PICCO監(jiān)測的意義和影響因素課件

重癥患者我們關(guān)注什么？容量組織器官灌注心功能肺部情況氧供、氧耗血壓、心率CVP、PAWP皮膚彈性尿量心血管彩超血氧飽和度氧分壓、二氧化碳分壓（敏感性、特異性差，主觀性強，影響因素多，缺乏連續(xù)性）1PICCO監(jiān)測的意義和影響因素7/20/2023PICCO監(jiān)測技術(shù)直觀準確特異性連續(xù)性2PICCO監(jiān)測的意義和影響因素7/20/20233次熱稀釋校準經(jīng)肺熱稀釋曲線injectiontT

動脈脈搏輪廓分析Pt

＝兩種技術(shù)

經(jīng)熱稀釋方法得到的非連續(xù)性參數(shù)

心輸出量

CO

全心舒張末期容積

GEDV

胸腔內(nèi)血容量

ITBV

血管外肺水

EVLW*

肺血管通透性指數(shù)

PVPI*

心功能指數(shù)

CFI

全心射血分數(shù)

GEF

動脈輪廓分析法得到的連續(xù)性參數(shù)

連續(xù)心輸出量

PCCO

動脈壓

AP

心率HR

每搏量

SV

每搏量變異

SVV

脈壓變異

PPV

系統(tǒng)血管阻力

SVR

左心室收縮力指數(shù)

dPmax*血液動力學和容量進行監(jiān)護管理＋兩部分參數(shù)PiCCOPiCCO(PulseindicateContourCardiacOutput)脈搏輪廓動脈壓波形分析法3PICCO監(jiān)測的意義和影響因素7/20/2023中心靜脈導管注射液溫度探頭容納管PV4046PCCIAP13.0316.28

TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625壓力線206PMK動脈熱稀釋導管PULSION一次性壓力傳感器PV8115（包括PV4046）溫度測量電纜PC80150注射液溫度電纜PC80109導管連接4PICCO監(jiān)測的意義和影響因素7/20/2023PICCO2連接圖5PICCO監(jiān)測的意義和影響因素7/20/2023ScvO2–中心靜脈氧飽和度通過標準中心靜脈導管放置SvO2(混合靜脈氧飽和度)目前只能通過高創(chuàng)傷性的右心導管獲得ScvO2和SvO2之間有良好的相關(guān)性正常值范圍: ScvO2 70-80%

SvO2 65-75%6PICCO監(jiān)測的意義和影響因素7/20/2023氧供和氧耗DO2I–氧供(Index)通過CI，血紅蛋白，動脈血氧飽和度來計算VO2I

–氧耗(Index)通過CI，血紅蛋白，動脈以及混合靜脈氧飽和度來計算

正常值范圍:

DO2 400-650ml/min/m2

VO2 125-175ml/min/m2S(c)vO2CO,HbOxygenintakeOxygentransportOxygendeliveryOxygenconsumptionVO2I=CIxHbx1,34x(SaO2

–S(c)vO2)

DO2I=CIxHbx1,34xSaO2

SaO2ConsumptionDelivery7PICCO監(jiān)測的意義和影響因素7/20/2023經(jīng)肺熱稀釋在中心靜脈內(nèi)注射冷（<8oC）生理鹽水作為指示劑動脈導管尖端的熱敏電阻測量溫度下降的變化曲線使用Stewart-Hamilton公式計算得出心輸出量（CO）

PiCCO測得的CO與肺動脈導管測得的CO相關(guān)良好

[s]010203040500,00,20,40,6[°C]-DT注射熱稀釋測量曲線Tb=血流溫度Ti=注射指示劑溫度Vi=注射指示劑容積∫?Tb.

dt=熱稀釋曲線下面積K=校正系數(shù)Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate8PICCO監(jiān)測的意義和影響因素7/20/2023熱稀釋曲線下的面積與心輸出量成反比

36,537510熱稀釋曲線NormalCO:5.5l/min36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperature9PICCO監(jiān)測的意義和影響因素7/20/2023MTt:MeanTransittime

平均通過時間themeantimerequiredfortheindicatortoreachthedetectionpointDSt:DownSlopetime斜面下時間

theexponentialdownslopetimeofthethermodilutioncurveRecirculationte-1TbFromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters根據(jù)熱稀釋曲線可以算出時間參數(shù)對熱稀釋曲線做進一步分析IntroductiontothePiCCO-Technology–ThermodilutionInjectionInTbMTtDStTb=bloodtemperature;lnTb=logarithmicbloodtemperature;t=time10PICCO監(jiān)測的意義和影響因素7/20/2023PulmonaryThermalVolumePTV肺內(nèi)熱容積=DstxCOByusingthetimeparametersfromthethermodilutioncurveandtheCOITTVandPTVcanbecalculated計算ITTV與PTVIntroductiontothePiCCO-Technology–ThermodilutionRecirculationte-1TbInjectionInTbIntrathoracicThermalVolumeITTV胸腔內(nèi)熱容積=MTtxCOMTtDSt11PICCO監(jiān)測的意義和影響因素7/20/2023PulmonaryThermalVolume(PTV)IntrathoracicThermalVolume(ITTV)CalculationofITTVandPTVEinführungindiePiCCO-Technologie–ThermodilutionITTV=MTtxCOPTV=DstxCORARVLALVPBVEVLWEVLW12PICCO監(jiān)測的意義和影響因素7/20/2023GEDVisthedifferencebetweenintrathoracicandpulmonarythermalvolumesGlobalEnd-diastolicVolume(GEDV)Volumetricpreloadparameters–GEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroductiontothePiCCO–Technology–Thermodilution13PICCO監(jiān)測的意義和影響因素7/20/2023Volumetricpreloadparameters–ITBVIntrathoracicBloodVolume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroductiontothePiCCO–Technology–ThermodilutionITBVisthetotaloftheGlobalEnd-DiastolicVolumeandthebloodvolumeinthepulmonaryvessels(PBV)14PICCO監(jiān)測的意義和影響因素7/20/2023 ITTV

– ITBV= EVLWTheExtravascularLungWateristhedifferencebetweentheintrathoracicthermalvolumeandtheintrathoracicbloodvolume.Itrepresentstheamountofwaterinthelungsoutsidethebloodvessels.CalculationofExtravascularLungWater(EVLW)IntroductiontothePiCCO–Technology–ExtravascularLungWater15PICCO監(jiān)測的意義和影響因素7/20/2023容量測量小結(jié)ITTV=CO*MTtTDaPTV=CO*DStTDaITBV

=1.25*GEDVEVLW=ITTV-ITBVGEDV

=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW16PICCO監(jiān)測的意義和影響因素7/20/2023TranspulmonaryThermodilutionThepulsecontouranalysisiscalibratedthroughthetranspulmonarythermodilutionandisabeattobeatrealtimeanalysisofthearterialpressurecurve動脈脈搏波形校準IntroductiontothePiCCO-Technology–PulsecontouranalysisInjectionPulseContourAnalysisT=bloodtemperaturet=timeP=bloodpressureCOTPD=SVTDHR17PICCO監(jiān)測的意義和影響因素7/20/2023脈搏輪廓分析Cal=校準系數(shù)來自經(jīng)肺熱稀釋方法Surface

=Cal.x

Strokevolume18PICCO監(jiān)測的意義和影響因素7/20/2023動脈脈搏輪廓分析壓力曲線下面積壓力曲線型狀PCCO=cal?HR?SystoleP(t)SVR+

C(p)?dPdt()dt動脈順應性參數(shù)心率與病人有關(guān)的校正因子t[s]P[mmHg]19PICCO監(jiān)測的意義和影響因素7/20/2023t[s]P[mmHg]左心室收縮力指數(shù)dPmx=動脈壓力曲線的上升枝PiCCO心肌收縮力參數(shù)收縮力參數(shù)dPmx指的是左心室壓力曲線上的最大值。20PICCO監(jiān)測的意義和影響因素7/20/2023SVmax–SVminSVV=SVmeanSVmaxSVminSVmeanTheStrokeVolumeVariationisthevariationinstrokevolumeovertheventilatorycycle,measuredovertheprevious30secondperiod.IntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–StrokeVolumeVariationSVV提示心臟對容量治療的反應好壞每博量變異是每博量在一個呼吸周期中的變異，它所測量的是之前30秒的值。21PICCO監(jiān)測的意義和影響因素7/20/2023PPmax–PPminPPV=PPmeanThepulsepressurevariationisthevariationinpulsepressureovertheventilatorycycle,measuredovertheprevious30secondperiod.IntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–PulsePressureVariationPPmaxPPmeanPPmin脈壓變異是在一個呼吸周期里面脈搏壓力的變異，它測得的是之前30秒的值。22PICCO監(jiān)測的意義和影響因素7/20/2023GEF是4倍的SV除以全心舒張末期容量它反應的是全心功能參數(shù)GEF=GlobalEjectionFractionContractilityparametersfromthethermodilutionmeasurementIntroductiontothePiCCO-Technology–Contractilityparameters4xSVGEF=GEDVLALVRARV23PICCO監(jiān)測的意義和影響因素7/20/2023

CFI是CI除以全心舒張末期容量指數(shù)它與GEF相似，是反映全心功能的參數(shù)CFI=CardiacFunctionIndexCICFI=GEDVIIntroductiontothePiCCO-Technology–ContractilityparametersContractilityparametersfromthethermodilutionmeasurement24PICCO監(jiān)測的意義和影響因素7/20/2023作為一個后負荷指數(shù)，它是心血管狀況更深層的決定性因素。這是一個非常重要的參數(shù)，它可以提示容量控制和兒茶酚胺的治療。(MAP–CVP)x80SVR=COAfterloadparameter后負荷SVR=SystemicVascularResistance全身血管阻力MAP=MeanArterialPressureCVP=CentralVenousPressureCO=CardiacOutput80=FactorforcorrectionofunitsIntroductiontothePiCCO–Technology–Afterloadparameter25PICCO監(jiān)測的意義和影響因素7/20/2023DifferentiatingLungOedemaPVPI=PulmonaryVascularPermeabilityIndex肺血管通透性指數(shù)

肺血管通透性可以鑒別肺水腫的類型（靜水壓型vs滲透型）EVLWPVPI=PBVPBVEVLWIntroductiontoPiCCOTechnology–PulmonaryPermeability26PICCO監(jiān)測的意義和影響因素7/20/2023PBV肺血容量靜水壓肺水腫滲透性肺水腫PVPI=PBVEVLW正常升高升高PVPI=PBVEVLW升高升高正常PVPI=PBVEVLW正常正常正常PBVEVLW*PBVEVLW*PBVEVLW*正常肺EVLW血管外肺水用肺血管通透性指數(shù)（PVPI）判斷肺水腫的種類27PICCO監(jiān)測的意義和影響因素7/20/2023相關(guān)要素指示劑量、溫度、注射速度血溫、心率、血壓熱稀釋波形脈搏波形輪廓患者身高、體重28PICCO監(jiān)測的意義和影響因素7/20/2023

全心舒張末期血容量（GEDV）巨大主動脈瘤會造成數(shù)值偏高當血管內(nèi)容量嚴重不足時，數(shù)值偏大血管外肺水（EVLW）巨大肺栓塞的時候，數(shù)據(jù)偏大肺切除病人，數(shù)據(jù)偏低經(jīng)肺熱稀釋法所得參數(shù)左向右分流時，無法進行測量體外循環(huán)期間影響容量參數(shù)的監(jiān)測脈搏輪廓分析所得參數(shù)當病人使用IABP時皆不可測得嚴重心率不齊時皆不可測得哪些情況會造成PiCCO參數(shù)準確性偏差？29PICCO監(jiān)測的意義和影響因素7/20/2023冷注射液<8℃；（成人10-15ml；兒童3-5ml；單次不能超過20ml）。注射速度應快速、均勻，以5秒為佳；三次測量時間控制在