為重病患者的血流動力學(xué)監(jiān)測課件

危重病患者的血流動力學(xué)監(jiān)測

focusonPiCCO1醫(yī)學(xué)資源血流動力學(xué)監(jiān)測增加患者病死率ConnorsAFJr,SperoffT,DawsonNV,ThomasC,HarrelFEJr,WagnerD,DesbjensN,GoldmanL,WuAW,CaliffRM,FulkersonWJJr,VidailletH,BrosteS,BellamyP,LynnJ,KnausWA.Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA1996;276(11):889-8972醫(yī)學(xué)資源血流動力學(xué)監(jiān)測為何不能改善預(yù)后不恰當(dāng)?shù)倪m應(yīng)癥PAC的副作用或并發(fā)癥獲得數(shù)據(jù)的方法不正確儀器定標(biāo)錯誤,或傳感器位置錯誤獲得的數(shù)據(jù)不能反映血流動力學(xué)狀態(tài)錯誤使用數(shù)據(jù)(對數(shù)據(jù)的解讀錯誤)作出治療決定前未考慮其他相關(guān)因素CXR,尿量,血清白蛋白采用的治療措施無效或有害無需血流動力學(xué)監(jiān)測時未及時拔除PAC3醫(yī)學(xué)資源PAC的使用減少:Illinois,USA2000年2001年降低%出院患者數(shù)1,636,0461,684,089PAC使用數(shù)5,9695,02215.8PAC使用率(/1000)3.652.98年齡0–17歲2195765–74歲1,7391,37521>75歲1,9171,62015.5性別男性3,4922,97015女性2,4732,05217AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)4醫(yī)學(xué)資源PAC的使用減少:Illinois,USA2000年2001年降低%醫(yī)院大醫(yī)院87369620其他醫(yī)院5,0924,32615地區(qū)Chicago39.4Rockford40St.Louis33.6中部15AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)5醫(yī)學(xué)資源臨床評價vs.血流動力學(xué)目的:評價肺動脈導(dǎo)管(PAC)得到的血流動力學(xué)指標(biāo)是否能夠改變患者的治療設(shè)計:前瞻性觀察患者:103例留置PAC的患者方法:插管前,請醫(yī)生對一些血流動力學(xué)指標(biāo)的范圍,診斷及治療方案進行預(yù)測插管后,復(fù)習(xí)患者病例,記錄插管時及置管8小時內(nèi)的血流動力學(xué)EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5536醫(yī)學(xué)資源臨床評價vs.血流動力學(xué)EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5537醫(yī)學(xué)資源臨床評價vs.血流動力學(xué)結(jié) 果留置PAC后計劃治療方案需要改變 58%應(yīng)用未預(yù)計到的治療方案 30%EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5538醫(yī)學(xué)資源臨床評價vs.血流動力學(xué)結(jié) 論單純根據(jù)臨床表現(xiàn)難以準(zhǔn)確預(yù)測血流動力學(xué)指標(biāo)PAC監(jiān)測數(shù)據(jù)通常能夠改變治療方案EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5539醫(yī)學(xué)資源血流動力學(xué)數(shù)據(jù)的解釋臨床場景(n=44)心臟外科術(shù)后 16ARDS 9全身性感染 9心源性休克 5其他情況 5SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-74110醫(yī)學(xué)資源血流動力學(xué)數(shù)據(jù)的解釋不同意見數(shù)目Kappa計算機輔助診治前住院醫(yī)生與計算機5.72.20.640.14*計算機輔助診治后住院醫(yī)生與計算機1.92.00.880.12住院醫(yī)生與主治醫(yī)生1.21.70.920.10主治醫(yī)生與計算機0.91.20.950.07*p<0.05SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-74111醫(yī)學(xué)資源血流動力學(xué)數(shù)據(jù)的解釋計算機輔助前計算機輔助后RCRCRSSC酸堿失衡0.830.930.950.98機械通氣0.780.950.960.98代謝0.520.860.900.96充盈狀態(tài)0.560.840.910.93泵功能0.530.840.900.90循環(huán)0.720.910.940.96RC:住院醫(yī)生與計算機;RS:住院醫(yī)生與主治醫(yī)生;SC:主治醫(yī)生與計算機SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-74112醫(yī)學(xué)資源血流動力學(xué)參數(shù)改變治療決定SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-201513醫(yī)學(xué)資源ICU患者的輸液治療輸液治療的決定因素臨床經(jīng)驗中心靜脈壓或肺動脈楔壓BoldtJ,LenzM,KumleB,PapsdorfM.Volumereplacementstrategiesonintensivecareunits:resultsfromapostalsurvey.IntensiveCareMed1998;24:147-15114醫(yī)學(xué)資源臨床判斷缺乏準(zhǔn)確性:PAWP01015191915100預(yù)計PAWP(mmHg)測定PAWP(mmHg)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553NochangeinplannedtherapyaftercatheterizationChangeinplannedtherapyaftercatheterization15醫(yī)學(xué)資源0臨床判斷缺乏準(zhǔn)確性:CO04.57.0預(yù)計CO(L/min)測定CO(L/min)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5534.57.016醫(yī)學(xué)資源臨床判斷缺乏準(zhǔn)確性EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553參數(shù)判斷正確數(shù)目/測定數(shù)目正確率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/985517醫(yī)學(xué)資源Howgoodareourclinicalskills?CardiacoutputWedgepressureConnors(NEJM‘83)ICUpts44%

42%Eisenberg(CCM‘84)ICUpts50%33%Bayliss(BMJ‘83)CCUpts71%62%18醫(yī)學(xué)資源臨床判斷缺乏準(zhǔn)確性ClinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatientsEisenbergPR,etal.CritCareMed1984;12:349Assessinghemodynamicstatusincriticallyillpatients:Dophysiciansuseclinicalinformationoptimally?ConnorsAF,etal.JCritCare1987;2:174TherapeuticimpactofPACintheICUSteingrub,etal.Chest1991;99:1451PACincriticallyillpatients:Aprospectiveanalysisofoutcomechangesassociatedwithcatheter-promptedchangesintherapyMimozOetal.CritCareMed1994;22:573Hemodynamicandpulmonaryfluidstatusinthetraumapatient:areweslipping?VealeWNJr,etal.AmSurg.2005;71:62119醫(yī)學(xué)資源臨床判斷缺乏準(zhǔn)確性醫(yī)生常常相信自己的判斷,但自信與準(zhǔn)確性之間并無相關(guān)性與經(jīng)驗較少的醫(yī)生相比,盡管有經(jīng)驗的醫(yī)生更為自信,但他們的判斷并不準(zhǔn)確醫(yī)生不應(yīng)盲目根據(jù)自己對心臟功能的判斷,作為治療決策的依據(jù)DawsonNVetal.Hemodynamicassessmentinmanagingthecriticallyill:isphysicianconfidencewarranted?MedDecisMaking1993;13:258-26620醫(yī)學(xué)資源臨床判斷血流動力學(xué)的準(zhǔn)確性ClinicalSettingAccurateAssessment,%UnanticipatedChangesinTherapyBasedonPAC,%Connors,etal62noncardiacmedicalintensivecarepatients4848Eisenberg,etal103criticallyillpatients5030TuchschmidtandSharma35noncardiacmedicalintensivecarepatients<4265Steingrub,etal154combinedmedical/surgicalintensivecarepatients<5147Connors,etalCardiacandnoncardiacmedicalintensivecare<664721醫(yī)學(xué)資源臨床重要的血流動力學(xué)參數(shù)所有醫(yī)生(n=417)心內(nèi)科醫(yī)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?Chest2002;121:2009-201522醫(yī)學(xué)資源心臟手術(shù)后患者的血流動力學(xué)監(jiān)測問卷調(diào)查(39個問題)血流動力學(xué)監(jiān)測容量替代正性肌力藥物/升壓藥物輸血德國的80個ICU主任問卷回收率69%KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,Gro?eJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.Acta

Anaesthesiologica

Scandinavica2007;51(3):347-358.23醫(yī)學(xué)資源心臟手術(shù)后患者的血流動力學(xué)監(jiān)測血流動力學(xué)監(jiān)測比例(%)基本監(jiān)測100肺動脈導(dǎo)管(PAC)58.2經(jīng)食道超聲(TEE)38.1PICCO13.0KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,Gro?eJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.Acta

Anaesthesiologica

Scandinavica2007;51(3):347-358.24醫(yī)學(xué)資源英格蘭與威爾士ICU的CO監(jiān)測技術(shù)EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)25醫(yī)學(xué)資源英格蘭與威爾士ICU的CO監(jiān)測技術(shù)CO監(jiān)測技術(shù)2種69%首選經(jīng)食道多普勒監(jiān)測CO41%常規(guī)監(jiān)測ScvO220%EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)26醫(yī)學(xué)資源AreWeUsingPACCorrectly?27醫(yī)學(xué)資源PAWP測定中的技術(shù)問題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)628醫(yī)學(xué)資源PAWP測定中的技術(shù)問題MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170WPTechnicalProblemCorrectedbyInitialConfirmed228OverinflationDeflatedballoon812VenousbloodAdvance2cm308VenousbloodWithdrawn156VenousbloodNothing812PoordynamicresponseWithdrawn4cm248PoordynamicresponseDeflatedandinflatedballoon2313PoordynamicresponseWithdrawn128PoordynamicresponseFlushed3618PartialWPPatientcoughed214PartialWPRepositioned720PartialWPNothing1420?RepositionedWPinitial–WPconfirmed=116mmHgRange(-13,+22)29醫(yī)學(xué)資源PAWP測定中的技術(shù)問題MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708ProblemDescriptionsNumber(%)DampedtracingReducedhigh-frequencycontent40(43%)PoordynamicresponseAbsentoscillation,lowfrequency,orinadequatedurationofoscillationsafterasuddenpressuredecreasefromapproximately300mmHgtovascularlevels58(62%)OverinflationSlow,frequentlylinearincreaseinpressureafterballooninflation10(9%)PartialWPWaveformintermediatebetweenphasicPAandatrialwaveforms22(25%)30醫(yī)學(xué)資源PAWP測定中的技術(shù)問題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):705-70831醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識目的:評價歐洲國家ICU醫(yī)生對PAC相關(guān)知識的了解程度設(shè)計:調(diào)查問卷背景:86個歐洲大學(xué)及非大學(xué)醫(yī)院ICU對象:從兩個歐洲危重病醫(yī)學(xué)會目錄中選取134個ICU.其中86個ICU的535名醫(yī)生參加問卷調(diào)查干預(yù):在每個ICU中,所有醫(yī)生均被要求同時完成一項調(diào)查問卷,包括31個多選題,涉及床旁留置PAC的所有方面GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-22032醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220PAC相關(guān)知識調(diào)查問卷的內(nèi)容分類1壓力或心輸出量測定的技術(shù)問題2相關(guān)指標(biāo)的計算3血流動力學(xué)指標(biāo)的解讀4留置導(dǎo)管5導(dǎo)管相關(guān)并發(fā)癥的識別,預(yù)防及治療6應(yīng)用PAC指導(dǎo)治療7其他33醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識In-TrainingPostgraduateTrainingCompletedPrimaryMedicalSpecialtyAnesthesiology69.913.777.012.6InternalMedicine67.914.378.311.5Others62.416.369.815.2OpinionofRespondentsonTheirKnowledgeofPACsInadequate57.615.355.017.3Minimal65.714.371.914.1Adequate73.213.179.210.7Superfluous--83.30GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-22034醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-22035醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-22036醫(yī)學(xué)資源ICU醫(yī)生缺乏PAC的相關(guān)知識GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-22037醫(yī)學(xué)資源IsThereanEasyAlternativetoThisDilemma?38醫(yī)學(xué)資源CentralvenouscatheterInjectatetemperaturesensorhousingPV4046ArterialthermodilutioncatheterInjectatetemperaturesensorcablePC80109PULSIONdisposablepressuretransducerPV8115PCCIAP13.0316.28

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

DPTMonitorcablePMK-206InterfacecablePC80150Connection

cabletobedside

monitorPMK-XXXAUXadaptercablePC8120039醫(yī)學(xué)資源PiCCO的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成,用于更有效地進行血流動力和容量治療,使大多數(shù)病人不必使用肺動脈導(dǎo)管:a.經(jīng)肺熱稀釋技術(shù)b.動脈脈搏輪廓分析技術(shù)40醫(yī)學(xué)資源心輸出量的測定:經(jīng)肺熱稀釋技術(shù)中心靜脈內(nèi)注射指示劑后,動脈導(dǎo)管尖端的熱敏電阻測量溫度下降的變化曲線通過分析熱稀釋曲線,使用Stewart-Hamilton公式計算得出心輸出量(CO)Tb注射t41醫(yī)學(xué)資源心輸出量的測定:經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋測量只需要在中心靜脈內(nèi)注射冷(<8C)或室溫(<24C)生理鹽水中心靜脈注射右心左心肺PiCCO導(dǎo)管如插在股動脈內(nèi)42醫(yī)學(xué)資源熱稀釋法測定CO:PiCCOvs.PACPCCO動脈熱稀釋測量位置靜脈注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常規(guī)熱稀釋測量位置[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)43醫(yī)學(xué)資源動脈脈搏輪廓分析動脈脈搏輪廓分析通過動脈壓力波型的形狀獲得連續(xù)的每搏參數(shù)通過經(jīng)肺熱稀釋法的初始校正后,該公式可以在每次心臟搏動時計算出每搏量(SV)t[s]P[mmHg]SV44醫(yī)學(xué)資源連續(xù)心輸出量測定:PiCCO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(yīng)性參數(shù)心率與病人有關(guān)的校正因子t[s]P[mmHg]PCCOisdisplayedaslast12smean45醫(yī)學(xué)資源心輸出量的測定:PiCCOvs.熱稀釋AuthorPt/ObsCOTDa–COTDpaBiasSDrVonSpiegel,etal.Anaesthesist1996;45(11)21/48-4.71.5%.97McLuckie,etal.Acta

Paediatr1996;859/?0.190.21L/min/m2Goedje,etal.Chest1998;113(4)30/1500.160.31L/min/m2.96Goedje,etal.Thorac

Cardiovasc

Surg1998;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.JCardiothorac

Vasc

Anesth2000;14(2)12/510.730.38L/min.96Zoolner,etal.JCardiothorac

Vasc

Anesth2000;14(2)19/760.210.73L/min.96Bindels,etal.CritCare2000;445/2830.490.45L/min/m2.9546醫(yī)學(xué)資源PiCCO的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成,用于更有效地進行血流動力和容量治療,使大多數(shù)病人不必使用肺動脈導(dǎo)管:a.經(jīng)肺熱稀釋技術(shù)b.動脈脈搏輪廓分析技術(shù)47醫(yī)學(xué)資源PiCCO容量參數(shù)全心舒張末期容積 GEDV胸腔內(nèi)血容積 ITBV血管外肺水 EVLW通過對熱稀釋曲線的分析,可以得到這些容量參數(shù)lnc(I)注射At再循環(huán)MTtte-1DStc(I)48醫(yī)學(xué)資源全心舒張末期容積(GEDV)全心舒張末期容積(GEDV)是心臟4個腔室內(nèi)的血容量49醫(yī)學(xué)資源胸腔內(nèi)血容積(ITBV)胸腔內(nèi)血容積(ITBV)是心臟4個腔室的容積+肺血管內(nèi)的血液容量50醫(yī)學(xué)資源血管外肺水(EVLW)血管外肺水(EVLW)是肺內(nèi)含有的水量,可以在床旁定量判斷肺水腫的程度51醫(yī)學(xué)資源容量的測量原理lnc(I)注射At再循環(huán)的影響MTtte-1DStc(I)

MTt:Meantransittime平均傳輸時間

≈halfoftheindicatorpassedthepointofdetection DSt:Downslopetime下降時間≈exponentialdownslopetimeofTDcurve52醫(yī)學(xué)資源容量的測量原理Vall=

V1+V2+V3+V4

=

MTtxFlowMeieretal.JAppl

Physiol.1954V3=

最大腔的容積 =DStx

FlowNewmanetal.Circulation.1951指示劑由注射點到檢測點的平均傳輸時間MTt由兩點間的總?cè)莘e決定下降時間DSt由其中最大的腔室決定(比其它腔至少大20%成立!)flowV3V4V2V1注射檢測53醫(yī)學(xué)資源胸腔內(nèi)的容積組成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV=肺內(nèi)熱容積,在一系列混合腔室中具有最大的熱容積(DSt–容積)ITTV=胸腔內(nèi)總熱容積,從注射點到測量的熱容積之和(MTt–容積)GEDV =全心舒張末期容積=ITTV–PTV54醫(yī)學(xué)資源容量的測量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔總熱容積(ITTV)ITTV=COxMTtTDa肺內(nèi)總熱容積(PTV)PTV=COxDStTDa全心舒張末期容積GEDV=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTV55醫(yī)學(xué)資源ITBV的測量原理Sakkaetal,IntensiveCareMed2000;26:180-187ITBV=1.25*GEDV–28.4[ml]r=0.96ITBVTD(ml)GEDVST(ml)GEDVvs.ITBVin57intensivecarepatients56醫(yī)學(xué)資源ITBV準(zhǔn)確性的臨床驗證Sakkaetal,IntensiveCareMed26:180-187,2000n=209r=0.97Bias = -7.6ml/m2

SD = 57.4ml/m2ITBVISTvs.ITBVITDin209intensivecarepatients57醫(yī)學(xué)資源容量測量小結(jié)ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTV58醫(yī)學(xué)資源PiCCO前負(fù)荷指標(biāo)在反映心臟前負(fù)荷的敏感性和特異性方面,已經(jīng)證實ITBV和GEDV不但優(yōu)于CVP及PAWP,也優(yōu)于RVEDVITBV和GEDV最主要的優(yōu)點是不受機械通氣的影響而產(chǎn)生錯誤,因此能夠在任何情況下提供前負(fù)荷情況的正確信息經(jīng)由GEDV和SV計算得到的全心射血分?jǐn)?shù)(GEF),在一定程度上反映了心肌收縮功能GEF=4xSV/GEDV59醫(yī)學(xué)資源容量負(fù)荷反應(yīng)組與無反應(yīng)組的CVP60醫(yī)學(xué)資源擴容治療前的肺動脈楔壓PAOP(mmHg)有反應(yīng)者無反應(yīng)者Calvinetal8172Schneideretal101101Reuseetal104103Diebeletal14772?Diebeletal166155WagnerandLeatherman103144?Tavernieretal104123Tousignantetal123163?Michardetal103112?p<0.0561醫(yī)學(xué)資源擴容治療前的右室舒張末容積指數(shù)62醫(yī)學(xué)資源擴容治療前的右室舒張末面積LVEDA(cm2/m2)有反應(yīng)者無反應(yīng)者Tavernieretal93124?Tousignantetal155205?Feisseletal104102?p<0.0563醫(yī)學(xué)資源CVP/PAWP不能預(yù)測擴容反應(yīng)

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-14764醫(yī)學(xué)資源ITBV能夠更好地反映前負(fù)荷

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-14765醫(yī)學(xué)資源預(yù)測擴容反應(yīng):PAWP/CVPvs.ITBV1.MichardF,BoussatS,ChemlaD,AnguelN,MercatA,LecarpentierY,RichardC,PinskyMR,TeboulJL.RelationbetweenRespiratoryChangesinArterialPulsePressureandFluidResponsivenessinSepticPatientswithAcuteCirculatoryFailure.AmJRespir

CritCareMed2000;162:134-138.2.RexS,BroseS,MetzelderS,HunekeR,SchalteG,AutschbachR,RossaintR,BuhreW.Predictionoffluidresponsivenessinpatientsduringcardiacsurgery.BrJAnaesth2004;93:782-78866醫(yī)學(xué)資源前負(fù)荷指標(biāo)與SV/CI的相關(guān)性所有患者單一患者相關(guān)系數(shù),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,EurJCardiothorac

Surg

1998;13(5):533-539;discussion539-54067醫(yī)學(xué)資源心輸出量和全身循環(huán)阻力由于脈搏輪廓分析連續(xù)測量每搏量和動脈壓,可以如下計算得到心輸出量(CO)和全身循環(huán)阻力(SVR):CO=每搏量x心率SVR=(平均動脈壓

–中心靜脈壓)/CO68醫(yī)學(xué)資源每搏量變異(SVV)對于沒有心律失常的機械通氣患者SVV反映了心臟對因機械通氣導(dǎo)致的心臟前負(fù)荷周期性變化的敏感性SVV可以用于預(yù)測擴容治療是否會使每搏量增加SVmaxSVminSVmeanSVmax–SVminSVV(30秒)=SVmean69醫(yī)學(xué)資源對擴容反應(yīng)的預(yù)測性:CVPvs.SVVSensitivity1–SpecificityBerkenstadtetal,Anesth

Analg

2001;92:984-989---CVP__SVV70醫(yī)學(xué)資源血管外肺水的測定:EVLW放射影像學(xué)(radiology)指示劑稀釋技術(shù)(indicatordilutiontechnique)顯像技術(shù)(imagingtechnique)重力測定技術(shù)(gravimetrictechnique)71醫(yī)學(xué)資源氧合與肺水腫靜水壓升高引起肺水腫CMVFiO20.4ScilliaP,DelcroixM,LejeuneP,MelotC,StruyvenJ,NaeijeR,GevenoisPA.Hydrostaticpulmonaryedema:evaluationwiththin-sectionCTindogs.Radiology1999;211:161-16872醫(yī)學(xué)資源血管外肺水與氧合MartinGS,EatonS,MealerM,MossM.Extravascularlungwaterinpatientswithseveresepsis:aprospectivecohortstudy.CritCare2005;9:R74-R82(DOI10.1186/cc3025)73醫(yī)學(xué)資源血管外肺水與病死率Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-13974醫(yī)學(xué)資源血管外肺水的測定當(dāng)EVLW增加>100%時,胸片才會發(fā)生改變BongardFS,Surgery1984胸片對EVLW的改變并不敏感HelperinBD,Chest1984確定患者是否符合ARDS影像學(xué)表現(xiàn)時,醫(yī)生之間存在非常明顯的差異Rubenfeldetal,Chest199975醫(yī)學(xué)資源容量測量小結(jié)ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVEVLW=ITTV–ITBVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW76醫(yī)學(xué)資源EVLW:PiCCOvs.重力法測定Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-13977醫(yī)學(xué)資源血管外肺水的臨床驗證Sakkaetal,IntensiveCareMed26:180-187,2000Bias = -0.2ml/kg

SD = 1.4ml/kgn=209r=0.96EVLWISTvs.EVLWITDin209intensivecarepatients78醫(yī)學(xué)資源減少血管外肺水:臨床試驗Mitchelletal,AmRevRespDis145:990-998,199279醫(yī)學(xué)資源血管外肺水血管外肺水(EVLW)通過經(jīng)肺熱稀釋法得到,已被染料稀釋法和重量法證實已證實血管外肺水(EVLW)與ARDS的嚴(yán)重程度,病人機械通氣的天數(shù),住ICU的時間及死亡率明確相關(guān),其評估肺水腫遠遠優(yōu)于胸部X線肺血管通透性指數(shù)(PVPI)一定程度上反映了肺水腫形成的原因PVPI=EVLW/PBV80醫(yī)學(xué)資源隱匿性肺水腫的檢測指標(biāo)EVLW增加臨床癥狀100–200%胸片100–200%氧合(機械通氣時)300%EVLW(PiCCO)10–15%81醫(yī)學(xué)資源原發(fā)性與繼發(fā)性ARDS/ALI的鑒別患者人群(n=10)原發(fā)性ARDS/ALI(n=4):肺炎,誤吸繼發(fā)性ARDS/ALI(n=6):全身性感染評價指標(biāo)ITBVIEVLWIPVPI(EVLW/ITBV)MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673)82醫(yī)學(xué)資源原發(fā)性與繼發(fā)性ARDS/ALI的鑒別MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673)直接ARDS/ALI間接ARDS/ALIP值ITBVI984331.71279312.10.0001EVLWI13.24.716.86.50.014PVPI0.590.270.440.220.00683醫(yī)學(xué)資源SIRS及ARDS:肺血管通透性與肺水腫PVPISIRS組(n=31)2.371.0ARDS組(n=13)3.21.10非ARDS組(n=18)1.70.44非SIRS組(n=10)1.20.21TagamiT,KushimotoS,AtsumiT,MatsudaK,MiyazakiY,OyamaR,KoidoY,KawaiM,YokotaH,YamamotoY.InvestigationofthepulmonaryvascularpermeabilityindexandextravascularlungwaterinpatientswithSIRSandARDSunderthePiCCOsystem.CriticalCare2006;10(Suppl1):P352(doi:10.1186/cc4699)84醫(yī)學(xué)資源血管外肺水的測定胸片,氧合障礙及PAWP與EVLW之間的相關(guān)性很差床旁測定EVLW為危重病患者的診斷,隨訪及治療評估提供了新的方法85醫(yī)學(xué)資源PiCCO技術(shù)問題86醫(yī)學(xué)資源熱稀釋法測定心輸出量目的:確定熱稀釋法一次測定心輸出量是否準(zhǔn)確方法:回顧分析18名神經(jīng)外科ICU患者共417次測定,1465次操作ANOVA分析WolfS,PlevD,SchürerL,LumentaC.Therepeatabilityoftranspulmonary

thermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524)87醫(yī)學(xué)資源熱稀釋法測定心輸出量差值中位數(shù)兩次測定95%可重復(fù)系數(shù)相當(dāng)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.Therepeatabilityoftranspulmonary

thermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524)88醫(yī)學(xué)資源熱稀釋法測定心輸出量目的:確定熱稀釋法測定心輸出量時2次測定與3次測定的準(zhǔn)確性方法:回顧分析2年期間PiCCO監(jiān)測的所有數(shù)據(jù)共25名感染性休克患者共249次心輸出量測定比較前2次(M1)與3次測定心輸出量(M2)的平均值A(chǔ)layaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P29389醫(yī)學(xué)資源熱稀釋法測定心輸出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293CI(L/min/m2)M13.281.07M25.741.0743%90醫(yī)學(xué)資源熱稀釋法測定心輸出量結(jié) 論采用PiCCO進行監(jiān)測時,2次熱稀釋法顯然不足以可靠地測定心輸出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P29391醫(yī)學(xué)資源中心靜脈插管部位的影響SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vander

GietM.Effectofthevenouscathetersiteontranspulmonary

thermodilutionmeasurementvariables.CritCareMed2007;35:783-786頸內(nèi)靜脈vs.股靜脈92醫(yī)學(xué)資源中心靜脈插管部位的影響人口統(tǒng)計學(xué)資料MSD范圍性別男8,女3年齡,歲58.717.521–74身高,cm174.97.9165–185體重,kg75.510.265–90體表面積,m21.900.151.73–2.14SAPSII51.310.136–61SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vander

GietM.Effectofthevenouscathetersiteontranspulmonary

thermodilutionmeasurementvariables.CritCareMed2007;35:783-78693醫(yī)學(xué)資源中心靜脈插管部位的影響心肺指標(biāo)MSD范圍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,vander

GietM.Effectofthevenouscathetersiteontranspulmonary

thermodilutionmeasurementvariables.CritCareMed2007;35:783-78694醫(yī)學(xué)資源中心靜脈插管部位的影響差異95%范圍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,vander

GietM.Effectofthevenouscathetersiteontranspulmonary

thermodilutionmeasurementvariables.CritCareMed2007;35:783-78695醫(yī)學(xué)資源中心靜脈插管部位的影響頸內(nèi)靜脈,sec股靜脈,secPMTt43.418.946.618.30.0068DSt23.315.224.113.50.35AUC6.52.56.62.60.27SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vander

GietM.Effectofthevenouscathetersiteontranspulmonary

thermodilutionmeasurementvariables.CritCareMed2007;35:783-78696醫(yī)學(xué)資源中心靜脈插管部位的影響頸內(nèi)靜脈股靜脈差異%PITBVI(ml/m2)1059134527<.001EVLWI(ml/kg)14.215.812.049CI(L/min/m2)4.054.06<1.92GrundlerS,MacchiavelloL.Femoralcentralvenouscatheter(CVC)versusinternaljugularCVCforassessmentofhaemodynamicparametersbytranspulmonary

thermodilutionusingpulsecontourcardiacoutput.CriticalCare2005;9(Suppl1):P64(DOI10.1186/cc3127)97醫(yī)學(xué)資源腎臟替代治療對PICCO測定的影響24名危重病患者(男性15名,女性9名)血流動力學(xué)監(jiān)測5-F股動脈插管(PV2015L20;PulsionMedicalSystems)腎臟替代治療12-F股靜脈血透插管(TrilyseExpert;Vygon)(n=12)12-F上腔靜脈血透插管(n=12)測定部位:上腔靜脈插管(CertofixTrio;Braun,Melsungen)測定時間:RRT過程中,終止RRT即刻,重新開始后即刻SakkaS,HanuschT,ThuemerO,WegscheiderK.Influenceofveno-venousrenalreplacementtherapyontranspulmonary

thermodilutionmeasurements.CriticalCare2006;10(Suppl1):P355(doi:10.1186/cc4702)98醫(yī)學(xué)資源腎臟替代治療對PICCO測定的影響RRTNoRRTRRTHR(bpm)9927100279927MAP(mmHg)741476127413CVP(mmHg)144144144CI(L/min/m2)3.81.43.91.33.81.3ITBVI(ml/m2)934254945255920247EVLWI(ml/kg)8.33.78.33.68.43.6SakkaS,HanuschT,ThuemerO,WegscheiderK.Influen