cvp与血流动力学监测学习教案

1、会计学1cvp与血流动力学监测与血流动力学监测2021-12-52第1页/共61页2021-12-53第2页/共61页2021-12-54第3页/共61页2021-12-55中心静脉压的标准测定方法1经中心静脉插管测定中心静脉压2经PICC测定中心静脉压34经外周静脉测定中心静脉压第4页/共61页2021-12-56中心静脉压的标准测定方法1经中心静脉插管测定中心静脉压2经PICC测定中心静脉压34经外周静脉测定中心静脉压第5页/共61页2021-12-57第6页/共61页2021-12-58第7页/共61页2021-12-59平卧位: 腋中线与第四肋间交点第8页/共61页2021-12-51

2、0去除三通帽将三通拨至传感器与大气相通位置第9页/共61页2021-12-511去除无菌帽将三通与大气相通第10页/共61页2021-12-512第11页/共61页2021-12-513无菌三通帽第12页/共61页2021-12-514第13页/共61页2021-12-515第14页/共61页2021-12-516第15页/共61页2021-12-517中心静脉压的标准测定方法1经中心静脉插管测定中心静脉压2经PICC测定中心静脉压34经外周静脉测定中心静脉压第16页/共61页2021-12-518第17页/共61页2021-12-5191. Whalen, D.A., & Kelle

3、her, R.M. (1998). Cardiovascular patient assessment. In M.R. Kinney, S.B. Dunbar, J.A. Brooks-Brunn, N. Molter, & J.M. Vitello-Cicciu (Eds.), AACN clinical reference for critical care nursing (4th ed., pp. 277-318). St. Louis: Mosby. 2. Keckeisen, M. (1999). Monitoring pulmonary artery pressure.

4、 Critical Care Nurse, 19(6), 88-91. 3. Wilson, A.E., Bermingham-Mitchell, K., Wells, N., & Zachary, K. (1996). Effect of backrest position on hemodynamic and right ventricular measurements in critically ill adults. American Journal of Critical Care, 5, 264-270.第18页/共61页2021-12-520胸骨左缘与床面垂直距离的一半右

5、: 第四肋间与胸骨中线交点左: 第四肋间与左胸骨旁线交点第19页/共61页2021-12-521Scott SS, Giuliano KK, Pysznik E, Elliott S, Welsh K, Delbuono N. Influence of port site on central venous pressure measurements from triple-lumen catheters in critically ill adults. Am J Crit Care 1998; 7: 60-63第20页/共61页2021-12-522Scott SS, Giuliano K

6、K, Pysznik E, Elliott S, Welsh K, Delbuono N. Influence of port site on central venous pressure measurements from triple-lumen catheters in critically ill adults. Am J Crit Care 1998; 7: 60-63第21页/共61页2021-12-523第22页/共61页2021-12-524Ho AMH, Dion PW, Karmakar MK, Jenkins CR. Accuracy of central venous

7、 pressure monitoring during simultaneous continuous infusion through the same catheter. Anaesthesia 2005; 60: 1027-1030第23页/共61页2021-12-525Joynt GM, Gomersall CD, Buckley TA, Oh TE, Young RJ, Freebairn RC. Comparison of intrathoracic and intra-abdominal measurements of central venous pressure. Lance

8、t 1996; 347(9009): 1155-7.第24页/共61页2021-12-526Ho K, Joynt GM, Tan P. A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Critical Care Medicine 1998; 26(3): 461-464.第25页/共61页2021-12-527Ho K, Joynt GM, Tan P. A comparison of cen

9、tral venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Critical Care Medicine 1998; 26(3): 461-464.第26页/共61页2021-12-5281234中心静脉压的标准测定方法经中心静脉插管测定中心静脉压经外周静脉测定中心静脉压经PICC测定中心静脉压第27页/共61页2021-12-5291234中心静脉压的标准测定方法经PICC测定中心静脉压经中心静脉插管测定中心静脉压经外周静脉测定中心静脉压第2

10、8页/共61页2021-12-530第29页/共61页2021-12-531Charalambous C, Barker TA, Zipitis CS, Siddique I, Swindell R, Jackson R, Benson J. Comparison of peripheral and central venous pressures in critically Ill patients. Anaesth Intensive Care. 2003; 31(1): 34-9.第30页/共61页2021-12-532低体温外周血管收缩收缩血管中的循环血量占心输出量的10%无循环改变S

11、ahin A, Salman MA, Salman AE, Aypar U. Effect of Body Temperature on Peripheral Venous Pressure Measurements and Its Agreement with Central Venous Pressure in Neurosurgical Patients. J Neurosurg Anesthesiol 2005; 17: 91-96第31页/共61页2021-12-533第32页/共61页2021-12-534第33页/共61页2021-12-535第34页/共61页2021-12-5

12、36第35页/共61页2021-12-537第36页/共61页2021-12-538能反应容量能反应容量, 但昂贵、麻烦，不能普但昂贵、麻烦，不能普及及第37页/共61页2021-12-539第38页/共61页2021-12-540近年新开发CO：热稀释，连续容量性前负荷：GEDV副产品ITBV（胸腔内血量）GEF（全心射血分数）EVLW（血管外肺水）SVV/PVV不间断容量反应PVPI（肺血管通透性指数）第39页/共61页2021-12-541PiCCO plus 的连接的连接中心静脉导管中心静脉导管注射水温度测量管注射水温度测量管 PV4046 动脉热稀释导管（动脉热稀释导管（PiCCO导

13、管导管） 注射水温度测量电缆注射水温度测量电缆PC80109 PULSION 动脉压力传感器动脉压力传感器 PV8115PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP) 5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI) 625 DPT Monitor cablePMK-206Interface cablePC80150 连接床旁监护仪连接床旁监护仪PMK - XXX AUX adaptercable PC81200 第40页/共61页2021-12-542第41页/共61页2021-12-543Volume

14、Drugs第42页/共61页2021-12-544第43页/共61页2021-12-545第44页/共61页2021-12-546第45页/共61页2021-12-547经肺热稀释法与传统右心热稀释法经肺热稀释法与传统右心热稀释法经肺热稀释导管测量经肺热稀释导管测量点点静脉注射指示剂静脉注射指示剂RAEDVPBVETVLAEDVLVEDVETVRVEDV010203040500,00,20,40,6CD D TInjections传统热稀释导管测量传统热稀释导管测量点点SWAN-GANS第46页/共61页2021-12-548第47页/共61页2021-12-549第48页/共61页2021-

15、12-550第49页/共61页2021-12-551RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV PTVGEDV ITTVGEDV = ITTV- PTV第50页/共61页2021-12-552RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV ITBVITBV = 1.25 * GEDVEVLW = ITTV - ITBV第51页/共61页2021-12-553ITTV = CO * MTtTDaPTV = CO * DStTDaITBV = 1.25 * GEDVEVLW = ITTV -ITBVGEDV = ITTV - PTVRAEDVRVEDVLAEDV

16、LVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW第52页/共61页2021-12-554第53页/共61页2021-12-555压力曲线压力曲线下面积下面积压力曲线压力曲线型状型状PCCO = cal HR SystoleP(t)SVR+ C(p) dPdt() dt主动脉主动脉顺应性顺应性心率心率校正系数校正系数 (通过通过热稀释法校正热稀释法校正) t sP mm Hg基本原理（基本原理（3）结合热稀释将脉搏波图形面积变成持续COPCCO is displayed as last 12s mean第54页/共61页

17、2021-12-556第55页/共61页2021-12-557Relevance of EVLW - managementAfter: Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992 22 days15 days9 days7 daysRHC groupRHC groupEVLW groupEVLW group*Ventilation daysICU daysn=101第56页/共61页2021-12-558 SVmax 和和 SVmin 是过去是过去 30 秒中的最大和最小值秒中的最大和最小值每搏量变异每搏量变异 (SVV) 只在受控机械

18、通气病人有意义只在受控机械通气病人有意义 第57页/共61页2021-12-559The increase of preload volume is equal: EDV1 = EDV2 SV1 SV2SVV 提示心脏对容量治疗的反应好坏提示心脏对容量治疗的反应好坏EDVSVSVV smallSVV large EDV1 EDV2 SV1 SV2第58页/共61页2021-12-560PiCCO监测指标正常值范围正常值范围ParameterRangeUnitCI3.0 5.0l/min/m2SVI40 60ml/m2 SVRI1200 1800 dyn*s*cm-5*MAP70 90mmHgGEF25 35%CFI4.5 6.51/minHR60 901/minGEDVI680 800ml/m2ITBVI850 1000ml/m2SVV 10%EVLWI 3.0 7.0ml/kgPVPI1.0 3.0第59页/共61页2021-12-561CI (l/min/m2)ITBVI (ml/m2)TherapyTargetITBVICFIEVLWI (slowly