PiCCO参数的临床意义1课件

PiCCO监护仪的临床应用前茂企业付家红1PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02血流动力不稳定的综合分析

急性循环衰竭可能源于心输出量降低或系统低血压（压力和流量对于防止器官衰竭都是非常重要的）。系统低血压可能源于血管张力的降低（血管麻痹）或心输出量降低。除非有严重的心动过缓，病人的低心输出量与低每搏输出量密切相关，其原因可能是前负荷不足、心肌收缩功能下降或后负荷增加。急性循环衰竭时了解病理生理反应需要的所有血流动力学参数PiCCOplus都能够提供。对于带有中心静脉导管和动脉导管的病人（如大多数血流动力不稳定的ICU病人），PiCCO技术足以获得这些参数并用于指导治疗.2PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_023PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心静脉导管•颈内静脉•锁骨下静脉•股静脉大多数血流动力学不稳定的患者都会置•中心静脉导管(给血管活性药物…)•动脉导管(监测动脉压、动脉血气分析…)连接动脉热稀释导管股动脉导管腋动脉导管5PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心静脉导管•颈内静脉•锁骨下静脉•股静脉6PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO

plus

连接示意图中心静脉导管注射液温度探头容纳管（T型管）动脉热稀释导管注射液温度电缆PULSION一次性压力传感器PCCIAP13.0316.28

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

温度测量电缆压力电缆7PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO技术可以监测心输出量第一：8PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Tb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫∆Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate心输出量是利用Stewart-Hamilton公式对热稀释曲线进行分析所得热稀释方法所得心输出量的计算Tb

xdt(Tb-Ti)xVix

KTbInjectiont∫D=COTDa10PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02经肺热稀释法测量CO(vs肺动脉导管)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

12PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PCCO=cal.HR.

(P(t)/SVR+C(p).dP/dt)dtsystolePatient-specificcalibrationfactor(determinedwiththermodilution)complianceshapeofpressurecurveareaofpressurecurveP(mmHg)t(s)14PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO所得连续心排量数值准确性论证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;50:1044-104915PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

PiCCO不仅是心排量监测仪16PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

GEDV(全心舒张末期容量）

ITBV(胸腔内的血容量）

—评估心脏前负荷容量

----是充足CO的必要前提----GEDIisindexedto“理想体表面积”第二：17PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02全心舒张末期容积（GEDV）是整个心脏四个腔室血量总合，即：在舒张末期心房和心室的血量总和。胸腔内血容积（ITBV）代表整个胸腔血管内血量的总合。全心舒张末期容积（GEDV）和胸腔内血容积（ITBV）反映了循环容量状态，是心脏前负荷良好的指标。全心舒张末期容积（GEDV）和胸腔内血容积（ITBV）用于管理患者血管充盈状态以及指导容量治疗。18PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,CritCareMed2004;32:691-69920灌注压CVP/PCWP反映前负荷中心静脉压和每搏输出量的关联监测前负荷20PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,CritCareMed2004;32:691-69921肺动脉嵌压和每搏输出量的关联监测前负荷灌注压CVP/PCWP反映前负荷21PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02GEDV和ITBV的（病理）生理意义证明了GEDV指数（GEDI）和每搏输出量指数（SVI）之间存在的关系。实验总共包括36位感染性休克病人，这些病人均需容量治疗或给予更大剂量的多巴酚丁胺。血流动力学参数通过经肺热稀释法重复三次测量得到。总共在27位病人中进行了66次液体治疗，在9位病人中28次提高了多巴酚丁胺的输注速度。补充容量显著增加了中心静脉压（CVP）、全心舒张末期容积指数（GEDI）、每搏量指数（SVI）、以及心指数（CI）。GEDI的变化与SVI相关，而CVP的变化则与SVI无关。灌注前GEDI赿低的病例中正性反应越明显，灌注前GEDI的高低与治疗后GEDI和SVI提升的百分比呈负相关。输入多巴酚丁胺可以增加SVI和CI，但不会显著改变CVP和GEDI。此结果证实GEDI是心脏前负荷的指标[46]。

23PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02%*fluidloadingdobutamine**

GEDV是反映前负荷的指标Chest2003;124:1900-190824PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

SVV（每搏量变异）---预测容量反应26PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02SVmaxSVminSVmeanSVmax–SVminSVV=SVmean每搏量变异SVV

每搏量变异（StrokeVolumeVariation，SVV）反映了每搏量随通气周期变化的情况。SVV是...…过去30秒的测量结果…只适用于心律规律的完全机械通气病人27PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Intrathoracicpressure Venousreturntoleftandrightventricle Leftventricularpreload Leftventricularstrokevolume SystolicarterialbloodpressureIntrathoracicpressure „Squeezing“ofthepulmonaryblood Leftventricularpreload Leftventricularstokevolume SystolicarterialbloodpressurePPmaxPPminPPmaxPPmin吸气Reuteretal.,Anästhesist2003;52:1005-1013容量反映值的生理学意义呼气吸气呼气吸气早期吸气晚期呼吸周期中血压的波动监测前负荷28PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0200.511-specificitysensitivitySVVCVP00.60.410.80.210%StrokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbrainsurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9sensitivity=79%specificity=93%30PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02心肌收缩状况FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSION左室舒张末容量

每搏量FromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,197631PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI（心功能指数）—心肌收缩功能第三：32PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI=CI/GEDVI33PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI是一种反映心脏肌力情况的变量，与前负荷无关[33,34]。正性肌力刺激会使CI/GEDVI曲线变得更陡峭，收缩力降低则使代表心功能指数的曲线斜率变得平缓。（见图8）CFI的（病理）生理意义34PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02-15-551525354555VolumeexpansionDobutamine*percentchangesinCFI(%)

CFIbehavesasamarkerofsystolicfunctionJabotetal(submitted)AlowCFI(<4)canalerttheclinicianandincitetoperformanechoCFI(<4)提醒医生应当进一步使用超声技术诊断

RepetitivemeasurementsofCFIallowfollowingthechangesofcardiacfunctionwiththerapy多次监测CFI可以用来跟踪治疗方案实施以后心脏功能的改变35PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI和GEF的（病理）生理意义右心室和左心室射血分数的影响因素都会对CFI和GEF造成影响（心室射血分数是每搏输出量除以心室舒张末期容积）。因此，CFI和GEF不但依赖于心肌收缩力，还受右心室和左心室后负荷的影响。在这方面，实验性正性肌力刺激可以成比例增加左心室dp/dtmax（左心室收缩功能最好的指标，但是无法在床旁测量）和CFI[60]。最近有报告发现心电图测量得到的左心室收缩时间百分比与CFI之间有非常密切的相关性[61]。总的来说，CFI和GEF主要依赖于右心室和左心室收缩力，可以用来检测右心和左心室功能障碍[59-62]。36PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02t[s]P[mmHg]左心室收缩力指数dPmx

=

动脉压力曲线的上升枝PiCCO心肌收缩力参数37PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02在基础生理学中，左心室的收缩力通过左心室（LV）压力曲线的最大速度来评估。大部分的最大压力上升速度都位于LV的射血期内，即动脉压力曲线的上升枝。因此，动脉压曲线的最大变化速度可以用来反映左心的最大收缩力。严格地说，LVdP/dtmax只能在心室收缩的等电相作为定量测量收缩力的参数。因为无法直接在病人左心室内连续测量，建议在大动脉内测量压力变化的速度，以获得较好的LVdP/dtmax指标。38PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLW（血管外肺水）—肺水肿指数第四：39PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02床边直接量化肺水肿包括细胞内液，间质液以及肺泡内液(不受胸腔积液的影响)

ELWIisindexedto“PredictedBodyWeight”(theoreticalbodyweight)40PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02肺水肿severelyincreasedLungWaterELWI21ml/kgBWmoderatelyincreasedLungWaterELWI11ml/kgBWnoLungWaterincreaseELWI5ml/kgBWPulmonaryOedemaInfiltrationofwaterintothelungtissuecausedbyinflammatoryorcardiacprocessesdisablesthegasexchange(oxygenationofblood)andisdifficulttoquantifybyconventionalmethods41PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLW的（病理）生理意义肺内所含的水份可因左心衰竭、肺炎、脓毒症、中毒、烧伤等原因而增加。EVLW的增加是因为液体向组织间隙渗出增加，后者可由血管内滤过压的升高（左心衰竭，容量过多）或肺血管血浆蛋白通透性增加引起，血浆蛋白产生的胶体渗透压会将水份拉向组织间隙（内毒素休克，肺炎，脓血症，醉酒，烧伤）。EVLW是唯一可以在床旁定量监测肺部状态和肺通透性损伤情况的参数，特别是当肺水肿由肺血管通透性增加引起时。上述情况下得出的血气和肺功能指标没有器官特异性，因为它们不仅受肺部状态的影响，而且受到肺灌流和通气状况的影响。EVLW与氧合指标之间的相关性在r=0.5左右[55,63,66]。肺部X线显示的是整个胸腔的密度，它不仅受血管外肺水的影响，而且受到空气和血液含量的影响。另外，肌肉和脂肪层也会对定量评价肺部X线显影造成影响[45,51-54,56,63]。因此，血气和胸片不能用于床旁准确判断病人肺水肿的情况。肺顺应性是肺表面活性膜的参数，与肺水含量没有相关性[40]。42PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02根据EVLW判断什么样的病人

可以从限液中受益Schuster及其合作者在一些研究中发现[64,69,70]，在容量管理过程中是否考虑EVLW会对重症监护室病人的病程有所影响。所有的研究都表明，治疗医生了解血管外肺水的准确数值和变化趋势会有积极影响。一个包含100位病人的前瞻性随机对照研究表明，通过监测和控制EVLW，可以缩短机械通气和呆在ICU的时间[69]。因此，在循环容量管理过程中同时考虑EVLW可以减少肺水肿、减少机械通气天数及重症监护的天数。43PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02根据EVLW选择特定的通气模式近期有关PULSIONCOLD系统的两个实验，研究了急性呼吸衰竭病人通气模式的选择。Zeravik等人[65]发现，当ARDS的病人肺水含量较高时，联合高频通气只提高氧合。另一个研究表明，对肺水正常或略有升高的急性呼吸衰竭病人而言，压力支持通气比控制通气的效果更好[68]。这些结果说明，通过对肺水的测量，医生可以清楚病人是从联合高频通气受益，还是从压力支持自主通气受益更多。这种认识无法通过传统的评估项目获得，如氧合指标、顺应性或其它参数。44PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02ITBV和EVLW的关系过去几年内大量研究显示，根据容量测量治疗重症病人的血管内容积，比根据压力测量进行治疗有更多的优点[23-45]。EVLW的水平与病人能否出院有关[66,75]，任何降低EVLW的方法都很有可能缩短病人机械通气的时间和住在ICU的时间[68]，并且减少可能的并发症（肺炎、气胸等）。因静水压造成的EVLW增加部分，可以通过容量控制的方式来降低。下图显示当ITBV处于“正常范围”之下时，EVLW就无法再降低了。因此，代表心脏前负荷的ITBV，不能低于这个“正常范围”，以避免使心输出量进一步降低从而导致身体供氧不足。45PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0246PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02373位重症ICU病人中EVLWI与死亡率的关系：其中193人感染，49人ARDS，48人头部创伤，83人出血性休克。根据EVLW的数值病人分成四组。Sakkaetal,Chest2002EVLW与死亡率2ELWI[ml/kg]47PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLWp00.5100.51PaO2/FiO2sensitivity1-specificity16mL/kgEVLW48PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02利用EVLW治疗病人101位肺水肿病人随时分成肺动脉导管（PAC）组与血管外肺水组（EVLW），分别依据PCWP和EVLW的测量结果进行治疗。在EVLW组的病人在ICU的时间和机械通气时间都显著降低。Mitchelletal,AmRevRespDis145:990-998,1992

22天15天9天7天**机械通气天数住ICU天数n=101EVLW组PAC组EVLW组PAC组49PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema针对危重病人，甄别病人是否有肺水肿Incaseofdoubtfuldiagnosisbasedonconventionalcriteria尤其当传统的标准产生不确定诊断时

如何应用EVLW指标？50PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02监测ELWI能够发现肺水10-15%的增加X-ray只有在肺水100-300%增长时才能甄别51PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema针对危重病人，甄别病人是否有肺水肿Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema针对已经确诊肺水肿的病人，诊断肺水肿的类型（静水压型，高渗透型）

如何应用EVLW指标？

52PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO肺相关指标

肺血管通透性指数（PulmonaryVascularPermeabilityIndex，PVPI）=血管外肺水（EVLW）与肺血容积（PBV），反映了肺水肿的类型PulmonarvBlood

Volume静水压肺水肿通透性肺水肿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

LungWater53PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CardiogenicLungOedema

IncreasedhydrostaticpressurewithnormalpermeabilityPermeabilityLungOedema

NormalhydrostaticpressurewithincreasedpermeabilityAlveolusAlveoluswallAlveoluswallCapillaryCapillary54PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02109876543210PVPIALI/ARDSHydrostaticpulmonaryedema*Se=85%Sp=100%cut-offvalue=355PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02胸片、心电图和楔压测量可能会混淆由静水压引起的肺水肿病人和由通透性增加引起的肺水肿病人。事实上，心电图显示左心室收缩功能障碍并不意味着肺水肿一定是由容量过多引起的（心衰可以合并急性肺损伤）。在急性肺损伤的病人，液体过多可能会伴随肺楔压升高。在静水压型肺水肿中，可以发现EVLW增加但PVPI正常；而在通透性肺水肿中，EVLW和PVPI都增加。此外，对于通透性肺水肿而言，PVPI与肺损伤的严重程度相关[74]。56PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLWPulmonarycapillaryhydrostaticpressurePcritnormallungcapillarypermeabilityIncreasedlungcapillarypermeability14mmHgPAPO:1057PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema针对危重病人，甄别病人是否有肺水肿Inpatientswithpulmonaryedema

fordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema针对已经确诊肺水肿的病人，诊断肺水肿的类型（静水压型，高渗透型）InALI/ARDSpatientsforidentifyingpatientswithhighdegreeofpulmonaryedema针对ALI/ARDS的病人群，从中甄别严重肺水肿的病人如何应用EVLW指标？

58PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

44patientshospitalizedinBicetreHospitalforALI/ARDSaccordingtostandarddefinitions(bilateralinfiltrates,P/F,etc)35%65%EVLW<7EVLW>7Michardetal.Chest2004Managementcouldbedifferentintermsofvolumeexpansionanddiureticsuseaccordingtolungwatermeasurements根据肺水量的不同，采取扩容或者利尿的不同治疗手段59PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02心内右向左分流的检测和量化PiCCOplusV7.0可以校正可能存在的右向左分流。在有严重右向左分流的情况下CO、GEDV和EVLW都可以被准确测量，分流比例自动计算。“卵圆孔未闭的情况并非少见。尸检发现在一般人群中这种情况的比例在25%到35%之间。”[135]“当右心房和左心房之间的压力梯度是正时，这种未闭的卵圆孔就是心内右向左分流的潜在途径……”[136]“对于ARDS的病人，通过未闭卵圆孔的心脏内右向左分流，导致使用机械通气和肺内高压可能会加重低氧血症。”[137]“早期发现这种低氧血症的机制就可以进行相应治疗，如吸入一氧化氮或去除PEEP。这些治疗措施的效果可以立即通过注射冷盐水进行评估。”60PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_027.文献经肺指示剂稀释技术（TPID）的方法FrankO:DieGrundformdesarteriellenPulses.ErsteAbhandlung.MathematischeAnalyse.ZBiol37:483-526,1899PfeifferUJ,BackusG,BlümelG,EckartJ,MüllerP,WinklerP,ZeravikJ,ZimenannGJ:AFiberoptics-BasedSystemforintegratedMonitoringofCardiacOutput,IntrathoracicBloodVolume,ExtravascularLungWater,O2Saturation,anda-vDifferences.In:LewisFRandPfeifferUJ(Eds.),PracticalApplicationsofFiberopticsinCriticalCareMonitoring.Springer-VerlagBerlin-Heidelberg-NewYork1990:114-125PfeifferUJ,Lichtwarck-AschoffM,BealeR:Singlethermodilutionmonitorofglobalend-diastolicvolume,intrathoracicbloodvolumeandextravascularlungwater.ClinicalIntensiveCare5(Suppl):28,1994HoeftA:TranspulmonaryIndicatorDilution:AnAlternativeApproachforHemodynamicMonitoring.YearbookofIntensiveCareandEmergencyMedicine,Springer-VerlagBerlin-Heidelberg-NewYork,593-605,1995BuhreW,BendykK,WeylandA,KazmaierS,SchmidtM,MurschK,SonntagH:Assessmentofintrathoracicbloodvolume:Thermo-dyedilutiontechniquevssingle-thermodilutiontechnique.Anaesthesist47:51-53,1998NeumannP:Extravascularlungwaterandintrathoracicbloodvolume:doubleversussingleindicatordilutiontechnique.IntensiveCareMed25:216-219,1999SakkaSG,RühlCC,PfeifferUJ,BealeR,McLuckieA,ReinhartK,Meier-HellmannA:Assessmentofcardicacpreloadandextravascularlungwaterbysingletranspulmonarythermodilution.IntensiveCareMed26:180-187,2000SakkaSG,Meier-HellmannA:Evaluationofcardiacoutputandcardiacpreload.In:Year-bookofintensivecareandemergencymedicine2000,Ed.JLVincent,SpringerVerlag:671-67961PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02经肺指示剂稀释技术（TPID）的有效性动脉心输出量（COa）BöckJC,BarkerBC,MackersieRC,TranbaughRF,LewisFR:CardiacOutputMeasurementUsingFemoralArteryThermodilutioninPatients.JCritCare4(2):106-111,1989MurdochIA,MarshMJ,MorrisonG:Measurementofcardiacoutputinchildren.YearbookofIntensiveCareandEmergencyMedicine,Springer-VerlagBerlin-Heidelberg-NewYork,606-614,1995McLuckieA,MarshM,MurdochI,AndersonD:Acomparisonofpulmonaryandfemoralarterythermodilutioncardiacindicesinpaediatricintensivecarepatients.ActaPaediatr85:336-338,1996VonSpiegelT,WietaschG,BurschJ,HoeftA:

HZV-BestimmungmittelstranspulmonalerThermodilution.EineAlternativezumRechtscherzkatheter?[Cardiacoutputmeasurementbytranspulmonaryindicatordilutiontechnique.Analternativetopulmonarycatheterization?]Anaesthesist45(11),1045-`050,1996[EnglishAbstract]TibbySM,HatherillM,MarshMJ,MorrisonG,AndersonD,MudochIA:

ClinicalvalidationofcardiacoutputmeasurementsusingfemoralarterythermodilutionwithdirectFickinventilatedchildrenandinfants.IntensiveCareMed23:987-991,1997GödjeO,PeyerlM,SeebauerT,DewaldO,ReichartB:Reproducibilityofdoubleindicatordilutionmeasurementsofintrathoracicbloodvolumecompartments,extravascularlungwater,andliverfunction.Chest,113:1070-1077,1998

TibbySM,HatherillM,JonesG,MudochA:Measurementofcardiacoutputininfantslessthan10kg:AccurancyoffemoralarterythermodilutionascomparedwithdirectFick.CritCare2(Suppl1):P79,37,1998ZöllnerC,BriegelJ,KilgerE,HallerM:RetrospektiveAnalysedesHerzzeitvolumensmitdertranspulmonalenThermodilutionsmethodebeiARDS-Patienten.[Determinationofcardiacoutputusingthetranspulmonarythermodilutiontechniqueinpatientswithacuterespiratorydistresssyndrome]Anästhesist47(11),1998[EnglishAbstract]SakkaSG,ReinhartK,Meier-HellmannA:Comparisonofpulmonaryarterialandarterialthermodilutioncardiacoutputincriticallyillpatients.IntensiveCareMed25(8):843-846,1999SakkaSG,ReinhartK,WegscheiderK,Meier-HellmannA:Istheplacementofapulmonaryarterycatheterstilljustifiedsolelyforthemeasurementofcardiacoutput.JCardiothoracVascAnesth14:119-124,2000FriedmanZ,BerkenstadtH,MargalitN,SegalE,PerelA:Cardiacoutputassessedbyarterialthermodilutionduringexsanguinationsandfliudresuscitation:experimentalvalidationagainstareferencetechnique.EurJAnasthethiol19(5):337-40,2002KuntscherMV,Blome-EberweinS,PelzerM,ErdmannD,GermannG:Transcardioplumonaryvspulmonaryarterialthermodilutionmethodsforhemodynamicmonitoringforburnedpatients.JBurnCareRehabil2002;23:21-26PauliC,FaklerU,GenzT,HenningM,LorenzHP,HessJ:Cardiacoutputdeterminationinchildren:equivalenceofthetranspulmonarythermodilutionmethodtothedirectFickprinciple.IntensiveCareMed,28:947-952,2002FaybikP,HetzH,BakerA,etal.Icedversusroomtemperatureinjectateforassessmentofcardiacoutput.JournalofCritCareVol19(2):103-107,200462PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02胸腔内血容积（ITBV）PfeifferUJ,PerkerM,ZeravikJ,ZimmermannG:Sensitivityofcentralvenouspressure,pulmonarycapillarywedgepressure,andintrathoracicbloodvolumeasindicatorsforacuteandchronichypovolemia.In:LewisFRandPfeifferUJ(Eds.),PracticalApplicationsofFiberopticsinCriticalCareMonitoring.Springer-VerlagBerlin-Heidelberg-NewYork1990:25-31Lichtwarck-AschoffM,ZeravikJ,PfeifferUJ:Intrathoracicbloodvolumeaccuratelyreflectscirculatoryvolumestatusincriticallyillpatientswithmechanicalventilation.IntensiveCareMed18:142-147,1992HedenstiernaG:Whatvaluedoestherecordingofintrathoracicbloodvolumehaveinclinicalpractice?IntensiveCareMed18:137-138,1992Lichtwarck-AschoffM,BealeR,PfeifferUJ:Centralvenouspressure,pulmonaryarteryocclusionpressure,intrathoracicbloodvolumeandrightventricularend-diastolicvolumesasindicatorsofcardiacpreload.JCritCare11(4):180-188,1996HüttemannE:Intrathoracicbloodvolumeversusechocardiographicparameters.IntensiveCareMed7(1)(Suppl):20,1996PreismanS,PfeifferU,LiebermanN,PerelA:Newmonitorsofintravascularvolume:acomparisonofarterialpressurewaveformanalysisandtheihtrathoracicbloodvolume.IntensiveCareMed.23:651-657,1997GödjeO,PeyerlM,SeebauerT,LammP,MairH,ReichartB:Centralvenouspressure,pulmonarycapillarywedgepressureandintrathoracicbloodvolumesaspreloadindicatorsincardiacsurgerypatients.EurJCardiothoracSurg13(5):533-539;discussion539-540,1998

HinderF,PoelaertJ,SchmidtC,HoeftA,MoellhoffT,LoickH,VanAkenH:Assessmentofcardiovascularvolumestatusbytransoesophagealechocardiographyanddyedilutionduringcardiacsurgery.EurJAnaesthesiol15(6):633-640,1998SakkaSG,BredleDL,ReinhartK,Meier-HellmannA:ComparisonBetweenIntrathoracicBloodVolumeandCardiacFillingPressuresintheEarlyPhaseofHemodynamicInstabilityofPatientsWithSepsisorSepticShock.JCritCare14(2):78-83,1999McLuckieA,BihariD:Investigatingtherelationshipbetweenintrathoracicbloodvolumeindexandcardiacindex.IntensiveCareMed2000;26:1376-1378BindelsAJGH,vanderHoevenJG,GraaflandAD,deKoningJ,MeindersAE:Relationshipbetweenvolumeandpressuremeasurementsandstrokevolumeincriticallyillpatients.CritCare2000;4:193-199GoedjeO,SeebauerT,PeyerlM,PfeifferUJ,ReichartB:Hemodynamicmonitoringbydouble-indicatordilutiontechniqueinpatientsafterorthotopichearttransplantation.Chest2000;118:775-781HolmC,MelcerB,HörbrandF,WörlHH,HenkelvonDonnersmarckG,MühlbauerW:Intrathoracicbloodvolumeasanendpointresuscitationoftheseverelyburned:anobservationstudyof24patients.JTrauma2000;48:728-734BuhreW,WeylandA,BuhreK,KazmaierS,MurschK,SchmidtM,SydowM,SonntagH:Effectsofthesittingpositiononthedistributionofbloodvolumeinpatientsundergoingneurosurgicalprocedures.BrJAnesthesia2000;84:354-357BuhreW,BuherK,KazmaierS,SonntagH,WeylandA:Assessmentofcardiacpreloadbyindicatordilutionandtransesophagealechocardiography.EurJAnesthesiol2001;18:662-667WiesenackC,PrasserC,KeylC,RodijgG:Assessmentofintrathoracicbloodvolumeasanindicatorofcardiacpreload:singletranspulmonarydilutiontechniqueversusassessmentofpressurepreloadparametersderivedfromapulmonaryarterycatheter.JCardiothoracVascAnesth2001;15:584-588BuhreW,KazmaierS,SonntagH,WeylandA:Changesincardiacoutputandintrathoracicbloodvolume:amathematicalcouplingofdata.ActaAnaesthesiolScand2001;45:863-867MichardF,AlayaS,TeboulJL:Transpulmonarythermodilutionasaguidetofliudtherapyinsepticpatientswithacutecirculatoryfailure.CritCareMed2001;29:A116MalbrainM:Optimalpreloadmarkersinintra-abdominalhypertension.CritCareMed2001;29:A54ReuterDA,FelbingerTW,MoerstedtK,WeisF,SchmidtC,KilgerE,GoetzAE:Intrathoracicbloodvolumeindexmeasuredbythermodilutionforpreloadmonitoringaftercardiacsurgery.JCardiothoracVascAnesth16:191-195,2002BrockH,GabrielC,BiblD,NecekS:Monitoringintravascularvolumesforpostoperativevolumetherapy.EurJAnesthasiol19:288-294,2002HoferCK,ZalunardoMP,KlaghoferR,SpahrT,PaschT,ZollingerA:Changersinintrathoracicbloodvolumeassociatedwithpneumoperitoneumandpositioning.ActaAnaesthesiolScand46:303-308,2002JunghansT,BoehmB,HaaseO,FritzmannJ,Zuckermann-BeckerH:Conventionalmonitoringandintravascularvolumemeasurementcanleadtodifferenttherapyafteruppergastrointestinaltractsurgery.IntensiveCareMed,28:1273-12752002MichardF,AlayaS,ZarkaV,BahloulM,RichardC,TeboulJL:Global-enddiastolicvolumeasanindicatorofcardiacperloadinpatientswithsepticshock.Chest124(5):1900-1908,2003

KumarA,AnelR,BunnellE,HabetK,ZanottiS,etal.Pulmonaryarteryocclusionpressureandcentralvenouspressurefailtopredictventricularfillingvolume,cardiacperformance,ortheresponsetovolumeinfusioninnormalsubjects.CritCareMedvol32nr3:691-699,2004DellaRocaG,CostaMG,CocciaC,PompeiL,Pietropaoli:Perloadandhaemodynamicassessmentduringlivertransplantation:acomparisionbetweenthepulmonaryarterycatheterandtranspulmonaryindicatordilutiontechniques.EurJAnaesthesiol19:868-875,200263PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02GödjeO,PeyerlM,SeebauerT,LammP,MairH,ReichartB:Centralvenouspressure,pulmonarycapillarywedgepressureandintrathoracicbloodvolumesaspreloadindicatorsincardiacsurgerypatients.EurJCardiothoracSurg13(5):533-539;discussion539-540,1998

HinderF,PoelaertJ,SchmidtC,HoeftA,MoellhoffT,LoickH,VanAkenH:Assessmentofcardiovascularvolumestatusbytransoesophagealechocardiographyanddyedilutionduringcardiacsurgery.EurJAnaesthesiol15(6):633-640,1998SakkaSG,BredleDL,ReinhartK,Meier-HellmannA:ComparisonBetweenIntrathoracicBloodVolumeandCardiacFillingPressuresintheEarlyPhaseofHemodynamicInstabilityofPatientsWithSepsisorSepticShock.JCritCare14(2):78-83,1999McLuckieA,BihariD:Investigatingtherelationshipbetweenintrathoracicbloodvolumeindexandcardiacindex.IntensiveCareMed2000;26:1376-1378BindelsAJGH,vanderHoevenJG,GraaflandAD,deKoningJ,MeindersAE:Relationshipbetweenvolumeandpressuremeasurementsandstrokevolumeincriticallyillpatients.CritCare2000;4:193-199GoedjeO,SeebauerT,PeyerlM,PfeifferUJ,ReichartB:Hemodynamicmonitoringbydouble-indicatordilutiontechniqueinpatientsafterorthotopichearttransplantation.Chest2000;118:775-781HolmC,MelcerB,HörbrandF,WörlHH,HenkelvonDonnersmarckG,MühlbauerW:Intrathoracicbloodvolumeasanendpointresuscitationoftheseverelyburned:anobservationstudyof24patients.JTrauma2000;48:728-734BuhreW,WeylandA,BuhreK,KazmaierS,MurschK,SchmidtM,SydowM,SonntagH:Effectsofthesittingpositiononthedistributionofbloodvolumeinpatientsundergoingneurosurgicalprocedures.BrJAnesthesia2000;84:354-357BuhreW,BuherK,KazmaierS,SonntagH,WeylandA:Assessmentofcardiacpreloadbyindicatordilutionandtransesophagealechocardiography.EurJAnesthesiol2001;18:662-667WiesenackC,Pra