血流动力学监测专家讲座

危重病患者血流动力学监测

focusonPiCCO北京协和医院杜 斌血流动力学监测第1页血流动力学监测增加患者病死率ConnorsAFJr,SperoffT,DawsonNV,ThomasC,HarrelFEJr,WagnerD,DesbjensN,GoldmanL,WuAW,CaliffRM,FulkersonWJJr,VidailletH,BrosteS,BellamyP,LynnJ,KnausWA.Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA1996;276(11):889-897血流动力学监测第2页血流动力学监测为何不能改进预后不恰当适应症PAC副作用或并发症取得数据方法不正确仪器定标错误,或传感器位置错误取得数据不能反应血流动力学状态错误使用数据(对数据解读错误)作出治疗决定前未考虑其它相关原因CXR,尿量,血清白蛋白采取治疗办法无效或有害无需血流动力学监测时未及时拔除PAC血流动力学监测第3页PAC使用降低:Illinois,USA降低%出院患者数1,636,0461,684,089PAC使用数5,9695,02215.8PAC使用率(/1000)3.652.98年纪0–17岁2195765–74岁1,7391,37521>75岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare;9(Suppl1):P69(DOI10.1186/cc3132)血流动力学监测第4页PAC使用降低:Illinois,USA降低%医院大医院87369620其它医院5,0924,32615地域Chicago39.4Rockford40St.Louis33.6中部15AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare;9(Suppl1):P69(DOI10.1186/cc3132)血流动力学监测第5页临床评价vs.血流动力学目标:评价肺动脉导管(PAC)得到血流动力学指标是否能够改变患者治疗设计:前瞻性观察患者:103例留置PAC患者方法:插管前,请医生对一些血流动力学指标范围,诊疗及治疗方案进行预测插管后,复习患者病例,统计插管时及置管8小时内血流动力学EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学监测第6页临床评价vs.血流动力学EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学监测第7页临床评价vs.血流动力学结 果留置PAC后计划治疗方案需要改变 58%应用未预计到治疗方案 30%EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学监测第8页临床评价vs.血流动力学结 论单纯依据临床表现难以准确预测血流动力学指标PAC监测数据通常能够改变治疗方案EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学监测第9页血流动力学数据解释临床场景(n=44)心脏外科术后 16ARDS 9全身性感染 9心源性休克 5其它情况 5SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed;29:735-741血流动力学监测第10页血流动力学数据解释不一样意见数目Kappa计算机辅助诊治前住院医生与计算机40.14*计算机辅助诊治后住院医生与计算机1.92.00.880.12住院医生与主治医生20.10主治医生与计算机50.07*p<0.05SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed;29:735-741血流动力学监测第11页血流动力学数据解释计算机辅助前计算机辅助后RCRCRSSC酸碱失衡0.830.930.950.98机械通气0.780.950.960.98代谢0.520.860.900.96充盈状态0.560.840.910.93泵功效0.530.840.900.90循环0.720.910.940.96RC:住院医生与计算机;RS:住院医生与主治医生;SC:主治医生与计算机SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed;29:735-741血流动力学监测第12页血流动力学参数改变治疗决定SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest;121:-血流动力学监测第13页ICU患者输液治疗输液治疗决定原因临床经验中心静脉压或肺动脉楔压BoldtJ,LenzM,KumleB,PapsdorfM.Volumereplacementstrategiesonintensivecareunits:resultsfromapostalsurvey.IntensiveCareMed1998;24:147-151血流动力学监测第14页临床判断缺乏准确性:PAWP01015191915100预计PAWP(mmHg)测定PAWP(mmHg)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553NochangeinplannedtherapyaftercatheterizationChangeinplannedtherapyaftercatheterization血流动力学监测第15页0临床判断缺乏准确性:CO04.57.0预计CO(L/min)测定CO(L/min)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5534.57.0血流动力学监测第16页临床判断缺乏准确性EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553参数判断正确数目/测定数目正确率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855血流动力学监测第17页Howgoodareourclinicalskills?CardiacoutputWedgepressureConnors(NEJM‘83)ICUpts44%

42%Eisenberg(CCM‘84)ICUpts50%33%Bayliss(BMJ‘83)CCUpts71%62%血流动力学监测第18页临床判断缺乏准确性ClinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatientsEisenbergPR,etal.CritCareMed1984;12:349Assessinghemodynamicstatusincriticallyillpatients:Dophysiciansuseclinicalinformationoptimally?ConnorsAF,etal.JCritCare1987;2:174TherapeuticimpactofPACintheICUSteingrub,etal.Chest1991;99:1451PACincriticallyillpatients:Aprospectiveanalysisofoutcomechangesassociatedwithcatheter-promptedchangesintherapyMimozOetal.CritCareMed1994;22:573Hemodynamicandpulmonaryfluidstatusinthetraumapatient:areweslipping?VealeWNJr,etal.AmSurg.;71:621血流动力学监测第19页临床判断缺乏准确性医生经常相信自己判断,但自信与准确性之间并无相关性与经验较少医生相比,尽管有经验医生更为自信,但他们判断并不准确医生不应盲目依据自己对心脏功效判断,作为治疗决议依据DawsonNVetal.Hemodynamicassessmentinmanagingthecriticallyill:isphysicianconfidencewarranted?MedDecisMaking1993;13:258-266血流动力学监测第20页临床判断血流动力学准确性ClinicalSettingAccurateAssessment,%UnanticipatedChangesinTherapyBasedonPAC,%Connors,etal62noncardiacmedicalintensivecarepatients4848Eisenberg,etal103criticallyillpatients5030TuchschmidtandSharma35noncardiacmedicalintensivecarepatients<4265Steingrub,etal154combinedmedical/surgicalintensivecarepatients<5147Connors,etalCardiacandnoncardiacmedicalintensivecare<6647血流动力学监测第21页临床主要血流动力学参数全部医生(n=417)心内科医生(n=27)CO330(79%)21(75%)PAWP285(68%)27(100%)SvO2220(53%)10(38%)MPAP120(37%)10(38%)SV100(24%)3(13%)RAP20(5%)RVEF20(5%)RVEDV18(4%)SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest;121:-血流动力学监测第22页心脏手术后患者血流动力学监测问卷调查(39个问题)血流动力学监测容量替换正性肌力药品/升压药品输血德国80个ICU主任问卷回收率69%KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroßeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica;51(3):347-358.血流动力学监测第23页心脏手术后患者血流动力学监测血流动力学监测百分比(%)基本监测100肺动脉导管(PAC)58.2经食道超声(TEE)38.1PICCO13.0KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroßeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica;51(3):347-358.血流动力学监测第24页英格兰与威尔士ICUCO监测技术EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare;9(Suppl1):P68(DOI10.1186/cc3131)血流动力学监测第25页英格兰与威尔士ICUCO监测技术CO监测技术2种69%首选经食道多普勒监测CO41%常规监测ScvO220%EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare;9(Suppl1):P68(DOI10.1186/cc3131)血流动力学监测第26页AreWeUsingPACCorrectly?血流动力学监测第27页PAWP测定中技术问题MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170N(%)measurements%oftechnicalproblemsNoproblem1868(69)Technicalproblems843(31)Criterion1(total)(12)(38)Unabletoobtainan“atrialwaveform”1238Criterion2(total)156(6)19WPwaveformintermediatebetweenthephasicPAandatrialwaveforms100(4)12SpontaneousvariationofWP56(2)7Criterion3(total)381(14)45Poordynamicresponse184(7)22Dampedtracing65(2)8Overinflation42(2)5CannotaspiratebloodwiththecatheterinthePA36(1)4Cannotaspiratebloodwiththecatheterinthewedgeposition54(2)6血流动力学监测第28页PAWP测定中技术问题MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170WPTechnicalProblemCorrectedbyInitialConfirmed228OverinflationDeflatedballoon812VenousbloodAdvance2cm308VenousbloodWithdrawn156VenousbloodNothing812PoordynamicresponseWithdrawn4cm248PoordynamicresponseDeflatedandinflatedballoon2313PoordynamicresponseWithdrawn128PoordynamicresponseFlushed3618PartialWPPatientcoughed214PartialWPRepositioned720PartialWPNothing1420?RepositionedWPinitial–WPconfirmed=116mmHgRange(-13,+22)血流动力学监测第29页PAWP测定中技术问题MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708ProblemDescriptionsNumber(%)DampedtracingReducedhigh-frequencycontent40(43%)PoordynamicresponseAbsentoscillation,lowfrequency,orinadequatedurationofoscillationsafterasuddenpressuredecreasefromapproximately300mmHgtovascularlevels58(62%)OverinflationSlow,frequentlylinearincreaseinpressureafterballooninflation10(9%)PartialWPWaveformintermediatebetweenphasicPAandatrialwaveforms22(25%)血流动力学监测第30页PAWP测定中技术问题DistributionofWPmeasurementsandfrequencyofaWPerror4mmHgTraumaICURespiratoryICUN%(95%CI)N%(95%CI)TotalWPattempts10917%(11–26%)17710%(6–15%)WPultimatelyconfirmed80158InitialWPwithouttechnicalproblems468%(3–16%)1334%(1–8%)InitialWPwithtechnicalproblems5326%(18–44%)4031%(17–47%)NoWPobtained104MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708血流动力学监测第31页ICU医生缺乏PAC相关知识目标:评价欧洲国家ICU医生对PAC相关知识了解程度设计:调查问卷背景:86个欧洲大学及非大学医院ICU对象:从两个欧洲危重病医学会目录中选取134个ICU.其中86个ICU535名医生参加问卷调查干预:在每个ICU中,全部医生均被要求同时完成一项调查问卷,包含31个多项选择题,包括床旁留置PAC全部方面GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220血流动力学监测第32页ICU医生缺乏PAC相关知识GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220PAC相关知识调查问卷内容分类1压力或心输出量测定技术问题2相关指标计算3血流动力学指标解读4留置导管5导管相关并发症识别,预防及治疗6应用PAC指导治疗7其它血流动力学监测第33页ICU医生缺乏PAC相关知识In-TrainingPostgraduateTrainingCompletedPrimaryMedicalSpecialtyAnesthesiology69.913.777.012.6InternalMedicine67.914.378.311.5Others62.416.369.815.2OpinionofRespondentsonTheirKnowledgeofPACsInadequate57.615.355.017.3Minimal65.714.371.914.1Adequate10.7Superfluous--83.30GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220血流动力学监测第34页ICU医生缺乏PAC相关知识GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220血流动力学监测第35页ICU医生缺乏PAC相关知识GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220血流动力学监测第36页ICU医生缺乏PAC相关知识GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220血流动力学监测第37页IsThereanEasyAlternativetoThisDilemma?血流动力学监测第38页CentralvenouscatheterInjectatetemperaturesensorhousingPV4046ArterialthermodilutioncatheterInjectatetemperaturesensorcablePC80109PULSIONdisposablepressuretransducerPV8115PCCIAP13.0316.28

TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625

DPTMonitorcablePMK-206InterfacecablePC80150ConnectioncabletobedsidemonitorPMK-XXXAUXadaptercablePC81200血流动力学监测第39页PiCCO技术原理PiCCO技术由以下两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人无须使用肺动脉导管:a.经肺热稀释技术b.动脉脉搏轮廓分析技术血流动力学监测第40页心输出量测定:经肺热稀释技术中心静脉内注射指示剂后,动脉导管尖端热敏电阻测量温度下降改变曲线经过分析热稀释曲线,使用Stewart-Hamilton公式计算得出心输出量(CO)Tb注射t血流动力学监测第41页心输出量测定:经肺热稀释技术经肺热稀释测量只需要在中心静脉内注射冷(<8C)或室温(<24C)生理盐水中心静脉注射右心左心肺PiCCO导管如插在股动脉内血流动力学监测第42页热稀释法测定CO:PiCCOvs.PACPCCO动脉热稀释测量位置静脉注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常规热稀释测量位置[s]010203040500,00,20,40,6[°C]-DT注射热稀释测量曲线Tb=血流温度Ti=注射指示剂温度Vi=注射指示剂容积∫∆Tb.

dt=热稀释曲线下面积K=校正系数血流动力学监测第43页动脉脉搏轮廓分析动脉脉搏轮廓分析经过动脉压力波型形状取得连续每搏参数经过经肺热稀释法初始校正后,该公式能够在每次心脏搏动时计算出每搏量(SV)t[s]P[mmHg]SV血流动力学监测第44页连续心输出量测定:PiCCO压力曲线下面积压力曲线型状PCCO=cal•HR•SystoleP(t)SVR+C(p)•dPdt()dt动脉顺应性参数心率与病人相关校正因子t[s]P[mmHg]PCCOisdisplayedaslast12smean血流动力学监测第45页心输出量测定:PiCCOvs.热稀释AuthorPt/ObsCOTDa–COTDpaBiasSDrVonSpiegel,etal.Anaesthesist1996;45(11)21/48-4.71.5%.97McLuckie,etal.ActaPaediatr1996;859/?0.190.21L/min/m2Goedje,etal.Chest1998;113(4)30/1500.160.31L/min/m2.96Goedje,etal.ThoracCardiovascSurg1998;4630/8100.260.71L/min.96Zoolner,etal.Anaesthesist1998;47(11)18/1600.031.04L/min.91Goedje,etal.CritCareMed1999;27(11)24/216-0.290.66L/min.93Sakka,etal.IntensiveCareMed1999;2537/4490.680.62L/min.97Sakka,etal.JCardiothoracVascAnesth;14(2)12/510.730.38L/min.96Zoolner,etal.JCardiothoracVascAnesth;14(2)19/760.210.73L/min.96Bindels,etal.CritCare;445/2830.490.45L/min/m2.95血流动力学监测第46页PiCCO技术原理PiCCO技术由以下两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人无须使用肺动脉导管:a.经肺热稀释技术b.动脉脉搏轮廓分析技术血流动力学监测第47页PiCCO容量参数全心舒张末期容积 GEDV胸腔内血容积 ITBV血管外肺水 EVLW经过对热稀释曲线分析,能够得到这些容量参数lnc(I)注射At再循环MTtte-1DStc(I)血流动力学监测第48页全心舒张末期容积(GEDV)全心舒张末期容积(GEDV)是心脏4个腔室内血容量血流动力学监测第49页胸腔内血容积(ITBV)胸腔内血容积(ITBV)是心脏4个腔室容积+肺血管内血液容量血流动力学监测第50页血管外肺水(EVLW)血管外肺水(EVLW)是肺内含有水量,能够在床旁定量判断肺水肿程度血流动力学监测第51页容量测量原理lnc(I)注射At再循环影响MTtte-1DStc(I)

MTt:Meantransittime平均传输时间

≈halfoftheindicatorpassedthepointofdetection DSt:Downslopetime下降时间≈exponentialdownslopetimeofTDcurve血流动力学监测第52页容量测量原理Vall=

V1+V2+V3+V4

=

MTtxFlowMeieretal.JApplPhysiol.1954V3=

最大腔容积 =DStx

FlowNewmanetal.Circulation.1951指示剂由注射点到检测点平均传输时间MTt由两点间总容积决定下降时间DSt由其中最大腔室决定(比其它腔最少大20%成立!)flowV3V4V2V1注射检测血流动力学监测第53页胸腔内容积组成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV=肺内热容积,在一系列混合腔室中含有最大热容积(DSt–容积)ITTV=胸腔内总热容积,从注射点到测量热容积之和(MTt–容积)GEDV =全心舒张末期容积=ITTV–PTV血流动力学监测第54页容量测量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔总热容积(ITTV)ITTV=COxMTtTDa肺内总热容积(PTV)PTV=COxDStTDa全心舒张末期容积GEDV=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTV血流动力学监测第55页ITBV测量原理Sakkaetal,IntensiveCareMed;26:180-187ITBV=1.25*GEDV–28.4[ml]r=0.96ITBVTD(ml)GEDVST(ml)GEDVvs.ITBVin57intensivecarepatients血流动力学监测第56页ITBV准确性临床验证Sakkaetal,IntensiveCareMed26:180-187,n=209r=0.97Bias = -7.6ml/m2

SD = 57.4ml/m2ITBVISTvs.ITBVITDin209intensivecarepatients血流动力学监测第57页容量测量小结ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTV血流动力学监测第58页PiCCO前负荷指标在反应心脏前负荷敏感性和特异性方面,已经证实ITBV和GEDV不但优于CVP及PAWP,也优于RVEDVITBV和GEDV最主要优点是不受机械通气影响而产生错误,所以能够在任何情况下提供前负荷情况正确信息经由GEDV和SV计算得到全心射血分数(GEF),在一定程度上反应了心肌收缩功效GEF=4xSV/GEDV血流动力学监测第59页容量负荷反应组与无反应组CVP血流动力学监测第60页扩容治疗前肺动脉楔压PAOP(mmHg)有反应者无反应者Calvinetal8172Schneideretal101101Reuseetal104103Diebeletal14772¶Diebeletal166155WagnerandLeatherman103144¶Tavernieretal104123Tousignantetal123163¶Michardetal103112¶p<0.05血流动力学监测第61页扩容治疗前右室舒张末容积指数血流动力学监测第62页扩容治疗前右室舒张末面积LVEDA(cm2/m2)有反应者无反应者Tavernieretal93124¶Tousignantetal155205¶Feisseletal104102¶p<0.05血流动力学监测第63页CVP/PAWP不能预测扩容反应

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147血流动力学监测第64页ITBV能够更加好地反应前负荷

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147血流动力学监测第65页预测扩容反应:PAWP/CVPvs.ITBV1.MichardF,BoussatS,ChemlaD,AnguelN,MercatA,LecarpentierY,RichardC,PinskyMR,TeboulJL.RelationbetweenRespiratoryChangesinArterialPulsePressureandFluidResponsivenessinSepticPatientswithAcuteCirculatoryFailure.AmJRespirCritCareMed;162:134-138.2.RexS,BroseS,MetzelderS,HunekeR,SchalteG,AutschbachR,RossaintR,BuhreW.Predictionoffluidresponsivenessinpatientsduringcardiacsurgery.BrJAnaesth;93:782-788血流动力学监测第66页前负荷指标与SV/CI相关性全部患者单一患者相关系数,rSVIartCIartCIart(最低值–最高值)CVP-0.090.00-0.01–0.33PAWP-0.02-0.01-0.36–0.03RAEDVI0.28-0.11-0.02–0.37RVEDVI0.03-0.020.02–0.03ITBVI0.760.830.67–0.91GEDVI0.820.870.70–0.93Goedjeetal,EurJCardiothoracSurg1998;13(5):533-539;discussion539-540血流动力学监测第67页心输出量和全身循环阻力因为脉搏轮廓分析连续测量每搏量和动脉压,能够以下计算得到心输出量(CO)和全身循环阻力(SVR):CO=每搏量x心率SVR=(平均动脉压–中心静脉压)/CO血流动力学监测第68页每搏量变异(SVV)对于没有心律失常机械通气患者SVV反应了心脏对因机械通气造成心脏前负荷周期性改变敏感性SVV能够用于预测扩容治疗是否会使每搏量增加SVmaxSVminSVmeanSVmax–SVminSVV(30秒)=SVmean血流动力学监测第69页对扩容反应预测性:CVPvs.SVVSensitivity1–SpecificityBerkenstadtetal,AnesthAnalg;92:984-989---CVP__SVV血流动力学监测第70页血管外肺水测定:EVLW放射影像学(radiology)指示剂稀释技术(indicatordilutiontechnique)显像技术(imagingtechnique)重力测定技术(gravimetrictechnique)血流动力学监测第71页氧合与肺水肿静水压升高引发肺水肿CMVFiO20.4ScilliaP,DelcroixM,LejeuneP,MelotC,StruyvenJ,NaeijeR,GevenoisPA.Hydrostaticpulmonaryedema:evaluationwiththin-sectionCTindogs.Radiology1999;211:161-168血流动力学监测第72页血管外肺水与氧合MartinGS,EatonS,MealerM,MossM.Extravascularlungwaterinpatientswithseveresepsis:aprospectivecohortstudy.CritCare;9:R74-R82(DOI10.1186/cc3025)血流动力学监测第73页血管外肺水与病死率Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139血流动力学监测第74页血管外肺水测定当EVLW增加>100%时,胸片才会发生改变BongardFS,Surgery1984胸片对EVLW改变并不敏感HelperinBD,Chest1984确定患者是否符合ARDS影像学表现时,医生之间存在非常显著差异Rubenfeldetal,Chest1999血流动力学监测第75页容量测量小结ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVEVLW=ITTV–ITBVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW血流动力学监测第76页EVLW:PiCCOvs.重力法测定Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139血流动力学监测第77页血管外肺水临床验证Sakkaetal,IntensiveCareMed26:180-187,Bias = -0.2ml/kg

SD = 1.4ml/kgn=209r=0.96EVLWISTvs.EVLWITDin209intensivecarepatients血流动力学监测第78页降低血管外肺水:临床试验Mitchelletal,AmRevRespDis145:990-998,1992血流动力学监测第79页血管外肺水血管外肺水(EVLW)经过经肺热稀释法得到,已被染料稀释法和重量法证实已证实血管外肺水(EVLW)与ARDS严重程度,病人机械通气天数,住ICU时间及死亡率明确相关,其评定肺水肿远远优于胸部X线肺血管通透性指数(PVPI)一定程度上反应了肺水肿形成原因PVPI=EVLW/PBV血流动力学监测第80页隐匿性肺水肿检测指标EVLW增加临床症状100–200%胸片100–200%氧合(机械通气时)300%EVLW(PiCCO)10–15%血流动力学监测第81页原发性与继发性ARDS/ALI判别患者人群(n=10)原发性ARDS/ALI(n=4):肺炎,误吸继发性ARDS/ALI(n=6):全身性感染评价指标ITBVIEVLWIPVPI(EVLW/ITBV)MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare,10(Suppl1):P326(doi:10.1186/cc4673)血流动力学监测第82页原发性与继发性ARDS/ALI判别MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare,10(Suppl1):P326(doi:10.1186/cc4673)直接ARDS/ALI间接ARDS/ALIP值ITBVI984331.71279312.10.0001EVLWI13.24.714PVPI0.590.270.440.220.006血流动力学监测第83页SIRS及ARDS:肺血管通透性与肺水肿PVPISIRS组(n=31)2.371.0ARDS组(n=13)3.21.10非ARDS组(n=18)1.70.44非SIRS组(n=10)1.20.21TagamiT,KushimotoS,AtsumiT,MatsudaK,MiyazakiY,OyamaR,KoidoY,KawaiM,YokotaH,YamamotoY.InvestigationofthepulmonaryvascularpermeabilityindexandextravascularlungwaterinpatientswithSIRSandARDSunderthePiCCOsystem.CriticalCare;10(Suppl1):P352(doi:10.1186/cc4699)血流动力学监测第84页血管外肺水测定胸片,氧合障碍及PAWP与EVLW之间相关性很差床旁测定EVLW为危重病患者诊疗,随访及治疗评定提供了新方法血流动力学监测第85页PiCCO技术问题血流动力学监测第86页热稀释法测定心输出量目标:确定热稀释法一次测定心输出量是否准确方法:回顾分析18名神经外科ICU患者共417次测定,1465次操作ANOVA分析WolfS,PlevD,SchürerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare;8(Suppl1):P57(DOI10.1186/cc2524)血流动力学监测第87页热稀释法测定心输出量差值中位数两次测定95%可重复系数相当于正常值百分比CI(L/min)0.30.7248%ITBVI(ml/m2)80270180%EVLWI(ml/kg)13.587%WolfS,PlevD,SchürerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare;8(Suppl1):P57(DOI10.1186/cc2524)血流动力学监测第88页热稀释法测定心输出量目标:确定热稀释法测定心输出量时2次测定与3次测定准确性方法:回顾分析2年期间PiCCO监测全部数据共25名感染性休克患者共249次心输出量测定比较前2次(M1)与3次测定心输出量(M2)平均值AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare;11(Suppl2):P293血流动力学监测第89页热稀释法测定心输出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare;11(Suppl2):P293CI(L/min/m2)M13.281.07M25.741.0743%血流动力学监测第90页热稀释法测定心输出量结 论采取PiCCO进行监测时,2次热稀释法显然不足以可靠地测定心输出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare;11(Suppl2):P293血流动力学监测第91页中心静脉插管部位影响SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed;35:783-786颈内静脉vs.股静脉血流动力学监测第92页中心静脉插管部位影响人口统计学资料MSD范围性别男8,女3年纪,岁58.717.521–74身高,cm174.97.9165–185体重,kg75.510.265–90体表面积,m21.900.151.73–2.14SAPSII51.310.136–61SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed;35:783-786血流动力学监测第93页中心静脉插管部位影响心肺指标MSD范围HR,bpm88.517.966–124MAP,mmHg84.711.370–103COavg,L/min7.662.952.9–12.2GEDIavg,ml/m2947.2314.8577–1789EVLWIavg,ml/kg15.012.84–51SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed;35:783-786血流动力学监测第94页中心静脉插管部位影响差异95%范围COfemvs.COjug,L/min+0.16-1.13,1.45EVLWIfemvs.EVLWIjug,ml/kg+0.23-1.77,2.23GEDVIfemvs.GEDVIjug,ml/m2+140.7-2.58,284.02SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed;35:783-786血流动力学监测第95页中心静脉插管部位影响颈内静脉,sec股静脉,secPMTt43.418.946.618.30.0068DSt23.30.35AUC2.60.27SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed;35:783-786血流动力学监测第96页中心静脉插管部位影响颈内静脉股静脉差异%PITBVI(ml/m2)1059134527<.001EVLWI(ml/kg)14.215.812.049CI(L/min/m2)4.054.06<1.92GrundlerS,MacchiavelloL.Femoralcentralvenouscatheter(CVC)versusinternaljugularCVCforassessmentofhaemodynamicparametersbytranspulmonarythermodilutionusingpulsecontourcardiacoutput.CriticalCare;9(Suppl1):P64(DOI10.1186/cc3127)血流动力学监测第97页肾脏替换治疗对PICCO测定影响24名危重病患者(男性15名,女性9名)血流动力学监测5-F股动脉插管(PVL20;PulsionMedicalSystems)肾脏替换治疗12-F股静脉血透插管(TrilyseExpert;Vygon)(n=12)12-F上腔静脉血透插管(n=12)测定部位:上腔静脉插管(CertofixTrio;Braun,Melsungen)测定时间:RRT过程中,终止RRT即刻,重新开始后即刻SakkaS,HanuschT,ThuemerO,WegscheiderK.Influenceofveno-venousrenalreplacementtherapyontranspulmonarythermodilutionmeasurements.CriticalCare;10(Suppl1):P355(doi:10.1186/cc4702)血流动力学监测第98页肾脏替换治疗对PICCO测定影响RRTNoRRTRRTHR(bpm)9927100279927MAP(mmHg)741476127413CVP(mmHg)144144144CI(L/min/m2)ITBVI(ml/m2)934254945255920247EVLWI(ml/kg)SakkaS,HanuschT,ThuemerO,WegscheiderK.Influenceofveno-venousrenalreplacementtherapyontranspulmonarythermodilutionmeasurements.CriticalCare;10(Suppl1):P355(doi:10.1186/cc4702)血流动力学监测第99页肾脏替换治疗对PICCO测定影响在肾脏替换治疗过程中CI降低 (平均改变-0.1L/min/m2,P<0.01)ITBVI降低 (平均改变-18ml/m2,P=0.02)EVLWI不变 (平均改变+0.1ml/kg,P=0.42)SakkaS,HanuschT,ThuemerO,WegscheiderK.Influenceofveno-venousrenalreplacementtherapyontranspulmonarythermodilutionmeasurements.CriticalCare;10(Suppl1):P355(doi:10.1186/cc4702)血流动力学监测第100页肾脏替换治疗对PICCO测定影响MasonN,FroudeA,HolstB,SaaymanA,FindlayG.Theeffectofcontinuousveno-venoushaemofiltrationonPiCCO®haemodynamicparameters.CriticalCare;9(Suppl1):P65(DOI10.1186/cc3128)CVVH无CVVH95%CIPITBVI(ml/m2)943(873–1013)1324(1181–1467)(-1.38,-0.76)<.001EVLWI(ml/kg)11(9–13)9(7–11)(-500,-262)<.001C