PiCCO在ICU中的应用ppt课件

1,PiCCO容量监护仪在ICU中的应用,2,PiCCOTechnology,容量管理,IntroductiontothePiCCO-Technology,CO,Volumetricpreload,EVLW,Contractility,DifferentiatedVolumeManagement,static-dynamic,3,正确的监测才能进行正确的治疗,4,什么是PiCCO？,5,PiCCO是一种技术，是一种简便、微创、高效费比的，对重症病人主要血流动力学参数进行监测的工具。,6,Centralvenouscatheterjugularsubclavianfemoral,大多数血流动力学不稳定的患者都会置中心静脉导管(vasoactiveagentsadministration)动脉导管(monitoringofbloodpressure,bloodsamples),Thermodilutionarterialcatheterfemoralaxillarylongradial,连接,7,Centralvenouscatheterjugularsubclavianfemoral,8,PiCCO技术可以监测心输出量,9,PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysis,PrinciplesofMeasurement,LeftHeart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATHarterialthermodilutioncatheter,centralvenousbolusinjection,IntroductiontothePiCCO-TechnologyFunction,10,Transpulmonarythermodilutionmethod,ArterialTDcatheter动脉热稀释导管(e.g.PV2014L16),CVbolusinjection中心静脉一次注射,RAEDV右房舒张末容量,PBV肺血容量,EVLW,LAEDV左房舒张末容量,LVEDV左室舒张末容量,EVLW血管外肺水,RVEDV右室舒张末容量,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=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate,心输出量是利用Stewart-Hamilton公式对热稀释曲线进行分析所得,热稀释方法所得心输出量的计算,12,TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.,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,13,经肺vs.肺动脉热稀释,Leftheart,RightHeart,PulmonaryCirculation,Lungs,BodyCirculation,PULSIOCATHarterialthermo-dilutioncatheter,centralvenousbolusinjection,RA,RV,PA,LA,LV,Aorta,TranspulmonaryTD(PiCCO),PulmonaryArteryTD(PAC),这两种方法所得CO都是准确的，因为热稀释方法关注的只是时间以及温度改变！,14,TranspulmonarythermodilutionCOmeasurement(vsPAthermodilution),AuthorBias(L/min)SDrGodjeChest19980.160.350.96SakkaICM19990.680.620.97GoedjeCCM19990.290.600.93BindelsCC20000.490.780.95GoedjeChest20000.350.720.98DellaRoccaBJA20020.150.870.93SanderCC20050.000.700.95OstergaardAAS20060.460.55,15,Pulsecontouranalysis脉搏轮廓分析,Cal=calibrationfactorobtainedfromtranspulmonarythermodilution(coldbolusinjection)校准系数来自经肺热稀释方法,Surface=Cal.xStrokevolume,16,P(mmHg),t(s),17,Validationofcontinuouscardiacoutputmeasurementbythepulsecontouranalysis(PiCCOsystem)PiCCO所得连续心排量数值准确性论证,RoedigGetal.BrJAnaesth1999;82:525-530GoedjeOetal.AnnThoracSurg1999;68:1532-1536BuhreWetal.JCardiothoracVascAnesth1999;13:437-440GoedjeOetal.CritCareMed1999;27:2407-2412ZollnerCetal.JCardiothoracVascAnesth2000;14:125-129GoedjeOetal.MedSciMonit2001;7:1344-1350FelbingerTWetal.JClinAnaesth2002;14:296-301GoedjeOetal.CritCareMed2002;30:52-58RauchHetal.ActaAnaesthesiolScand2002;46:426-429Felbingeretal.JClinAnaesth2005;17:241-248Ostergaardetal.ActaAnaesthesiolScand2006;50:1044-1049,18,PiCCO不仅是心排量监测仪,19,PiCCOtechnology,GEDV评估心脏前负荷容量,20,目前医学界判斷心脏前負荷的标准,Centrolvenouspressure(CVP)Pulmonarycapillarywedgepressure(PCWP)但是這是基於以下的假設“压力=容量但這種假設並非完全正確,PULSIONMedicalSystems,21,Kumaretal.,CritCareMed2004;32:691-699,21,灌注压CVP/PCWP反映前负荷,中心静脉压和每搏输出量的关联,监测前负荷,22,Kumaretal.,CritCareMed2004;32:691-699,22,肺动脉嵌压和每搏输出量的关联,MeasuringPreload,监测前负荷,灌注压CVP/PCWP反映前负荷,23,RaperRandSibbaldWJ.Chest1986Misledbythewedge?TheSwan-Ganzcatheterandleftventricularpreload.,24,GEDV可以作为心脏前负荷的指标,GlobalEnd-DiastolicVolumeevaluatedbytranspulmonarythermodilution,GEDV,25,COxMTt=volumeofdistribution=1+2+3+4+5,3,Indicatorinjection,Indicatordilutioncurve,26,COxMTt=volumeofdistribution=1+2+3+4+5,3,COxDst=largestmixingchamber=3,Indicatorinjection,Indicatordilutioncurve,27,COxMTt=volumeofdistribution=GEDV+PBV+EVLW,EVLW,Meieretal.JApplPhysiol1954,28,Changesinstrokevolumeindex(%),Changesinglobalend-diastolicvolumeindex(%),r=0.72p0.001,Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM2002,29,治疗指南SurvivingSepsisCampaignGuidelines2008:灌注压在评估扩容治疗中已经被证实有局限性.使用血流量或者容量参数指导容量管理或许更有优势这些技术已经能够在ICU内实现,PiCCO技术,30,IntrathoracicpressureVenousreturntoleftandrightventricleLeftventricularpreloadLeftventricularstrokevolumeSystolicarterialbloodpressure,IntrathoracicpressureSqueezing“ofthepulmonarybloodLeftventricularpreloadLeftventricularstokevolumeSystolicarterialbloodpressure,PPmax,PPmin,PPmax,PPmin,吸气,Reuteretal.,Ansthesist2003;52:1005-1013,容量反映值的生理学意义,呼气,吸气,呼气,吸气早期,吸气晚期,呼吸周期中血压的波动,监测前负荷,31,SVmax,SVmin,SVmean,每搏量变异SVV,每搏量变异（StrokeVolumeVariation，SVV）反映了每搏量随通气周期变化的情况。,SVV是.过去30秒的测量结果只适用于心律规律的完全机械通气病人,32,SVV反映了心脏对因机械通气导致的前负荷周期性变化的敏感性。1,15,18,19,20SVV可用于预测扩容治疗对每搏量的提高程度。1,15,18,19,20,对于没有心律失常的完全机械通气病人而言，,每搏量变异-SVV,33,00.51,1-specificity,sensitivity,SVV,CVP,0,0.6,0.4,1,0.8,0.2,StrokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbrainsurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9,sensitivity=79%specificity=93%,34,心肌收缩状况,FORCE-FREQUENCYRELATION,DIGITALIS,OTHERINONOTROPICAGENTS,ANOXIAHYPERCAPNIAACIDOSIS,CIRCULATINGCATECHOLAMINES,SYMPATHETICNERVEIMPULSES,LOSSOFMYOCARDIUM,PHARMACOLOGICDEPRESSANTS,INTRINSICDEPRESSION,VENTRICULAREDV,VENTRICULARSTROKEVOLUME,FromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,1976,35,CFI心脏收缩功能指数,36,TEEFAC,PiCCOCFI,37,r=0.80,38,左心室收缩力指数dPmx=动脉压力曲线的上升枝,PiCCO心肌收缩力参数,39,PiCCO心肌收缩力参数,dPmx反映了左心室最大压力增加的速度，是心肌收缩力的参数,40,全心射血分数（GEF）（经肺热稀释导管）,GEF=,GEDV,4xSV,右心室射血分数（RVEF）（肺动脉热稀释导管）,左心室射血分数（LVEF）（心脏超声）,1,2,&,3,全心射血分数GEF,右心,左心,肺,PBV,EVLW,EVLW,RAEDV,RVEDV,LVEDV,每搏量（SV）,LAEDV,射血分数：与每搏量和舒张末期容积相关,41,EVLW肺水肿指数,42,Extravascularwatercontentofthelung,Pulmonarycirculation,LeftHeart,RightHeart,Lungs,血管外肺水EVLW在管理前负荷中的作用,EVLW=ExtravascularLungWater,Bodycirculation,监测前负荷,分辨以及量化肺水肿仅有的一个在床边获得肺水量化值的方法对容量过度补充有预警功能,43,44,45,COxMTtcold=coldindicatorvolumeofdistribution,EVLW,COxMTtICG=ICGvolumeofdistribution,RA,LA,RV,LV,PBV,46,47,EVLWmeasuredwiththePiCCOsystemcomparedwithgravimetricsindogswithcardiogenicandnon-cardiogenicpulmonaryedema,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%Laggneretal,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(3):481X-rayscorevs.EVLW*X-rayinsensitive,EVLW和胸部X光片的对比,胸部X光片常受到胸腔内渗出的影响，并受到床旁拍摄X光片技术方面的限制,49,监测ELWI能够发现肺水10-15%的增加X-ray只有在肺水100-300%增长时才能甄别,50,373位重症ICU病人中EVLWI与死亡率的关系：其中193人感染，49人ARDS，48人头部创伤，83人出血性休克。根据EVLW的数值病人分成四组。Sakkaetal,Chest2002,EVLW与死亡率2,ELWIml/kg,51,利用EVLW治疗病人,101位肺水肿病人随时分成肺动脉导管（PAC）组与血管外肺水组（EVLW），分别依据PCWP和EVLW的测量结果进行治疗。在EVLW组的病人在ICU的时间和机械通气时间都显著降低。Mitchelletal,AmRevRespDis145:990-998,1992,22天,15天,9天,7天,*,*,机械通气天数,住ICU天数,n=101,EVLW组,PAC组,EVLW组,PAC组,52,Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema针对危重病人，甄别病人是否有肺水肿,Incaseofdoubtfuldiagnosisbasedonconventionalcriteria尤其当传统的标准产生不确定诊断时,HowtouseEVLWmeasurements?如何应用EVLW指标？,53,Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema针对危重病人，甄别病人是否有肺水肿,Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema针对已经确诊肺水肿的病人，诊断肺水肿的类型（静水压型，高渗透型）,HowtouseEVLWmeasurements?如何应用EVLW指标？,54,PiCCO肺相关指标,肺血管通透性指数（PulmonaryVascularPermeabilityIndex，PVPI）=血管外肺水（EVLW）与肺血容积（PBV），反映了肺水肿的类型,PulmonarvBloodVolume,静水压肺水肿,通透性肺水肿,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针对危重病人，甄别病人是否有肺水肿,Inpatientswithpulmonaryedemafordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema针对已经确诊肺水肿的病人，诊断肺水肿的类型（静水压型，高渗透型）,InALI/ARDSpatientsforidentifyin