《icco的临床应用》PPT课件.ppt

1、血流动力学监测,Theory and Practice,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. William Ganz (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 HemoSon

2、icTM100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,Respiration Rate,Temperature,8,一些重要的指标,Monitoring,Blood Pressure (NiBP), no correlation with CO no correlation with oxygen delivery,ECG,Respiration Rate,Temperature,PiCCO Technology,液

3、体管理所需要的指标,Introduction to the PiCCO-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,Left Heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATH arter

4、ial thermodilution catheter,central venous bolus injection,Introduction to the PiCCO-Technology Function,Bolus injection,concentration changes over time (Thermodilution curve),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,Introduction to the PiCCO-Technology Function,Left heart,Right heart,Lungs,原理,胸腔内

5、各腔室,Introduction to the PiCCO-Technology Function,肺内热容积 (PTV),胸腔内热容积 (ITTV),Total of mixing chambers,最大混合腔室,血流动力学监测,Introduction to PiCCO Technology,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,Tb x dt,(Tb - Ti) x Vi x K,Tb,Injection,t,D,=,COTD a,Tb = Blood temperature Ti = Injectate temperature Vi

6、 = Injectate volume Tb . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate,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,Introduction to the PiCCO-Technology Thermodilution,热稀释曲线下面积反比例反映CO,36,5,37,5,10,热稀释曲线,Normal

7、 CO: 5.5l/min,Introduction to the PiCCO-Technology Thermodilution,36,5,37,36,5,37,Time,low CO: 1.9l/min,High CO: 19l/min,Time,Time,Temperature,Temperature,Temperature,经肺热稀释 vs. 肺动脉导管,Left heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH arterial thermo-dilution catheter,cent

8、ral venous bolus injection,RA,RV,PA,LA,LV,Aorta,Transpulmonary TD (PiCCO),Pulmonary Artery TD (PAC),In both procedures only part of the injected indicator passes the thermistor. Nonetheless the determination of CO is correct, as it is not the amount of the detected indicator but the difference in te

9、mperature over time that is relevant!,Introduction to the PiCCO Technology Thermodilution,Comparison with the Fick Method,0,97,0,68 0,62,37/449,Sakka SG et al., Intensive Care Med 25, 1999,- / -,0,19 0,21,9/27,McLuckie A. et a., Acta Paediatr 85, 1996,0,96,0,16 0,31,30/150,Gdje O et al., Chest 113 (

10、4), 1998,0.98,0,32 0,29,23/218,Holm C et al., Burns 27, 2001,0,93,0,13 0,52,60/180,Della Rocca G et al., Eur J Anaest 14, 2002,0,95,-0,04 0,41,17/102,Friedman Z et al., Eur J Anaest, 2002,0,95,0,49 0,45,45/283,Bindels AJGH et al., Crit Care 4, 2000,0,98,0,03 0,17,18/54,Pauli C. et al., Intensive Car

11、e Med 28, 2002,24/120,n (Pts / Measurements),0,99,0,03 0,24,Tibby S. et al., Intensive Care Med 23, 1997,r,bias SD(l/min),Comparison with Pulmonary Artery Thermodilution,经肺热稀释技术的有效性,Introduction to the PiCCO Technology Thermodilution,MTt: Mean Transit time the mean time required for the indicator to

12、 reach the detection point,DSt: Down Slope time the exponential downslope time of the thermodilution curve,Recirculation,t,e-1,Tb,From the characteristics of the thermodilution curve it is possible to determine certain time parameters,对热稀释曲线做进一步分析,Introduction to the PiCCO-Technology Thermodilution,

13、Injection,In Tb,MTt,DSt,Tb = blood temperature; lnTb = logarithmic blood temperature; t = time,Pulmonary Thermal Volume PTV = Dst x CO,By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated,计算 ITTV 与 PTV,Introduction to the PiCCO-Technology Thermodilutio

14、n,Recirculation,t,e-1,Tb,Injection,In Tb,Intrathoracic Thermal Volume ITTV = MTt x CO,MTt,DSt,Pulmonary Thermal Volume (PTV),Intrathoracic Thermal Volume (ITTV),Calculation of ITTV and PTV,Einfhrung in die PiCCO-Technologie Thermodilution,ITTV = MTt x CO,PTV = Dst x CO,GEDV is the difference between

15、 intrathoracic and pulmonary thermal volumes,Global End-diastolic Volume (GEDV),Volumetric preload parameters GEDV,ITTV,GEDV,PTV,Introduction to the PiCCO Technology Thermodilution,Volumetric preload parameters ITBV,Intrathoracic Blood Volume (ITBV),GEDV,ITBV,PBV,Introduction to the PiCCO Technology

16、 Thermodilution,ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV),ITBVTD (ml),ITBV = 1.25 * GEDV 28.4 ml,GEDV vs. ITBV in 57 Intensive Care Patients,Intrathoracic Blood Volume (ITBV),Introduction to the PiCCO-Technology Thermodilution,ITBV is ca

17、lculated from the GEDV by the PiCCO Technology,GEDV (ml),Sakka et al, Intensive Care Med 26: 180-187, 2000,Summary and Key Points - 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。,Introduction to the PiCCO-Technology,Haemodynamic Mon

18、itoring,Introduction to PiCCO Technology,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,Transpulmonary Thermodilution,The pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve,Calibration of the Pulse Con

19、tour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,Injection,Pulse Contour Analysis,T = blood temperature t = time P = blood pressure,COTPD,= SVTD,HR,PCCO = cal HR ,P(t),SVR,+ C(p) ,dP,dt,(,),dt,Cardiac Output,Heart rate,Systole,Introduction to the PiCCO-Technology Pulse conto

20、ur analysis,Parameters of Pulse Contour Analysis,n (Pts / Measurements),0,94,0,03 0,63,12 / 36,Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999,19 / 76,24 / 517,62 / 186,20 / 360,25 / 380,22 / 96,- / -,-0,40 1,3,Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003,0,88,0,31 1,25,Zllner C et

21、 al., J Cardiothorac Vasc Anesth 14 (2), 2000,0,88,-0,2 1,15,Gdje O et al., Crit Care Med 30 (1), 2002,0,94,-0,02 0,74,Della Rocca G et al., Br J Anaesth 88 (3), 2002,0,93,-0,14 0,33,Felbinger TW et al., J Clin Anesth 46, 2002,- / -,0,14 0,58,Rauch H et al., Acta Anaesth Scand 46, 2002,r,bias SD (l/

22、min),Comparison with pulmonary artery thermodilution,Validation of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,SVmax SVmin,SVV =,SVmean,The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 secon

23、d period.,Parameters of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Stroke Volume Variation,The increase of preload volume is equal: EDV1 = EDV2 SV1 SV2,SVV 提示心脏对容量治疗的反应好坏,EDV,SV,SVV small,SVV large, EDV1, EDV2, SV1,

24、SV2,PPmax PPmin,PPV =,PPmean,The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.,Parameters of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsi

25、veness Pulse Pressure Variation,PPmax,PPmean,PPmin,Summary pulse contour analysis - CO and volume responsiveness,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 (stroke volume variation) 和PPV (pulse pressure variation) 可以持续获得,Introduction to the PiCCO-Technology

26、 Pulse contour analysis,Haemodynamic Monitoring,Introduction to PiCCO Technology,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,Contractility is a measure for the performance of the heart muscle,Contractility parameters of PiCCO technology: dPmx (maximum rate of the increase in pressure) GEF (Global

27、Ejection Fraction) CFI (Cardiac Function Index),Contractility,Introduction to the PiCCO-Technology Contractility parameters,kg,Contractility parameter from the pulse contour analysis,Introduction to the PiCCO-Technology Contractility parameters,dPmx = maximum velocity of pressure increase,The contra

28、ctility parameter dPmx represents the maximum velocity of left ventricular pressure increase.,Contractility parameter from the pulse contour analysis,Introduction to the PiCCO-Technology Contractility parameters,femoral dP/max mmHg/s,LV dP/dtmax mmHg/s,dPmx was shown to correlate well with direct me

29、asurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients,de Hert et al., JCardioThor 254-265,High extravascular lung water is not reliably identified by blood gas analysis,EVLW as a quantifier of lung edema,PaO2 /FiO2,10,20,550,30,150,250,0,450,ELWI (ml/kg),0,50,350

30、,Introduction to the PiCCO Technology Extravascular Lung Water,ELWI = 7 ml/kg,ELWI = 8 ml/kg,ELWI = 14 ml/kg,ELWI = 19 ml/kg,Extravascular lung water index (ELWI) normal range:3 7 ml/kg,Pulmonary oedema,Normal range,EVLW as a quantifier of lung oedema,Introduction to the PiCCO Technology Extravascul

31、ar Lung Water,40,Halperin et al, 1985, Chest 88: 649,Chest x ray does not reliably quantify pulmonary oedema and is difficult to judge, particularly in critically ill patients,r = 0.1 p 0.05,0,20,80,15,-10,-15,10,60,D radiographic score,-80,-60,-40,-20,D ELWI,EVLW as a quantifier of lung oedema,Intr

32、oduction to the PiCCO Technology Extravascular Lung Water,ELWI (ml/kg), 21 n = 54,14 - 21 n = 100,7 - 14 n = 174, 7 n = 45,Mortality(%),Sturm J in: Lewis, Pfeiffer (eds): Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139

33、,Relevance of EVLW Assessment,The amount of extravascular lung water is a predictor for mortality in the intensive care patient,Sakka et al , Chest 2002,Introduction to the PiCCO Technology Extravascular Lung Water,Intensive Care days,Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992,Relevance of E

34、VLW Assessment,Volume management guided by EVLW can significantly reduce time on ventilation and ICU length of stay in critically ill patients, when compared to PCWP oriented therapy,Ventilation Days,PAC Group,n = 101,* p 0,05,PAC Group,EVLW Group,EVLW Group,22 days,15 days,9 days,7 days,* p 0,05,In

35、troduction to the PiCCO Technology Extravascular Lung Water,Haemodynamic Monitoring,Introduction to PiCCO Technology,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,Differentiating Lung Oedema,PVPI = Pulmonary Vascular Permeability Index,is the ratio of Extravascular Lung Water to Pulmonary Blood Volu

36、me is a measure of the permeability of the lung vessels and as such can classify the type of lung oedema (hydrostatic vs. permeability caused),EVLW,PVPI =,PBV,PBV,EVLW,Introduction to PiCCO Technology Pulmonary Permeability,permeability,PVPI normal (1-3),PVPI raised (3),Classification of Lung Oedema

37、 with the PVPI,Difference between the PVPI with hydrostatic and permeability lung oedema:,Lung oedema,hydrostatic,PBV,EVLW,PBV,EVLW,PBV,EVLW,PBV,EVLW,Introduction to PiCCO Technology Pulmonary Permeability,16 patients with congestive heart failure and acquired pneumonia. In both groups EVLW was 16 m

38、l/kg.,Validation of the PVPI,PVPI can differentiate between a pneumonia caused and a cardiac failure caused lung oedema.,Benedikz et al ESICM 2003, Abstract 60,Cardiac insufficiency,PVPI,Pneumonia,4,3,2,Introduction to PiCCO Technology Pulmonary Permeability,EVLWI answers the question:,Clinical Rele

39、vance of the Pulmonary Vascular Permeability Index,PVPI answers the question:,and can therefore give valuable aid for therapy guidance!,肺水有多少?,它是怎么来的?,Introduction to PiCCO Technology Pulmonary Permeability,Summary and Key Points,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

40、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,Introduction to PiCCO Technology EVLW and Pulmonary Permeability,PiCCO plus 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,13.03 16.28 TB37.0,AP 140 117 92 (CVP) 5 SVRI 2762 PC CI 3.24 HR 78 SVI 42 SVV 5% dPmx

41、1140 (GEDI) 625,DPT Monitor cable PMK-206,Interface cable PC80150,连接床旁监护仪 PMK - XXX,AUX adapter cable PC81200,CI (l/min/m2),ITBVI (ml/m2),Therapy Target ITBVI CFI EVLWI (slowly responding),4.5,10 V+! Cat temporary 750-850 5.5 10,4.5,3.0,3.0,10 Cat V- temporary 750-850 5.5 10,10 V+ 850-1000 10,10 V+

42、temporary 750-850 10,850,850,850,10 OK!,10 V- temporary 750-850 10,850,EVLWI (ml/kg),V+ = volume loading (! = cautiously),V- = volume contraction,Cat = catecholamines/ cardiovascular agents,PiCCO诊断治疗树,正常值,ParameterRangeUnit CI3.0 5.0l/min/m2 SVI40 60ml/m2 GEDI680 800ml/m2 ITBI850 1000ml/m2 ELWI*3.0

43、7.0ml/kg PVPI*1.0 3.0 SVV 10% PPV 10 % GEF25 35% CFI4.5 6.51/min MAP70 90mmHg SVRI1700 2400dyn*s*cm-5*m,* not available in the USA (p 63),Fields of Application,Septic Shock Cardiogenic Shock Hypovolaemic Shock Trauma Burns ARDS Cardiac Surgery Neuro Surgery Major Surgery,现在有效循环情况如何?.心输出量! 前负荷怎样补液OR利

44、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,CO GEDV dPmx SVR EVLW .,* not available in the USA (p 63),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

45、测量（beat to beat） 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,Berkenstadt H et al., Anesth Analg, 2001 Bindels A et al., Crit Care 4, 2000 Boussat S et al., Int Care Med 20

46、02 Brock H et al., Eur J Anaesth 19 (4), 2002 Della Rocca G et al., Eur J Anaesth 19, 2002 Della Rocca G et al., Anesth Analg 95, 2002 Eisenberg PR et al., Am Rev Respir Dis 136 (3), 1987 Gdje O et al., Chest 118, 2000 Gdje O et al., Eur J of Cardio-thoracic Surgery 13, 1998 Haperlin et al., Chest, 1985 Hoeft A, Yearbook of Intensive Care and Emergency Medicine, 1995 Katzenelson et al., SCCM 2001, San Diego Lichtwarck-Aschoff M et al., Journal of Critical Care 11 (4), 1996 Lichtwarck-A