血流动力学监测PICCO课件.ppt

危重病患者的血流动力学监测focusonPiCCO,北京协和医院杜斌,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,血流动力学监测为何不能改善预后,不恰当的适应症PAC的副作用或并发症获得数据的方法不正确仪器定标错误,或传感器位置错误获得的数据不能反映血流动力学状态错误使用数据(对数据的解读错误)作出治疗决定前未考虑其他相关因素CXR,尿量,血清白蛋白采用的治疗措施无效或有害无需血流动力学监测时未及时拔除PAC,PAC的使用减少:Illinois,USA,AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132),PAC的使用减少:Illinois,USA,AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132),临床评价vs.血流动力学,目的:评价肺动脉导管(PAC)得到的血流动力学指标是否能够改变患者的治疗设计:前瞻性观察患者:103例留置PAC的患者方法:插管前,请医生对一些血流动力学指标的范围,诊断及治疗方案进行预测插管后,复习患者病例,记录插管时及置管8小时内的血流动力学,EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,临床评价vs.血流动力学,EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,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%应用未预计到的治疗方案30%,EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,临床评价vs.血流动力学,结论单纯根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,血流动力学数据的解释,临床场景(n=44)心脏外科术后16ARDS9全身性感染9心源性休克5其他情况5,SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741,血流动力学数据的解释,SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741,血流动力学数据的解释,SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741,血流动力学参数改变治疗决定,SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015,ICU患者的输液治疗,输液治疗的决定因素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,临床判断缺乏准确性:PAWP,0,10,15,19,19,15,10,0,预计PAWP(mmHg),测定PAWP(mmHg),EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,Nochangeinplannedtherapyaftercatheterization,Changeinplannedtherapyaftercatheterization,0,临床判断缺乏准确性:CO,0,4.5,7.0,预计CO(L/min),测定CO(L/min),EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,4.5,7.0,临床判断缺乏准确性,EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553,Howgoodareourclinicalskills?,CardiacoutputWedgepressure,Bayliss(BMJ83)CCUpts71%62%,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.2005;71:621,临床判断缺乏准确性,医生常常相信自己的判断,但自信与准确性之间并无相关性与经验较少的医生相比,尽管有经验的医生更为自信,但他们的判断并不准确医生不应盲目根据自己对心脏功能的判断,作为治疗决策的依据,DawsonNVetal.Hemodynamicassessmentinmanagingthecriticallyill:isphysicianconfidencewarranted?MedDecisMaking1993;13:258-266,临床判断血流动力学的准确性,临床重要的血流动力学参数,SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015,心脏手术后患者的血流动力学监测,问卷调查(39个问题)血流动力学监测容量替代正性肌力药物/升压药物输血德国的80个ICU主任问卷回收率69%,KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.,心脏手术后患者的血流动力学监测,KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.,英格兰与威尔士ICU的CO监测技术,EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131),英格兰与威尔士ICU的CO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.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131),AreWeUsingPACCorrectly?,PAWP测定中的技术问题,MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170,PAWP测定中的技术问题,MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170,WPinitialWPconfirmed=116mmHgRange(-13,+22),PAWP测定中的技术问题,MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708,PAWP测定中的技术问题,MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708,ICU医生缺乏PAC的相关知识,目的:评价欧洲国家ICU医生对PAC相关知识的了解程度设计: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ICU的535名医生参加问卷调查干预:在每个ICU中,所有医生均被要求同时完成一项调查问卷,包括31个多选题,涉及床旁留置PAC的所有方面,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,ICU医生缺乏PAC的相关知识,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,ICU医生缺乏PAC的相关知识,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,ICU医生缺乏PAC的相关知识,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,ICU医生缺乏PAC的相关知识,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,ICU医生缺乏PAC的相关知识,GnaegiA,FeihlF,PerretC.Intensivecarephysiciansinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220,IsThereanEasyAlternativetoThisDilemma?,Centralvenouscatheter,InjectatetemperaturesensorhousingPV4046,Arterialthermodilutioncatheter,InjectatetemperaturesensorcablePC80109,PULSIONdisposablepressuretransducerPV8115,PCCI,AP,13.0316.28TB37.0,AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625,DPTMonitorcablePMK-206,InterfacecablePC80150,ConnectioncabletobedsidemonitorPMK-XXX,AUXadaptercablePC81200,PiCCO的技术原理,PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:,心输出量的测定:经肺热稀释技术,中心静脉内注射指示剂后,动脉导管尖端的热敏电阻测量温度下降的变化曲线通过分析热稀释曲线,使用Stewart-Hamilton公式计算得出心输出量(CO),心输出量的测定: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,热稀释法测定CO:PiCCOvs.PAC,动脉脉搏轮廓分析,动脉脉搏轮廓分析通过动脉压力波型的形状获得连续的每搏参数通过经肺热稀释法的初始校正后,该公式可以在每次心脏搏动时计算出每搏量(SV),SV,连续心输出量测定:PiCCO,压力曲线下面积,压力曲线型状,动脉顺应性参数,心率,与病人有关的校正因子,ts,PmmHg,PCCOisdisplayedaslast12smean,心输出量的测定:PiCCOvs.热稀释,PiCCO的技术原理,PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:,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通过对热稀释曲线的分析,可以得到这些容量参数,全心舒张末期容积(GEDV),全心舒张末期容积(GEDV)是心脏4个腔室内的血容量,胸腔内血容积(ITBV),胸腔内血容积(ITBV)是心脏4个腔室的容积+肺血管内的血液容量,血管外肺水(EVLW),血管外肺水(EVLW)是肺内含有的水量,可以在床旁定量判断肺水肿的程度,容量的测量原理,lnc(I),注射,At,再循环的影响,MTt,t,e,-1,DSt,c(I),MTt:Meantransittime平均传输时间halfoftheindicatorpassedthepointofdetection,DSt:Downslopetime下降时间exponentialdownslopetimeofTDcurve,容量的测量原理,Vall=V1+V2+V3+V4=MTtxFlowMeieretal.JApplPhysiol.1954,V3=最大腔的容积=DStxFlowNewmanetal.Circulation.1951,指示剂由注射点到检测点的平均传输时间MTt由两点间的总容积决定,下降时间DSt由其中最大的腔室决定(比其它腔至少大20%成立!),flow,V3,V4,V2,V1,注射,检测,胸腔内的容积组成,GEDV,PTV,RAEDV,PBV,LAEDV,LVEDV,RVEDV,EVLW,EVLW,ITTV,PTV=肺内热容积,在一系列混合腔室中具有最大的热容积(DSt容积)ITTV=胸腔内总热容积,从注射点到测量的热容积之和(MTt容积)GEDV=全心舒张末期容积=ITTVPTV,容量的测量原理,RAEDV,PTV,LAEDV,LVEDV,RVEDV,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=ITTVPTV,2019/12/16,56,可编辑,ITBV的测量原理,Sakkaetal,IntensiveCareMed2000;26:180-187,ITBV=1.25*GEDV28.4ml,r=0.96,ITBVTD(ml),GEDVST(ml),GEDVvs.ITBVin57intensivecarepatients,ITBV准确性的临床验证,Sakkaetal,IntensiveCareMed26:180-187,2000,n=209r=0.97,Bias=-7.6ml/m2SD=57.4ml/m2,ITBVISTvs.ITBVITDin209intensivecarepatients,容量测量小结,ITTV=COxMTtTDa,PTV=COxDStTDa,ITBV=1.25xGEDV,GEDV=ITTVPTV,PiCCO前负荷指标,在反映心脏前负荷的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最主要的优点是不受机械通气的影响而产生错误,因此能够在任何情况下提供前负荷情况的正确信息经由GEDV和SV计算得到的全心射血分数(GEF),在一定程度上反映了心肌收缩功能GEF=4xSV/GEDV,容量负荷反应组与无反应组的CVP,扩容治疗前的肺动脉楔压,p0.05,扩容治疗前的右室舒张末容积指数,扩容治疗前的右室舒张末面积,p100%时,胸片才会发生改变BongardFS,Surgery1984胸片对EVLW的改变并不敏感HelperinBD,Chest1984确定患者是否符合ARDS影像学表现时,医生之间存在非常明显的差异Rubenfeldetal,Chest1999,容量测量小结,ITTV=COxMTtTDa,PTV=COxDStTDa,ITBV=1.25xGEDV,EVLW=ITTVITBV,GEDV=ITTVPTV,EVLW:PiCCOvs.重力法测定,Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139,血管外肺水的临床验证,Sakkaetal,IntensiveCareMed26:180-187,2000,Bias=-0.2ml/kgSD=1.4ml/kg,n=209r=0.96,EVLWISTvs.EVLWITDin209intensivecarepatients,减少血管外肺水:临床试验,Mitchelletal,AmRevRespDis145:990-998,1992,血管外肺水,血管外肺水(EVLW)通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的严重程度,病人机械通气的天数,住ICU的时间及死亡率明确相关,其评估肺水肿远远优于胸部X线肺血管通透性指数(PVPI)一定程度上反映了肺水肿形成的原因PVPI=EVLW/PBV,隐匿性肺水肿的检测,原发性与继发性ARDS/ALI的鉴别,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?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673),原发性与继发性ARDS/ALI的鉴别,MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673),SIRS及ARDS:肺血管通透性与肺水肿,TagamiT,KushimotoS,AtsumiT,MatsudaK,MiyazakiY,OyamaR,KoidoY,KawaiM,YokotaH,YamamotoY.InvestigationofthepulmonaryvascularpermeabilityindexandextravascularlungwaterinpatientswithSIRSandARDSunderthePiCCOsystem.CriticalCare2006;10(Suppl1):P352(doi:10.1186/cc4699),血管外肺水的测定,胸片,氧合障碍及PAWP与EVLW之间的相关性很差床旁测定EVLW为危重病患者的诊断,随访及治疗评估提供了新的方法,PiCCO,技术问题,热稀释法测定心输出量,目的: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,SchrerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524),热稀释法测定心输出量,WolfS,PlevD,SchrerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524),热稀释法测定心输出量,目的:确定热稀释法测定心输出量时2次测定与3次测定的准确性方法:回顾分析2年期间PiCCO监测的所有数据共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)的平均值,AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoringaretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293,热稀释法测定心输出量,AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoringaretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293,43%,热稀释法测定心输出量,结论采用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.PiCCOmonitoringaretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293,中心静脉插管部位的影响,SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786,颈内静脉vs.股静脉,中心静脉插管部位的影响,SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786,中心静脉插管部位的影响,SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786,中心静脉插管部位的影响,SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786,中心静脉插管部位的影响,SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786,中心静脉插管部位的影响,GrundlerS,MacchiavelloL.Femoralcentralvenouscatheter(CVC)versusinternaljugularCVCforassessmentofhaemodynamicparametersbytranspulmonarythermodilutionusingpulsecontourcardiacoutput.CriticalCare2005;9(Suppl1):P64(DOI10.1186/cc3127),肾脏替代治疗对PICCO测定的影响,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(PV2015L20;PulsionMedicalSystems)肾脏替代治疗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.CriticalCare2006;10(Suppl1):P355(doi:10.1186/cc4702),肾脏替代治疗对PICCO测定的影响,SakkaS,HanuschT,ThuemerO,WegscheiderK.Influenceofveno-venousrenalreplacementtherapyontranspulmonarythermodilutionmeasurements.CriticalCare2006;10(Suppl1):P355(doi:10.1186/cc4702),肾脏替代治疗对PICCO测定的影响,在肾脏替代治疗过程中CI降低(平均改变-0.1L/min/m2,P0.01)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.CriticalCare2006;10(Suppl1):P355(doi:10.1186/cc4702),肾脏替代治疗对PICCO测定的影响,MasonN,FroudeA,HolstB,SaaymanA,FindlayG.Theeffectofcontinuousveno-venoushaemofiltrationonPiCCOhaemodynamicparameters.CriticalCare2005;9(Suppl1):P65(DOI10.1186/cc3128),胸穿对PICCO指标的影响,目的:了解胸穿对容量指标(ITBVI,EVLWI,PVPI)的影响对象:8名ICU患者,年龄66.07.9岁APACHEII评分22.512.5,SAPSII评分50.116.8,MODS评分4.63.2,SOFA评分74.6胸穿14次,平均1.80.7,胸水量765330ml,DeerenD,DaelemansR.LinsR,MalbrainML.EffectofthoracocenthesisonvolumetricindicesinmixedICUpatients.33rdCriticalCareCongress,Orlando,Florida,USA.,胸穿对PICCO指标的影响,DeerenD,DaelemansR.LinsR,MalbrainML.EffectofthoracocenthesisonvolumetricindicesinmixedICUpatients.33rdCriticalCareCongress,Orlando,Florida,USA.,PICCO的定标,建议:每8小时对PiC