血流动力学监测 最新picco的临床应用.ppt

血流动力学监测,theoryandpractice,血流动力学,swan和ganz发明通过血流引导的气囊漂浮导管（漂浮导管或swan-ganz导管或肺动脉导管）继中心静脉压（cvp）之后临床监测的一大新进展,dr.williamganz(1919-2009.11.10),swan-ganz导管,通过热稀释法获得心排假设pcwp(肺毛细血管嵌压)lap（左房压）lvedp(左室舒张末压)lvedv(左室舒张末容量)相当于前负荷来通过压力指标来反映容量状态,经食管超声技术（tee）,原理物体（红细胞）移动的速度和已知频率超声波的反射频率成正比hemosonictm100的超声多普勒探头通过测定红细胞移动的速度来推算降主动脉的血流量,tee,优势：准确性高降主动脉的血流量是co的70%劣势：误差多，对操作者经验要求高，需严格培训，费用高,7,监测生命体征,monitoring,respirationrate,temperature,8,一些重要的指标,monitoring,bloodpressure(nibp),nocorrelationwithconocorrelationwithoxygendelivery,ecg,respirationrate,temperature,piccotechnology,液体管理所需要的指标,introductiontothepicco-technology,co,前负荷,evlw,收缩力指数,个性化的容量管理,static-dynamic,picco技术监测,功能原理热稀释技术脉搏轮廓分析技术收缩力指数前、后负荷参数血管外肺水肺部通透性指数,血流动力学监测,picco技术依据经肺热稀释技术以及脉搏轮廓分析技术,原理,leftheart,rightheart,pulmonarycirculation,lungs,bodycirculation,pulsiocath,pulsiocath,cvc,pulsiocatharterialthermodilutioncatheter,centralvenousbolusinjection,introductiontothepicco-technologyfunction,bolusinjection,concentrationchangesovertime(thermodilutioncurve),中心静脉处注入冰盐水，依次经过胸腔内各腔室,股动脉导管内有热敏电阻，会记录温度的变化,introductiontothepicco-technologyfunction,leftheart,rightheart,lungs,原理,胸腔内各腔室,introductiontothepicco-technologyfunction,肺内热容积(ptv),胸腔内热容积(ittv),totalofmixingchambers,最大混合腔室,血流动力学监测,introductiontopiccotechnology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,tbxdt,(tb-ti)xvixk,tb,injection,t,d,=,cotda,tb=bloodtemperatureti=injectatetemperaturevi=injectatevolumetb.dt=areaunderthethermodilutioncurvek=correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate,co的计算是通过对热稀释曲线分析，使用stewart-hamilton方程式,心排的计算,introductiontothepicco-technologythermodilution,热稀释曲线下面积反比例反映co,36,5,37,5,10,热稀释曲线,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,经肺热稀释vs.肺动脉导管,leftheart,rightheart,pulmonarycirculation,lungs,bodycirculation,pulsiocatharterialthermo-dilutioncatheter,centralvenousbolusinjection,ra,rv,pa,la,lv,aorta,transpulmonarytd(picco),pulmonaryarterytd(pac),inbothproceduresonlypartoftheinjectedindicatorpassesthethermistor.nonethelessthedeterminationofcoiscorrect,asitisnottheamountofthedetectedindicatorbutthedifferenceintemperatureovertimethatisrelevant!,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,经肺热稀释技术的有效性,introductiontothepiccotechnologythermodilution,mtt:meantransittimethemeantimerequiredfortheindicatortoreachthedetectionpoint,dst:downslopetimetheexponentialdownslopetimeofthethermodilutioncurve,recirculation,t,e-1,tb,fromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters,对热稀释曲线做进一步分析,introductiontothepicco-technologythermodilution,injection,intb,mtt,dst,tb=bloodtemperature;lntb=logarithmicbloodtemperature;t=time,pulmonarythermalvolumeptv=dstxco,byusingthetimeparametersfromthethermodilutioncurveandthecoittvandptvcanbecalculated,计算ittv与ptv,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,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),introductiontothepicco-technologythermodilution,itbviscalculatedfromthegedvbythepiccotechnology,gedv(ml),sakkaetal,intensivecaremed26:180-187,2000,summaryandkeypoints-thermodilution,picco技术是一种微创的方法，用以监测容量状态和心血管功能根据经肺热稀释技术可以计算出各种容积参数.co由热稀释曲线形状描记.心脏前负荷相关的容积参数可以通过对热稀释曲线进一步分析获得。,introductiontothepicco-technology,haemodynamicmonitoring,introductiontopiccotechnology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,transpulmonarythermodilution,thepulsecontouranalysisiscalibratedthroughthetranspulmonarythermodilutionandisabeattobeatrealtimeanalysisofthearterialpressurecurve,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.,parametersofpulsecontouranalysis,introductiontothepicco-technologypulsecontouranalysis,dynamicparametersofvolumeresponsivenessstrokevolumevariation,theincreaseofpreloadvolumeisequal:edv1=edv2sv1sv2,svv提示心脏对容量治疗的反应好坏,edv,sv,svvsmall,svvlarge,edv1,edv2,sv1,sv2,ppmaxppmin,ppv=,ppmean,thepulsepressurevariationisthevariationinpulsepressureovertheventilatorycycle,measuredovertheprevious30secondperiod.,parametersofpulsecontouranalysis,introductiontothepicco-technologypulsecontouranalysis,dynamicparametersofvolumeresponsivenesspulsepressurevariation,ppmax,ppmean,ppmin,summarypulsecontouranalysis-coandvolumeresponsiveness,picco脉搏轮廓分析技术是由经肺热稀释技术计算进一步获得picco技术分析动脉压力曲线每次的搏动，可以提供实时的参数co之外，反映容积相关的血流动力学参数svv(strokevolumevariation)和ppv(pulsepressurevariation)可以持续获得,introductiontothepicco-technologypulsecontouranalysis,haemodynamicmonitoring,introductiontopiccotechnology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,contractilityisameasurefortheperformanceoftheheartmuscle,contractilityparametersofpiccotechnology:dpmx(maximumrateoftheincreaseinpressure)gef(globalejectionfraction)cfi(cardiacfunctionindex),contractility,introductiontothepicco-technologycontractilityparameters,kg,contractilityparameterfromthepulsecontouranalysis,introductiontothepicco-technologycontractilityparameters,dpmx=maximumvelocityofpressureincrease,thecontractilityparameterdpmxrepresentsthemaximumvelocityofleftventricularpressureincrease.,contractilityparameterfromthepulsecontouranalysis,introductiontothepicco-technologycontractilityparameters,femoraldp/maxmmhg/s,lvdp/dtmaxmmhg/s,dpmxwasshowntocorrelatewellwithdirectmeasurementofvelocityofleftventricularpressureincreasein70cardiacsurgerypatients,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-diastolicvolumereflectsbothleftandrightventricularcontractility,gef=globalejectionfraction,contractilityparametersfromthethermodilutionmeasurement,introductiontothepicco-technologycontractilityparameters,4xsv,gef=,gedv,la,lv,ra,rv,combesetal,intensivecaremed30,2004,gef=globalejectionfraction,comparisonofthegefwiththegoldstandardteemeasuredcontractilityinpatientswithoutrightheartfailure,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-diastolicvolumeindexis-similartothegefaparameterofbothleftandrightventricularcontractility,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:,lungoedema,hydrostatic,pbv,evlw,pbv,evlw,pbv,evlw,pbv,evlw,introductiontopiccotechnologypulmonarypermeability,16patientswithcongestiveheartfailureandacquiredpneumonia.inbothgroupsevlwwas16ml/kg.,validationofthepvpi,pvpicandifferentiatebetweenapneumoniacausedandacardiacfailurecausedlungoedema.,benedikzetalesicm2003,abstract60,cardiacinsufficiency,pvpi,pneumonia,4,3,2,introductiontopiccotechnologypulmonarypermeability,evlwianswersthequestion:,clinicalrelevanceofthepulmonaryvascularpermeabilityindex,pvpianswersthequestion:,andcanthereforegivevaluableaidfortherapyguidance!,肺水有多少?,它是怎么来的?,introductiontopiccotechnologypulmonarypermeability,summaryandkeypoints,evlw用于评估肺间质的含水量，是唯一用于评估床旁肺水肿程度的参数.血气分析和胸片用于评估肺水肿，不能提供有价值的信息evlw可用于评估icu病人死亡率肺血管通透性指数pvpi用于鉴别静水压型肺水肿或是通透性肺水肿,introductiontopiccotechnologyevlwandpulmonarypermeability,piccoplus的连接,中心静脉导管,注射水温度测量管pv4046,动脉热稀释导管（picco导管）,注射水温度测量电缆pc80109,pulsion动脉压力传感器pv8115,pcci,ap,13.0316.28tb37.0,ap14011792(cvp)5svri2762pcci3.24hr78svi42svv5%dpmx1140(gedi)625,dptmonitorcablepmk-206,interfacecablepc80150,连接床旁监护仪pmk-xxx,auxadaptercablepc81200,ci(l/min/m2),itbvi(ml/m2),therapytargetitbvicfievlwi(slowlyresponding),4.5,10v+!cattemporary750-8505.53.0,10catv-temporary750-8505.510,10v+850-100010v+temporary750-850850,850,10v-temporary750-85010,850,evlwi(ml/kg),v+=volumeloading(!=cautiously),v-=volumecontraction,cat=catecholamines/cardiovascularagents,picco诊断治疗树,正常值,parameterrangeunitci3.05.0l/min/m2svi4060ml/m2gedi680800ml/m2itbi8501000ml/m2elwi*3.07.0ml/kgpvpi*1.03.0svv10%ppv10%gef2535%cfi4.56.51/minmap7090mmhgsvri17002400dyn*s*cm-5*m,*notavailableintheusa(p63),fieldsofapplication,septicshockcardiogenicshockhypovolaemicshocktraumaburnsardscardiacsurgeryneurosurgerymajorsurgery,现在有效循环情况如何?.心输出量!前负荷怎样补液or利尿?.全心舒张末期容积!后负荷如何血管活性药物?.系统血管阻力!还是给与正性肌力药物?.左室收缩力指数!是否有肺水肿以及程度?.血管外肺水!.?.,picco临床应用,cogedvdpmxsvrevlw.,*notavailableintheusa(p63),在重症病人中如何改善血流动力学状况?,怎样使用picco参数更深刻理解急性循环衰竭时的病理生理机制选择更合适或更符合逻辑的治疗方案,血管活性药物血管扩张,液体前负荷不足,正性肌力药物心功能衰竭,picco技术有什么优点？,导管不经过心脏，创伤更小对每一次心脏搏动进行分析和测量（beattobeat）测量全心指标，反映全心功能，不是以右心代表整个心脏直接给出容量参数，无需对其它指标（如压力）进行翻译不受机械通气等外部压力变化的影响,测量前负荷、后负荷和流量等多种指标在床旁就可以完成定量测量肺水肿情况，避免x线造成的困惑技术容易掌握，并发症少适用于儿科和新生儿的病人（2公斤以上）节省医疗资源，动脉picco导管可以放置10天,berkenstadthetal.,anesthanalg,2001bindelsaetal.,critcare4,2000boussatsetal.,intcaremed2002brockhetal.,eurjanaesth19(4),2002dellaroccagetal.,eurjanaesth19,2002dellaroccagetal.,anesthanalg95,2002eisenbergpretal.,amrevrespirdis136(3),1987gdjeoetal.,chest118,2000gdjeoetal.,eurjofcardio-thoracicsurgery13,1998haperlinetal.,chest,1985hoefta,yearbookofintensivecareandemergencymedicine,1995katzenelsonetal.,sccm2001,sandiegolichtwarck-aschoffmetal.,journalofcriticalcare11(4),1996lichtwarck-aschoffmetal.,intensivecaremed18,1992michardfetal.,yearbookofintensivecare