PiCCO在ICU中的應(yīng)用課件

PiCCO容量監(jiān)護(hù)儀在ICU中的應(yīng)用PiCCO在ICU中的應(yīng)用PiCCOTechnology容量管理IntroductiontothePiCCO-TechnologyCOVolumetricpreloadEVLWContractilityDifferentiatedVolumeManagementstatic-dynamic2PiCCO在ICU中的應(yīng)用正確的監(jiān)測(cè)才能進(jìn)行正確的治療3PiCCO在ICU中的應(yīng)用什么是PiCCO？4PiCCO在ICU中的應(yīng)用

PiCCO是一種技術(shù)，是一種簡(jiǎn)便、微創(chuàng)、高效費(fèi)比的，對(duì)重癥病人主要血流動(dòng)力學(xué)參數(shù)進(jìn)行監(jiān)測(cè)的工具。5PiCCO在ICU中的應(yīng)用Centralvenouscatheter?jugular?subclavian?femoral大多數(shù)血流動(dòng)力學(xué)不穩(wěn)定的患者都會(huì)置?中心靜脈導(dǎo)管(vasoactiveagentsadministration…)?動(dòng)脈導(dǎo)管(monitoringofbloodpressure,bloodsamples…)Thermodilutionarterialcatheter?femoral?axillary?longradial連接6PiCCO在ICU中的應(yīng)用Centralvenouscatheter?jugular?subclavian?femoral7PiCCO在ICU中的應(yīng)用PiCCO技術(shù)可以監(jiān)測(cè)心輸出量8PiCCO在ICU中的應(yīng)用PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysisPrinciplesofMeasurementLeftHeartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHPULSIOCATHCVCPULSIOCATHarterialthermodilutioncathetercentralvenousbolusinjectionIntroductiontothePiCCO-Technology–Function9PiCCO在ICU中的應(yīng)用TranspulmonarythermodilutionmethodArterialTDcatheter動(dòng)脈熱稀釋導(dǎo)管

(e.g.PV2014L16)CVbolusinjection中心靜脈一次注射RAEDV右房舒張末容量PBV肺血容量EVLWLAEDV左房舒張末容量LVEDV左室舒張末容量EVLW血管外肺水RVEDV右室舒張末容量010203040500,00,20,40,6[°C]-DTInjection[s]LungsCVCAortaV.cava

sup.RAArterialTDcatheter10PiCCO在ICU中的應(yīng)用Tb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫?Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate心輸出量是利用Stewart-Hamilton公式對(duì)熱稀釋曲線進(jìn)行分析所得熱稀釋方法所得心輸出量的計(jì)算Tb

xdt(Tb-Ti)xVix

KTbInjectiont∫D=COTDa11PiCCO在ICU中的應(yīng)用TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.

36,537510ThermodilutioncurvesNormalCO:5.5l/minIntroductiontothePiCCO-Technology–Thermodilution36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperature12PiCCO在ICU中的應(yīng)用經(jīng)肺vs.肺動(dòng)脈熱稀釋LeftheartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHarterialthermo-dilutioncathetercentralvenousbolusinjectionRARVPALALVAortaTranspulmonaryTD(PiCCO)PulmonaryArteryTD(PAC)這兩種方法所得CO都是準(zhǔn)確的，因?yàn)闊嵯♂尫椒P(guān)注的只是時(shí)間以及溫度改變！13PiCCO在ICU中的應(yīng)用TranspulmonarythermodilutionCOmeasurement(vsPAthermodilution)Author

Bias(L/min) SD

rGodjeChest1998

0.16

0.35

0.96SakkaICM1999 0.68 0.62 0.97GoedjeCCM1999 0.29 0.60 0.93BindelsCC2000 0.49 0.78

0.95GoedjeChest2000 0.35 0.72 0.98DellaRoccaBJA2002 0.15 0.870.93SanderCC2005 0.00 0.70 0.95OstergaardAAS2006 0.46 0.55

14PiCCO在ICU中的應(yīng)用Pulsecontouranalysis脈搏輪廓分析Cal=calibrationfactorobtainedfromtranspulmonarythermodilution(coldbolusinjection)

校準(zhǔn)系數(shù)來自經(jīng)肺熱稀釋方法Surface

=Cal.x

Strokevolume15PiCCO在ICU中的應(yīng)用PCCO=cal.HR.

(P(t)/SVR+C(p).dP/dt)dtsystolePatient-specificcalibrationfactor(determinedwiththermodilution)complianceshapeofpressurecurveareaofpressurecurveP(mmHg)t(s)PiCCO在ICU中的應(yīng)用Validationofcontinuouscardiacoutputmeasurementbythepulsecontouranalysis(PiCCOsystem)PiCCO所得連續(xù)心排量數(shù)值準(zhǔn)確性論證RoedigGetal.

BrJAnaesth1999;82:525-530GoedjeOetal.

AnnThoracSurg1999;68:1532-1536BuhreWetal.

JCardiothoracVascAnesth1999;13:437-440GoedjeOetal.

CritCareMed1999;27:2407-2412ZollnerCetal.

JCardiothoracVascAnesth2000;14:125-129GoedjeOetal.

MedSciMonit2001;7:1344-1350FelbingerTWetal.

JClinAnaesth2002;14:296-301GoedjeOetal.

CritCareMed2002;30:52-58RauchHetal.

ActaAnaesthesiolScand2002;46:426-429Felbingeretal.JClinAnaesth2005;17:241-248Ostergaardetal.

ActaAnaesthesiolScand2006;50:1044-104917PiCCO在ICU中的應(yīng)用

PiCCO不僅是

心排量監(jiān)測(cè)儀18PiCCO在ICU中的應(yīng)用

PiCCO?technologyGEDV—評(píng)估心臟前負(fù)荷容量19PiCCO在ICU中的應(yīng)用目前醫(yī)學(xué)界判斷心臟前負(fù)荷的標(biāo)準(zhǔn)Centrolvenouspressure(CVP)Pulmonarycapillarywedgepressure(PCWP)

但是這是基於以下的假設(shè)“壓力=容量

"但這種假設(shè)並非完全正確

PULSIONMedicalSystems20PiCCO在ICU中的應(yīng)用Kumaretal.,CritCareMed2004;32:691-69921灌注壓CVP/PCWP反映前負(fù)荷中心靜脈壓和每搏輸出量的關(guān)聯(lián)監(jiān)測(cè)前負(fù)荷21PiCCO在ICU中的應(yīng)用Kumaretal.,CritCareMed2004;32:691-69922肺動(dòng)脈嵌壓和每搏輸出量的關(guān)聯(lián)MeasuringPreload監(jiān)測(cè)前負(fù)荷灌注壓CVP/PCWP反映前負(fù)荷22PiCCO在ICU中的應(yīng)用RaperRandSibbaldWJ.Chest1986

Misledbythewedge?TheSwan-Ganzcatheterandleftventricularpreload.23PiCCO在ICU中的應(yīng)用GEDV可以作為心臟前負(fù)荷的指標(biāo)GlobalEnd-DiastolicVolume

evaluatedbytranspulmonarythermodilutionGEDV24PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=1+2+3+4+53IndicatorinjectionIndicatordilutioncurve1425325PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=1+2+3+4+53COxDst=largestmixingchamber=33IndicatorinjectionIndicatordilutioncurve1425326PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVGEDVNewmanetal.Circulation1951COxDSt=largestmixingchamber=PBV+EVLWPBVEVLW27PiCCO在ICU中的應(yīng)用Changesinstrokevolumeindex(%)Changesinglobalend-diastolicvolumeindex(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM200228PiCCO在ICU中的應(yīng)用治療指南－SurvivingSepsisCampaignGuidelines2008:?

灌注壓在評(píng)估擴(kuò)容治療中已經(jīng)被證實(shí)有局限性

...使用血流量或者容量參數(shù)指導(dǎo)容量管理或許更有優(yōu)勢(shì)

…

這些技術(shù)已經(jīng)能夠在ICU內(nèi)實(shí)現(xiàn)

…?

PiCCO技術(shù)29PiCCO在ICU中的應(yīng)用Intrathoracicpressure Venousreturntoleftandrightventricle Leftventricularpreload Leftventricularstrokevolume SystolicarterialbloodpressureIntrathoracicpressure ?Squeezing“ofthepulmonaryblood Leftventricularpreload Leftventricularstokevolume SystolicarterialbloodpressurePPmaxPPminPPmaxPPmin吸氣Reuteretal.,An?sthesist2003;52:1005-1013容量反映值的生理學(xué)意義呼氣吸氣呼氣吸氣早期吸氣晚期呼吸周期中血壓的波動(dòng)監(jiān)測(cè)前負(fù)荷30PiCCO在ICU中的應(yīng)用SVmaxSVminSVmeanSVmax–SVminSVV=SVmean每搏量變異SVV

每搏量變異（StrokeVolumeVariation，SVV）反映了每搏量隨通氣周期變化的情況。SVV是...

…過去30秒的測(cè)量結(jié)果…只適用于心律規(guī)律的完全機(jī)械通氣病人31PiCCO在ICU中的應(yīng)用SVV

反映了心臟對(duì)因機(jī)械通氣導(dǎo)致的前負(fù)荷周期性變化的敏感性。1,15,18,19,20

SVV

可用于預(yù)測(cè)擴(kuò)容治療對(duì)每搏量的提高程度。1,15,18,19,20對(duì)于沒有心律失常的完全機(jī)械通氣病人而言，每搏量變異-SVV32PiCCO在ICU中的應(yīng)用00.511-specificitysensitivitySVVCVP00.60.410.80.210%StrokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbrainsurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9sensitivity=79%specificity=93%33PiCCO在ICU中的應(yīng)用心肌收縮狀況FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSIONVENTRICULAREDVVENTRICULARSTROKEVOLUMEFromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,197634PiCCO在ICU中的應(yīng)用CFI—心臟收縮功能指數(shù)35PiCCO在ICU中的應(yīng)用

TEEFACPiCCOCFIPiCCO在ICU中的應(yīng)用Jabotetal(submitted)r=0.80PiCCO在ICU中的應(yīng)用t[s]P[mmHg]左心室收縮力指數(shù)dPmx

=

動(dòng)脈壓力曲線的上升枝PiCCO心肌收縮力參數(shù)38PiCCO在ICU中的應(yīng)用PiCCO心肌收縮力參數(shù)dPmx反映了左心室最大壓力增加的速度，是心肌收縮力的參數(shù)39PiCCO在ICU中的應(yīng)用全心射血分?jǐn)?shù)（GEF）（經(jīng)肺熱稀釋導(dǎo)管）GEF=GEDV4xSVRVEF=RVEDVSVLVEF=LVEDVSV右心室射血分?jǐn)?shù)（RVEF）（肺動(dòng)脈熱稀釋導(dǎo)管）左心室射血分?jǐn)?shù)（LVEF）（心臟超聲）12&

3全心射血分?jǐn)?shù)GEF右心左心肺PBVEVLWEVLWRAEDVRVEDVLVEDV每搏量（SV）LAEDV

射血分?jǐn)?shù)：與每搏量和舒張末期容積相關(guān)40PiCCO在ICU中的應(yīng)用EVLW—肺水腫指數(shù)41PiCCO在ICU中的應(yīng)用ExtravascularwatercontentofthelungPulmonarycirculationLeftHeartRightHeartLungs血管外肺水EVLW在管理前負(fù)荷中的作用EVLW=ExtravascularLungWaterBodycirculation監(jiān)測(cè)前負(fù)荷分辨以及量化肺水腫僅有的一個(gè)在床邊獲得肺水量化值的方法對(duì)容量過度補(bǔ)充有預(yù)警功能42PiCCO在ICU中的應(yīng)用RALARVLVGEDVRALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDV43PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDVEVLW=(COxMTt)-ITBVEVLW44PiCCO在ICU中的應(yīng)用COxMTtcold=coldindicatorvolumeofdistributionRALARVLVPBVEVLWCOxMTtICG=ICGvolumeofdistributionEVLWEVLWRALARVLVPBV45PiCCO在ICU中的應(yīng)用46PiCCO在ICU中的應(yīng)用EVLWmeasuredwiththePiCCOsystemcomparedwithgravimetricsindogswithcardiogenicandnon-cardiogenicpulmonaryedemaKatzenelsonetal.SCCM2002EVLWPiCCOEVLWGrav.47PiCCO在ICU中的應(yīng)用Source Comparison CorrelationBaudendisteletal,1982,JTrauma22:983 X-rayscorevs.EVLW*

77%Sibbaldetal,1983,Chest83:725

comparisoncardiacedema

r=0,66

comparisonnoncardiacedema

r=0,7Sivaketal,1983,CritCareMed.11:498

X-rayscorevsEVLW*

64%

X-rayscorevs.

EVLW*

42%Laggneretal,1984,IntensiveCareMed.10:309

X-rayscorevs.EVLW*

r=0,84 no/low/highPE,estimatedbyradiologists Halperinetal,1985,Chest88:649

X-rayscorevs.

EVLW* r=0,51

Halleretal,1985,Fortschr.R?ntgenstr.142:68 X-rayscorevs.EVLW*

66%Eisenbergetal,1987,AmRevRespDis136:662 X-rayscorevs.EVLW*

76%Takedaetal,1995,J

VetMedSci57(3):481 X-rayscorevs.EVLW* X-rayinsensitive

EVLW和胸部X光片的對(duì)比

胸部X光片常受到胸腔內(nèi)滲出的影響，并受到床旁拍攝X光片技術(shù)方面的限制48PiCCO在ICU中的應(yīng)用監(jiān)測(cè)ELWI能夠發(fā)現(xiàn)肺水10-15%的增加X-ray只有在肺水100-300%增長(zhǎng)時(shí)才能甄別49PiCCO在ICU中的應(yīng)用373位重癥ICU病人中EVLWI與死亡率的關(guān)系：其中193人感染，49人ARDS，48人頭部創(chuàng)傷，83人出血性休克。根據(jù)EVLW的數(shù)值病人分成四組。Sakkaetal,Chest2002EVLW與死亡率2ELWI[ml/kg]50PiCCO在ICU中的應(yīng)用利用EVLW治療病人101位肺水腫病人隨時(shí)分成肺動(dòng)脈導(dǎo)管（PAC）組與血管外肺水組（EVLW），分別依據(jù)PCWP和EVLW的測(cè)量結(jié)果進(jìn)行治療。在EVLW組的病人在ICU的時(shí)間和機(jī)械通氣時(shí)間都顯著降低。Mitchelletal,AmRevRespDis145:990-998,1992

22天15天9天7天**機(jī)械通氣天數(shù)住ICU天數(shù)n=101EVLW組PAC組EVLW組PAC組51PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Incaseofdoubtfuldiagnosisbasedonconventionalcriteria尤其當(dāng)傳統(tǒng)的標(biāo)準(zhǔn)產(chǎn)生不確定診斷時(shí)HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標(biāo)？PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema針對(duì)已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標(biāo)？

PiCCO在ICU中的應(yīng)用PiCCO肺相關(guān)指標(biāo)

肺血管通透性指數(shù)（PulmonaryVascularPermeabilityIndex，PVPI）=血管外肺水（EVLW）與肺血容積（PBV），反映了肺水腫的類型PulmonarvBlood

Volume靜水壓肺水腫通透性肺水腫PVPI=PBVEVLW正常升高升高

PVPI=PBVEVLW升高升高正常PVPI=PBVEVLW正常正常正常

PBVEVLWPBVEVLWPBVEVLW正常ExtraVascular

LungWater54PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedema

fordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema針對(duì)已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）InALI/ARDSpatientsforidentifyingpatientswithhighdegreeofpulmonaryedema針對(duì)ALI/ARDS的病人群，從