PiCCO在ICU中的应用资料

PiCCO在ICU中的应用资料第1页/共62页2PiCCOTechnology容量管理IntroductiontothePiCCO-TechnologyCOVolumetricpreloadEVLWContractilityDifferentiatedVolumeManagementstatic-dynamic第2页/共62页3正确的监测才能进行正确的治疗第3页/共62页4什么是PiCCO？第4页/共62页5

PiCCO是一种技术，是一种简便、微创、高效费比的，对重症病人主要血流动力学参数进行监测的工具。第5页/共62页6Centralvenouscatheter•jugular•subclavian•femoral大多数血流动力学不稳定的患者都会置•中心静脉导管(vasoactiveagentsadministration…)•动脉导管(monitoringofbloodpressure,bloodsamples…)Thermodilutionarterialcatheter•femoral•axillary•longradial连接第6页/共62页7Centralvenouscatheter•jugular•subclavian•femoral第7页/共62页8PiCCO技术可以监测心输出量第8页/共62页9PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysisPrinciplesofMeasurementLeftHeartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHPULSIOCATHCVCPULSIOCATHarterialthermodilutioncathetercentralvenousbolusinjectionIntroductiontothePiCCO-Technology–Function第9页/共62页10TranspulmonarythermodilutionmethodArterialTDcatheter动脉热稀释导管

(e.g.PV2014L16)CVbolusinjection中心静脉一次注射RAEDV右房舒张末容量PBV肺血容量EVLWLAEDV左房舒张末容量LVEDV左室舒张末容量EVLW血管外肺水RVEDV右室舒张末容量010203040500,00,20,40,6[°C]-DTInjection[s]LungsCVCAortaV.cava

sup.RAArterialTDcatheter第10页/共62页11Tb=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=COTDa第11页/共62页12TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.

36,537510ThermodilutioncurvesNormalCO:5.5l/minIntroductiontothePiCCO-Technology–Thermodilution36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperature第12页/共62页13经肺vs.肺动脉热稀释LeftheartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHarterialthermo-dilutioncathetercentralvenousbolusinjectionRARVPALALVAortaTranspulmonaryTD(PiCCO)PulmonaryArteryTD(PAC)这两种方法所得CO都是准确的，因为热稀释方法关注的只是时间以及温度改变！第13页/共62页14TranspulmonarythermodilutionCOmeasurement(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

第14页/共62页15Pulsecontouranalysis脉搏轮廓分析Cal=calibrationfactorobtainedfromtranspulmonarythermodilution(coldbolusinjection)

校准系数来自经肺热稀释方法Surface

=Cal.x

Strokevolume第15页/共62页PCCO=cal.HR.

(P(t)/SVR+C(p).dP/dt)dtsystolePatient-specificcalibrationfactor(determinedwiththermodilution)complianceshapeofpressurecurveareaofpressurecurveP(mmHg)t(s)第16页/共62页17Validationofcontinuouscardiacoutputmeasurementbythepulsecontouranalysis(PiCCOsystem)PiCCO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;50:1044-1049第17页/共62页18

PiCCO不仅是

心排量监测仪第18页/共62页19

PiCCO™technologyGEDV—评估心脏前负荷容量第19页/共62页20目前医学界判斷心脏前負荷的标准Centrolvenouspressure(CVP)Pulmonarycapillarywedgepressure(PCWP)

但是這是基於以下的假設“压力=容量

"但這種假設並非完全正確

PULSIONMedicalSystems第20页/共62页21Kumaretal.,CritCareMed2004;32:691-69921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第21页/共62页22Kumaretal.,CritCareMed2004;32:691-69922肺动脉嵌压和每搏输出量的关联MeasuringPreload监测前负荷灌注压CVP/PCWP反映前负荷第22页/共62页23RaperRandSibbaldWJ.Chest1986

Misledbythewedge?TheSwan-Ganzcatheterandleftventricularpreload.第23页/共62页24GEDV可以作为心脏前负荷的指标GlobalEnd-DiastolicVolume

evaluatedbytranspulmonarythermodilutionGEDV第24页/共62页25COxMTt=volumeofdistribution=1+2+3+4+53IndicatorinjectionIndicatordilutioncurve14253第25页/共62页26COxMTt=volumeofdistribution=1+2+3+4+53COxDst=largestmixingchamber=33IndicatorinjectionIndicatordilutioncurve14253第26页/共62页27COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVGEDVNewmanetal.Circulation1951COxDSt=largestmixingchamber=PBV+EVLWPBVEVLW第27页/共62页28Changesinstrokevolumeindex(%)Changesinglobalend-diastolicvolumeindex(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM2002第28页/共62页29治疗指南－SurvivingSepsisCampaignGuidelines2008:»

灌注压在评估扩容治疗中已经被证实有局限性...使用血流量或者容量参数指导容量管理或许更有优势

…

这些技术已经能够在ICU内实现

…«

PiCCO技术第29页/共62页30Intrathoracicpressure 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第30页/共62页31SVmaxSVminSVmeanSVmax–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第31页/共62页32SVV

反映了心脏对因机械通气导致的前负荷周期性变化的敏感性。1,15,18,19,20SVV

可用于预测扩容治疗对每搏量的提高程度。1,15,18,19,20对于没有心律失常的完全机械通气病人而言，每搏量变异-SVV第32页/共62页3300.511-specificitysensitivitySVVCVP00.60.410.80.210%StrokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbrainsurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9sensitivity=79%specificity=93%第33页/共62页34心肌收缩状况FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSIONVENTRICULAREDVVENTRICULARSTROKEVOLUMEFromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,1976第34页/共62页35CFI—心脏收缩功能指数第35页/共62页

TEEFACPiCCOCFI第36页/共62页Jabotetal(submitted)r=0.80第37页/共62页38t[s]P[mmHg]左心室收缩力指数dPmx

=

动脉压力曲线的上升枝PiCCO心肌收缩力参数第38页/共62页39PiCCO心肌收缩力参数dPmx反映了左心室最大压力增加的速度，是心肌收缩力的参数第39页/共62页40全心射血分数（GEF）（经肺热稀释导管）GEF=GEDV4xSVRVEF=RVEDVSVLVEF=LVEDVSV右心室射血分数（RVEF）（肺动脉热稀释导管）左心室射血分数（LVEF）（心脏超声）12&3全心射血分数GEF右心左心肺PBVEVLWEVLWRAEDVRVEDVLVEDV每搏量（SV）LAEDV

射血分数：与每搏量和舒张末期容积相关第40页/共62页41EVLW—肺水肿指数第41页/共62页42ExtravascularwatercontentofthelungPulmonarycirculationLeftHeartRightHeartLungs血管外肺水EVLW在管理前负荷中的作用EVLW=ExtravascularLungWaterBodycirculation监测前负荷分辨以及量化肺水肿仅有的一个在床边获得肺水量化值的方法对容量过度补充有预警功能第42页/共62页43RALARVLVGEDVRALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDV第43页/共62页44COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDVEVLW=(COxMTt)-ITBVEVLW第44页/共62页45COxMTtcold=coldindicatorvolumeofdistributionRALARVLVPBVEVLWCOxMTtICG=ICGvolumeofdistributionEVLWEVLWRALARVLVPBV第45页/共62页46第46页/共62页47EVLWmeasuredwiththePiCCOsystemcomparedwithgravimetricsindogswithcardiogenicandnon-cardiogenicpulmonaryedemaKatzenelsonetal.SCCM2002EVLWPiCCOEVLWGrav.第47页/共62页48Source 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.Röntgenstr.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光片的对比

胸部X光片常受到胸腔内渗出的影响，并受到床旁拍摄X光片技术方面的限制第48页/共62页49监测ELWI能够发现肺水10-15%的增加X-ray只有在肺水100-300%增长时才能甄别第49页/共62页50373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]第50页/共62页51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组第51页/共62页Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema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HowtouseEVLWmeasurements?如何应用EVLW指标？第52页/共62页Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema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）HowtouseEVLWmeasurements?如何应用EVLW指标？

第53页/共62页54PiCCO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

LungWater第54页/共62页Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema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Howtou