pulsepressurevariation)aredeterminedcontinuously.除了心输出量，SVV和PPV都是连续性的参数。,IntroductiontothePiCCO-TechnologyPulsecontouranalysis,HaemodynamicMonitoring,E.IntroductiontoPiCCOTechnology,PrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability,Contractilityisameasurefortheperformanceoftheheartmuscle收缩力指数是评估心肌功能的参数,ContractilityparametersofPiCCOtechnology:PiCCO技术监测心肌收缩力的参数:dPmx(maximumrateoftheincreaseinpressure)GEF(GlobalEjectionFraction)CFI(CardiacFunctionIndex),Contractility,IntroductiontothePiCCO-TechnologyContractilityparameters,kg,Contractilityparameterfromthepulsecontouranalysis,IntroductiontothePiCCO-TechnologyContractilityparameters,dPmx=maximumvelocityofpressureincrease,ThecontractilityparameterdPmxrepresentsthemaximumvelocityofleftventricularpressureincrease.收缩力参数dPmx指的是左心室压力曲线上的最大值。,Contractilityparameterfromthepulsecontouranalysis,IntroductiontothePiCCO-TechnologyContractilityparameters,femoraldP/maxmmHg/s,LVdP/dtmaxmmHg/s,dPmxwasshowntocorrelatewellwithdirectmeasurementofvelocityofleftventricularpressureincreasein70cardiacsurgerypatientsdPmx的值与左心室压力的测量值在70个心脏手术的病例中，呈现很好的正相关。,deHertetal.,JCardioThor&VascAnes2006,n=220y=-120+(0,8*x)r=0,82p0,001,0,500,1000,1500,0,1000,1500,2000,2000,500,dPmx=maximumvelocityofpressureincrease,iscalculatedas4timesthestrokevolumedividedbytheglobalend-diastolicvolumeGEF是4倍的SV除以全心舒张末期容量reflectsbothleftandrightventricularcontractility它反应的是全心功能参数,GEF=GlobalEjectionFraction,Contractilityparametersfromthethermodilutionmeasurement,IntroductiontothePiCCO-TechnologyContractilityparameters,4xSV,GEF=,GEDV,LA,LV,RA,RV,Combesetal,IntensiveCareMed30,2004,GEF=GlobalEjectionFraction,ComparisonoftheGEFwiththegoldstandardTEEmeasuredcontractilityinpatientswithoutrightheartfailure.GEF和金标准TEE同时在右心功能正常的病例中的对比。,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1specifity,22,20,19,18,16,12,8,DFAC,%,DGEF,%,5,10,-5,-20,-10,10,20,15,-15,-10,r=076,p0,0001n=47,IntroductiontothePiCCO-TechnologyContractilityparameters,Contractilityparametersfromthethermodilutionmeasurement,istheCIdividedbyglobalend-diastolicvolumeindexCFI是CI除以全心舒张末期容量指数is-similartotheGEFaparameterofbothleftandrightventricularcontractility它与GEF相似，是反映全心功能的参数,CFI=CardiacFunctionIndex,CI,CFI=,GEDVI,IntroductiontothePiCCO-TechnologyContractilityparameters,Contractilityparametersfromthethermodilutionmeasurement,Combesetal,IntensiveCareMed30,2004,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1specificity,6,5,4,3,5,3,2,DFAC,%,DGEF,%,5,10,-5,-20,-10,10,20,15,-15,-10,r=079,p21n=54,14-21n=100,7-14n=174,3),ClassificationofLungOedemawiththePVPI,DifferencebetweenthePVPIwithhydrostaticandpermeabilitylungoedema:静水压型肺