picco機器原理培訓(xùn)chinese.ppt

PULSIONPiCCO PiCCO 連續(xù)動脈波形心排量監(jiān)護 Simple Safe Speedy Specific簡單 安全 快速 敏感 上海前茂公司市場部 PULSIONMedicalSystems 概述ContinuouscardiacoutputpulsecontourcardiacoutputPCCO PiCCO提供的是連續(xù)的心排血量 心臟的前負荷容量和血管外肺水的監(jiān)測以溫度稀釋法測量各項 容積量 Preloadvolume Lungwater真正的連續(xù)性心輸出量測量運用脈搏曲線分析法 Pulsecontouranalysis 不需使用肺動脈導(dǎo)管 swan ganz 連續(xù)動脈壓力測量 PULSIONMedicalSystems 心肺生理學(xué) Intrathoracicgasvolume GAS Intrathoracicbloodvolume ITBV Extravasularlungwater EVLW 肺部的容量由以上三種構(gòu)成 其中一個改變將會影響另外一個或者兩個的容量 PULSIONMedicalSystems 目前醫(yī)學(xué)界判斷心臟前負荷的標(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 PULSIONMedicalSystems 臨床上評估血量的可靠程度 近年來已有大量病人分析的資料 並且證實 目前通用的監(jiān)測CVP PCWP MAP及Hct 血球容積比 並不足以反應(yīng)出重癥病患的體內(nèi)血含量 PULSIONMedicalSystems Criticalcaremed 12 107 1121984reliabilityofclinicalmonitoringtoassesbloodvolumeincriticallyillpatient 所以根據(jù)CVP PCWP等來判斷容量負荷 Volumeload 可能有誤導(dǎo)的情形 特別是在使用呼吸機做正壓機械通氣時會造成病人胸內(nèi)壓上升等情況下 如果我們可以直接測量心臟的前負荷血量 Volume 則能幫助我們作更精確的診斷及治療 PULSIONMedicalSystems 臨床上評估血量的可靠程度 PiCCO配置示意圖 中心靜脈通道 e g PV2014L16 動脈熱稀釋導(dǎo)管 PV8015 一次性壓力傳感器 PV4046 注射液體溫度傳感器 partofPV8015 Transpulmonarythermodilutionmethod ArterialTDcatheter動脈熱稀釋導(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 EVLW LAEDV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 0 1 0 2 0 3 0 4 0 5 0 0 0 0 2 0 4 0 6 C D T Injection s Lungs CVC Aorta V cavasup RA ArterialTDcatheter Transpulmonarythermodilutionparameters CardiacoutputCO 心排血量 IntrathoracicbloodvolumeITBV 胸腔內(nèi)血容量 ExtravascularlungwaterEVLW 血管外肺水 CardiacfunctionindexCFI 心功能指數(shù) 經(jīng)肺熱稀釋測量的參數(shù) CardiacOutput Tb injection t 經(jīng)肺熱稀釋法 CardiacOutput Stewart Hamiltonmethod ComparisonofCOTDaandCOTDpa Authorpat obsCOTDa COTDparbias SDvonSpiegeletal 199621 48 4 7 1 5 0 97Anaesthesist45 11 McLuckieetal 19969 0 19 0 21l min m2ActaPaediatr85Goedjeetal 199830 150 triple 0 16 0 31l min m20 96Chest113 4 Goedjeetal 199830 8100 26 0 7l min0 96ThoracCardiovascSurg46Z llneretal 199818 160 131double 29triple 0 03 1 04l min0 91Anaesthesist47 11 Goedjeetal 199924 216 triple 0 29 0 66l min0 93CritCareMed27 11 Sakkaetal 199937 4490 68 0 62l min0 97IntensiveCareMed25Sakkaetal 200012 51 triple 0 73 0 38l min0 98JCardiothoracVascAnesth14 2 Z llneretal 200019 76 triple 0 21 0 73l min0 96JCardiothoracVascAnesth14 2 Bindelsetal 200045 2830 49 0 45l min m20 95CritCare4 VolumetricMonitoring 容量監(jiān)測的方法 I At AppearancetimeMTt MeantransittimeDSt Downslopetime 出現(xiàn)時間平均通過時間下斜時間 CVbolusinjection ArterialTDcatheter e g PV2014L16 ITTV IntrathoracicthermalvolumePTV PulmonarythermalvolumeGEDV Globalend diastolicvolumeEVLW ExtravascularlungwaterITBV Intrathoracicbloodvolume 容量監(jiān)測的方法 II RAEDV PBV EVLW LAEDV LVEDV EVLW RVEDV PTV GEDV ITTV ITBV ITTV CO MTtTDa PTV CO DStTDa ITBV 1 25 GEDV EVLW ITTV ITBV GEDV ITTV PTV Methodologyofvolumetricmonitoring III DeterminationofVolume At MTt DSt e 1 PULSIONMedicalSystems MTtxC Oa Volumeofallmixngchambers ITTV MTtxC Oa DStxC Oa Volumeoflargestmixingchamber PTV DStxC Oa injection GEDV GEDV ITTV PTV CardiacfunctionindexCFIanewcardiacperformanceindex CFI CFI取決于 contractilityafterloadheartrateCFI用于指導(dǎo)inotropic vasoactive藥物的使用 C Oa GEDV PULSIONMedicalSystems IntrathoracicBloodVolumeITBV RelationshipbetweenITBVandGEDV Sakkaetal IntensiveCareMed26 180 187 2000 GEDVvs ITBVin57intensivecarepatients r 0 96 ITBV 1 25 GEDV 28 4 ml Pressuresasindicatorsofcardiacpreload Lichtwarck AschoffM etal IntensivCareMed18 142 147 1992 Lichtwarck AschoffM etal IntensivCareMed18 142 147 1992 ITBVasindicatorofcardiacpreload CardiacPreloadisVolumeNOTPressure 許多研究證明ITBV比CVP PCWP更適合做為Preload的指標(biāo) IntrathoracicBloodVolume ITBV RAEDV PBV LAEDV LVEDV RVEDV Lichtwarck AschoffM etal IntensiveCareMed18 142 147 1992 ExtravascularLungWaterEVLW Sakkaetal IntensiveCareMed26 180 187 2000 ThermodilutionEVLWISTvs thermo dyedilutionEVLWITD Bias 0 2ml kgSD 1 4ml kg n 209r 0 96 EVLWISTvs EVLWITDin209intensivecarepatients SourceComparisonCorrelationHalperinetal 1985 X rayscorevs r 0 51Chest88 649 EVLWBaudendisteletal 1982X rayscorevs EVLW77 JTrauma22 983Sibbaldetal 1983comparisoncardiacedemar 0 66Chest83 725comparisonnoncardiacedemar 0 7Sivaketal 1983X rayscorevsEVLW64 CritCareMed 11 498 X rayscorevs EVLW42 Laggneretal 1984X rayscorevs EVLWr 0 84IntensiveCareMed 10 309Halleretal 1985X rayscorevs EVLW66 Fortschr R ntgenstr 142 68Eisenbergetal 1987X rayscorevs EVLW76 AmRevRespDis136 662Takedaetal 1995X rayscorevs EVLWX rayinsensitiveJVetMedSci57 3 481 ComparisonofEVLWandchestX ray B ckJ LewisFR In PracticalApplicationsofFiberopticsinCriticalCareMonitoring SpringerVerlagBerlin Heidelberg NewYork1990 pp129 139 EVLWandoxygenation EVLW ITTV ITBV Picco cold 測EVLW是唯一在bedsize就可得知肺部狀況數(shù)據(jù)的儀器肺血管滲透性損壞的情形可由EVLW PBV得知 正常為1最高可達5表示受損嚴重Bloodgas就不只完全受上述狀況所影響 因還牽涉到lungperfusion及ventilation的情況肺部X光是整個胸部密度的測量 它受許多因素影響而無法正確判斷Lungwater的狀況 SturmJA In PracticalApplicationsofFiberopticsinCriticalCareMonitoring SpringerVerlagBerlin Heidelberg NewYork1990 pp129 139 Lungwater EVLW andmortality RelevanceofEVLW management MitchellJP SchullerD CalandrinoFS SchusterDP AmRevRespDis145 990 998 1992 22days 15days 9days 7days RHCgroup RHCgroup EVLWgroup EVLWgroup Ventilationdays ICUdays RelationshipofITBVItoEVLWI 3 因此代表perload的ITBV不能降至低於正常范圍下 以避免cardiacoutput跟著下降 產(chǎn)生供氧不足 也無法進一步降低lungwater 1 對于lungwater增加的情況而言 可用限制volume的方法來降低 2 當(dāng)肺血管的permeability高于正常范圍時 用限水的方式不能讓ITBV低于正常范圍 否則EVLW也無法再被降低 0 200 400 600 800 1000 1200 2 5 5 0 7 5 10 0 GEDVI ml m2 CI l min m2 Volume Inotropics normalrange normalcardiacfunction CFI CI GEDVI Cardiacperformance PulseContourAnalysis t s P mmHg P t Aorticvalveopen HeartinsystolicPhase RiseofthebloodpressurecurvedependentonthecharacteristicComplianceoftheAorta Aorticcompliance Systole Aorticcompliance Diastole P t HeartindiastolicPhase Aorticvalveclosed FallofthebloodpressurecurvedependentonthecharacteristicComplianceoftheAorta IndividualaorticcomplianceC p Measuredbloodpressure P t MAP CVP ReferenceCOvaluefromthermodilution DeterminationoftheindividualaorticcomplianceC p Areaofpressurecurve Shapeofpressurecurve Compliance Heartrate Patient specificcalibrationfactor determinedwiththermodilution t s P mmHg CalculationofPCCO Model Pulsecontourparameters PulsecontourcardiacoutputPCCO 動脈連續(xù)心排血量 HeartrateHR 心率 ArterialpressureAP 動脈壓 StrokevolumeSV 每搏心排量 StrokevolumevariationSVV 每波心排量變異 SystemicvascularresistanceSVR 體循環(huán)阻力 IndexofleftventricularcontractilitydP dtmax 左室收縮力指數(shù) 連續(xù)動脈波形測量的參數(shù) Indexofleftventricularcontractility C O主要取決於四個因素 PreloadContractilityofheartAfterloadHeartrate dP dtmax t t p p p p t t Frank Starlinglaw 在可承受的限度內(nèi)增加preload可增加C O但如果心收縮力下降 應(yīng)用增加preload的方法 可能導(dǎo)致治療失當(dāng) 因為增加volume也無法使CFI回到正常曲線在這種情形下 既然心收縮力是心肌力量的指標(biāo) 只能用正性肌力藥物 inotropic 來刺激心肌 增加它的收縮力 PULSIONMedicalSystems ContinuouspulsecontouranalysisStrokevolumevariationSVV PULSIONMedicalSystems SVV SVmean x100 SVmax SVmin SVV計算SV平均30秒的變化程度 在一個使用呼吸器的病人 SVV主要取決於其血管的填充狀況 當(dāng)一個較大的SV變動時 通常是由機械換氣所引發(fā) 它會引導(dǎo)血管不適當(dāng)?shù)某涮?根據(jù)這點 SVV可以提供有關(guān)volume或因呼吸而改變的volume狀況一個大概的判斷 在一個很大的SVV建議執(zhí)行溫度稀釋法測量ITBV來判斷volume的狀況 ComparisonofPCCOandCOTDpa Authorpat obsPCCO COTDparbias SDGoedjeetal 199830 270 triple 0 11 0 6l min0 91ThoracCardiovascSurg46Goedjeetal 199924 216 triple 0 07 0 7l min m20 92CritCareMed27 11 Buhreetal 199912 36 triple 0 003 0 63l min0 94JCardiothoracVascAnesth13 4 Goedjeetal 199920 192 triple 0 1 0 42l min0 91AnnThoracSurg68 4 Z llneretal 200019 76 triple 0 31 1 25l min0 88JCardiothoracVascAnesth14 2 PCCOvsCOTDpain30patientsaftercardiacsurgery Goedjeetal ThoracCardiovascSurg46 242 249 1998 正常值范圍 ParameterRangeUnitCI3 0 5 0l min m2ITBVI850 1000ml m2EVLWI3 0 7 0ml kgCFI4 5 6 51 minHR60 901 minMAP70 90mmHgSVRI1200 2000dyn s cm 5 m2SVI40 60ml m2SVV 10 dP dtmax1200 2000mmHg sGEDVI600 750ml m2 DecisionTreeforvolumetrichemodynamicmonitoring CI l min m2 ITBVI ml m2 TherapyTargetITBVICFIEVLWI slowlyresponding 4 5 10V Cattemporary750 850 5 5 10 4 5 3 0 3 0 10CatV temporary750 850 5 5 10 10V 850 1000 10 10V temporary750 850 10 850 850 850 10OK 10V temporary750 850 10 850 EVLWI ml kg V volumeloading cautiously V volumecontraction Cat catecholamines cardiovascularagents PiCCOadvantages Method 相對于肺動脈導(dǎo)管有更小的創(chuàng)傷性同樣適用于小兒病人直接測量顯示胸腔內(nèi)血容量 ITBV 心臟舒張末