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 Technology Function 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 Technology Function Leftheart Rightheart Lungs PrinciplesofMeasurement IntrathoracicCompartments mixingchambers IntroductiontothePiCCO Technology Function 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 Injectatevolume Tb 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 Technology Thermodilution 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 Technology Thermodilution 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 IntroductiontothePiCCO Technology Thermodilution ComparisonwiththeFickMethod 0 97 0 68 0 62 37 449 SakkaSGetal IntensiveCareMed25 1999 0 19 0 21 9 27 McLuckieA eta ActaPaediatr85 1996 0 96 0 16 0 31 30 150 G djeOetal Chest113 4 1998 0 98 0 32 0 29 23 218 HolmCetal Burns27 2001 0 93 0 13 0 52 60 180 DellaRoccaGetal EurJAnaest14 2002 0 95 0 04 0 41 17 102 FriedmanZetal EurJAnaest 2002 0 95 0 49 0 45 45 283 BindelsAJGHetal CritCare4 2000 0 98 0 03 0 17 18 54 PauliC etal IntensiveCareMed28 2002 24 120 n Pts Measurements 0 99 0 03 0 24 TibbyS etal IntensiveCareMed23 1997 r bias SD l min ComparisonwithPulmonaryArteryThermodilution ValidationoftheTranspulmonaryThermodilution IntroductiontothePiCCO Technology Thermodilution 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 Technology Thermodilution 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 Technology Thermodilution Recirculation t e 1 Tb Injection InTb IntrathoracicThermalVolumeITTV MTtxCO MTt DSt PulmonaryThermalVolume PTV IntrathoracicThermalVolume ITTV CalculationofITTVandPTV Einf hrungindiePiCCO Technologie Thermodilution 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 Volumetricpreloadparameters GEDV ITTV GEDV PTV IntroductiontothePiCCO Technology Thermodilution Volumetricpreloadparameters ITBV IntrathoracicBloodVolume ITBV GEDV ITBV PBV IntroductiontothePiCCO Technology Thermodilution ITBVisthetotaloftheGlobalEnd DiastolicVolumeandthebloodvolumeinthepulmonaryvessels PBV ITBVTD ml ITBV 1 25 GEDV 28 4 ml GEDVvs ITBVin57IntensiveCarePatients IntrathoracicBloodVolume ITBV Volumetricpreloadparameters ITBV IntroductiontothePiCCO Technology Thermodilution 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 Technology Pulsecontouranalysis Injection PulseContourAnalysis T bloodtemperaturet timeP bloodpressure COTPD SVTD HR PCCO cal HR P t SVR C p dP dt dt CardiacOutput Heartrate Systole IntroductiontothePiCCO Technology Pulsecontouranalysis ParametersofPulseContourAnalysis n Pts Measurements 0 94 0 03 0 63 12 36 BuhreWetal JCardiothoracVascAnesth13 4 1999 19 76 24 517 62 186 20 360 25 380 22 96 0 40 1 3 Mielcketal JCardiothoracVascAnesth17 2 2003 0 88 0 31 1 25 Z llnerCetal JCardiothoracVascAnesth14 2 2000 0 88 0 2 1 15 G djeOetal CritCareMed30 1 2002 0 94 0 02 0 74 DellaRoccaGetal BrJAnaesth88 3 2002 0 93 0 14 0 33 FelbingerTWetal JClinAnesth46 2002 0 14 0 58 RauchHetal ActaAnaesthScand46 2002 r bias SD l min Comparisonwithpulmonaryarterythermodilution ValidationofPulseContourAnalysis IntroductiontothePiCCO Technology Pulsecontouranalysis SVmax SVmin 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 Technology PulseContourAnalysis Dynamicparametersofvolumeresponsiveness StrokeVolumeVariation PPmax PPmin 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 Technology PulseContourAnalysis Dynamicparametersofvolumeresponsiveness PulsePressureVariation 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 Technology Pulsecontouranalysis 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 Technology Contractilityparameters kg Contractilityparameterfromthepulsecontouranalysis IntroductiontothePiCCO Technology Contractilityparameters 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 Technology Contractilityparameters femoraldP max mmHg s LVdP dtmax mmHg 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 82p 0 001 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 Technology Contractilityparameters 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 p 0 0001n 47 IntroductiontothePiCCO Technology Contractilityparameters Contractilityparametersfromthethermodilutionmeasurement istheCIdividedbyglobalend diastolicvolumeindexCFI是CI除以全心舒张末期容量指数is similartotheGEF aparameterofbothleftandrightventricularcontractility它与GEF相似 是反映全心功能的参数 CFI CardiacFunctionIndex CI CFI GEDVI IntroductiontothePiCCO Technology Contractilityparameters 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 p 0 0001n 47 CFI CardiacFunctionIndex IntroductiontothePiCCO Technology Contractilityparameters CFIwascomparedtothegoldstandardTEEmeasuredcontractilityinpatientswithoutrightheartfailure CFI与金标准的TEE在右心功能正常病人中的对比 Contractilityparametersfromthethermodilutionmeasurement HaemodynamicMonitoring E IntroductiontoPiCCOtechnology FunctionsThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability iscalculatedasthedifferencebetweenMAPandCVPdividedbyCOasanafterloadparameteritrepresentsafurtherdeterminantofthecardiovascularsituation作为一个后负荷指数 它是心血管状况更深层的决定性因素 isanimportantparameterforcontrollingvolumeandcatecholaminetherapies这是一个非常重要的参数 它可以提示容量控制和儿茶酚胺的治疗 MAP CVP x80 SVR CO Afterloadparameter SVR SystemicVascularResistance MAP MeanArterialPressureCVP CentralVenousPressureCO CardiacOutput80 Factorforcorrectionofunits IntroductiontothePiCCO Technology Afterloadparameter TheparameterdPmxfromthepulsecontouranalysisasameasureoftheleftventricularmyocardialcontractilitygivesimportantinformationregardingcardiacfunctionandtherapyguidance 脉搏轮廓分析得出的参数dPmx能提示左心室心肌收缩力的重要信息 这关乎心肌的功能和治疗方向 ThecontractilityparametersGEFandCFIareimportantparametersforassessingtheglobalsystolicfunctionandsupportingtheearlydiagnosisofmyocardialinsufficiency 心功能指数GEF和CFI是非常重要的参数 可以用来评估整体收缩期的心肌功能以及对于心肌损伤的早期诊断 TheSystemicVascularResistanceSVRcalculatedfrombloodpressureandcardiacoutputisafurtherparameterofthecardiovascularsituation andgivesadditionalinformationforcontrollingvolumeandcatecholaminetherapies SVR是基于血压和心输出量来分析的 这是评估心血管功能重要的参数 能提示容量管理和儿茶酚胺类药物的治疗 SummaryandKeyPoints IntroductiontothePiCCO Technology ContractilityandAfterload HaemodynamicMonitoring E IntroductiontoPiCCOtechnology PrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability ITTV ITBV EVLW TheExtravascularLungWateristhedifferencebetweentheintrathoracicthermalvolumeandtheintrathoracicbloodvolume Itrepresentstheamountofwaterinthelungsoutsidethebloodvessels EVLW是胸腔内热容积和胸腔内血容积的差值 它反应肺血管外的水有多少 CalculationofExtravascularLungWater EVLW IntroductiontothePiCCO Technology ExtravascularLungWater Katzenelsonetal CritCareMed32 7 2004 Sakkaetal IntensiveCareMed26 180 187 2000 Gravimetry Dyedilution EVLWfromthePiCCOtechnologyhasbeenshowntohaveagoodcorrelationwiththemeasurementofextravascularlungwaterviathegravimetryanddyedilutionreferencemethods PiCCO技术测得的EVLW与通过重力实验与染料稀释法测得的血管外肺水有很好的相关性 ValidationofExtravascularLungWater n 209r 0 96 ELWIbygravimetry ELWIbyPiCCO R 0 97P 0 001 Y 1 03x 2 49 0 10 20 30 20 30 40 10 ELWITD ml kg 0 5 10 20 15 25 25 5 0 10 0 20 15 ELWIST ml kg IntroductiontothePiCCO Technology ExtravascularLungWater BoeckJ JSurgRes1990 254 265 Highextravascularlungwaterisnotreliablyidentifiedbybloodgasanalysis高血管外肺水与血气分析没有相关性 EVLWasaquantifieroflungedema PaO2 FiO2 10 20 550 30 150 250 0 450 ELWI ml kg 0 50 350 IntroductiontothePiCCO Technology ExtravascularLungWater ELWI 7ml kg ELWI 8ml kg ELWI 14ml kg ELWI 19ml kg Extravascularlungwaterindex ELWI normalrange 3 7ml kg Pulmonaryoedema Normalrange EVLWasaquantifieroflungoedema IntroductiontothePiCCO Technology ExtravascularLungWater 40 Halperinetal 1985 Chest88 649 Chestxray doesnotreliablyquantifypulmonaryoedemaandisdifficulttojudge particularlyincriticallyillpatients X线检查 并不能量化肺水肿 对于严重的病人尤其难以评估 r 0 1p 0 05 0 20 80 15 10 15 10 60 Dradiographicscore 80 60 40 20 DELWI EVLWasaquantifieroflungoedema IntroductiontothePiCCO Technology ExtravascularLungWater ELWI ml kg 21n 54 14 21n 100 7 14n 174 7n 45 Mortality SturmJin Lewis Pfeiffer eds PracticalApplicationsofFiberopticsinCriticalCareMonitoring SpringerVerlagBerlin Heidelberg NewYork1990 pp129 139 RelevanceofEVLWAssessment Theamountofextravascularlungwaterisapredictorformortalityintheintensivecarepatient 肺水的量在ICU病人中 可以提示死亡率 Sakkaetal Chest2002 IntroductiontothePiCCO Technology ExtravascularLungWater IntensiveCaredays Mitchelletal AmRevRespDis145 990 998 1992 RelevanceofEVLWAssessment VolumemanagementguidedbyEVLWcansignificantlyreducetimeonventilationandICUlengthofstayincriticallyillpatients whencomparedtoPCWPorientedtherapy 通过肺水指导液体管理可以缩短患者上呼吸机的时间和住ICU时间 VentilationDays PACGroup n 101 p 0 05 PACGroup EVLWGroup EVLWGroup 22days 15days 9days 7days p 0 05 IntroductiontothePiCCO Technology ExtravascularLungWater HaemodynamicMonitoring E IntroductiontoPiCCOTechnology PrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability D