血流動(dòng)力學(xué)監(jiān)測-PICCO(杜斌)

1、危重病患者的血流動(dòng)力學(xué)監(jiān)測危重病患者的血流動(dòng)力學(xué)監(jiān)測focus on PiCCO北京協(xié)和醫(yī)院杜斌血流動(dòng)力學(xué)監(jiān)測增加患者病死率血流動(dòng)力學(xué)監(jiān)測增加患者病死率Connors AF Jr, Speroff T, Dawson NV, Thomas C, Harrel FE Jr, Wagner D, Desbjens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ Jr, Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA. The effectiveness of right heart catheteriz

2、ation in the initial care of critically ill patients. SUPPORT Investigators. JAMA 1996; 276(11): 889-897 血流動(dòng)力學(xué)監(jiān)測為何不能改善預(yù)后血流動(dòng)力學(xué)監(jiān)測為何不能改善預(yù)后不恰當(dāng)?shù)倪m應(yīng)癥PAC的副作用或并發(fā)癥獲得數(shù)據(jù)的方法不正確n儀器定標(biāo)錯(cuò)誤, 或傳感器位置錯(cuò)誤獲得的數(shù)據(jù)不能反映血流動(dòng)力學(xué)狀態(tài)錯(cuò)誤使用數(shù)據(jù)(對(duì)數(shù)據(jù)的解讀錯(cuò)誤)作出治療決定前未考慮其他相關(guān)因素nCXR, 尿量, 血清白蛋白采用的治療措施無效或有害無需血流動(dòng)力學(xué)監(jiān)測時(shí)未及時(shí)拔除PACPAC的使用減少的使用減少: Illinois, US

3、A2000年年2001年年降低降低%出院患者數(shù)1,636,0461,684,089PAC使用數(shù)5,9695,02215.8PAC使用率(/1000)3.652.98年齡0 17歲2195765 74歲1,7391,37521 75歲1,9171,62015.5性別男性3,4922,97015女性2,4732,05217Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Critical Care 2005; 9(Suppl 1): P69 (DOI 10.1186/cc31

4、32)PAC的使用減少的使用減少: Illinois, USA2000年年2001年年降低降低%醫(yī)院大醫(yī)院87369620其他醫(yī)院5,0924,32615地區(qū)Chicago39.4Rockford40St. Louis33.6中部15Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Critical Care 2005; 9(Suppl 1): P69 (DOI 10.1186/cc3132)臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué)目的: 評(píng)價(jià)肺動(dòng)脈導(dǎo)管(PAC)得

5、到的血流動(dòng)力學(xué)指標(biāo)是否能夠改變患者的治療設(shè)計(jì): 前瞻性觀察患者: 103例留置PAC的患者方法:n插管前, 請(qǐng)醫(yī)生對(duì)一些血流動(dòng)力學(xué)指標(biāo)的范圍, 診斷及治療方案進(jìn)行預(yù)測n插管后, 復(fù)習(xí)患者病例, 記錄插管時(shí)及置管8小時(shí)內(nèi)的血流動(dòng)力學(xué)Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7)

6、: 549-553臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué)0%20%40%60%PAWPCOSVRRAP預(yù)測準(zhǔn)確性預(yù)測準(zhǔn)確性Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué)結(jié)果留置PAC后n計(jì)劃治療方案需要改

7、變58%u應(yīng)用未預(yù)計(jì)到的治療方案30%Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué)結(jié)論單純根據(jù)臨床表現(xiàn)難以準(zhǔn)確預(yù)測血流動(dòng)力學(xué)指標(biāo)PAC監(jiān)測數(shù)據(jù)通常能夠改變治療方案Eisenberg PR, Jaffe AS,

8、Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋臨床場景(n = 44)心臟外科術(shù)后16ARDS 9全身性感染 9心源性休克 5其他情況 5Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A,

9、Bakker J, Perret C. A computer program for interpreting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋不同意見數(shù)目不同意見數(shù)目Kappa計(jì)算機(jī)輔助診治前住院醫(yī)生與計(jì)算機(jī)5.7 2.20.64 0.14*計(jì)算機(jī)輔助診治后住院醫(yī)生與計(jì)算機(jī)1.9 2.00.88 0.12住院醫(yī)生與主治醫(yī)生1.2 1.70.9

10、2 0.10主治醫(yī)生與計(jì)算機(jī)0.9 1.20.95 0.07*p 0.05Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for interpreting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋

11、計(jì)算機(jī)輔助前計(jì)算機(jī)輔助前計(jì)算機(jī)輔助后計(jì)算機(jī)輔助后RCRCRSSC酸堿失衡0.830.930.950.98機(jī)械通氣0.780.950.960.98代謝0.520.860.900.96充盈狀態(tài)0.560.840.910.93泵功能0.530.840.900.90循環(huán)0.720.910.940.96RC: 住院醫(yī)生與計(jì)算機(jī); RS: 住院醫(yī)生與主治醫(yī)生; SC: 主治醫(yī)生與計(jì)算機(jī)Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for inter

12、preting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741血流動(dòng)力學(xué)參數(shù)改變治療決定血流動(dòng)力學(xué)參數(shù)改變治療決定Squara P, Bennett D, Perret C. Chest 2002; 121: 2009-2015ICU患者的輸液治療患者的輸液治療輸液治療的決定因素臨床經(jīng)驗(yàn)中心靜脈壓或肺動(dòng)脈楔壓Boldt J, Lenz M, Kumle B, Papsdorf M. Volume

13、replacement strategies on intensive care units: results from a postal survey. Intensive Care Med 1998; 24: 147-151臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性: PAWP01015191915100預(yù)計(jì)預(yù)計(jì)PAWP (mmHg)測定測定PAWP (mmHg)Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynam

14、ic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553No change in planned therapy after catheterizationChange in planned therapy after catheterization0臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性: CO04.57.0預(yù)計(jì)預(yù)計(jì)CO (L/min)測定測定CO (L/min)Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to

15、pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-5534.57.0臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill p

16、atients. Crit Care Med 1984; 12(7): 549-553參數(shù)參數(shù)判斷正確數(shù)目判斷正確數(shù)目/測定數(shù)目測定數(shù)目正確率正確率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855How good are our clinical skills?Cardiac outputWedge pressureConnors(NEJM 83)ICU pts44% 42%Eisenberg(CCM 84)ICU pts50% 33%Bayliss(BMJ 83)CCU pts71% 62%臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性Clinical eval

17、uation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patientsEisenberg PR, et al. Crit Care Med 1984; 12: 349Assessing hemodynamic status in critically ill patients: Do physicians use clinical information optimally?Connors AF, et al. J Crit Care 1987; 2

18、: 174Therapeutic impact of PAC in the ICUSteingrub, et al. Chest 1991; 99: 1451PAC in critically ill patients: A prospective analysis of outcome changes associated with catheter-prompted changes in therapyMimoz O et al. Crit Care Med 1994; 22: 573Hemodynamic and pulmonary fluid status in the trauma

19、patient: are we slipping?Veale WN Jr, et al. Am Surg.2005; 71: 621臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性醫(yī)生常常相信自己的判斷, 但自信與準(zhǔn)確性之間并無相關(guān)性與經(jīng)驗(yàn)較少的醫(yī)生相比, 盡管有經(jīng)驗(yàn)的醫(yī)生更為自信, 但他們的判斷并不準(zhǔn)確醫(yī)生不應(yīng)盲目根據(jù)自己對(duì)心臟功能的判斷, 作為治療決策的依據(jù)Dawson NV et al. Hemodynamic assessment in managing the critically ill: is physician confidence warranted? Med Decis Making

20、1993; 13: 258-266臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性Clinical SettingAccurate Assessment, %Unanticipated Changes in Therapy Based on PAC, %Connors, et al62 noncardiac medical intensive care patients4848Eisenberg, et al103 critically ill patients5030Tuchschmidt and Sharma35 noncardiac medical intensive care pa

21、tients 4265Steingrub, et al154 combined medical/surgical intensive care patients 5147Connors, et alCardiac and noncardiac medical intensive care 6647臨床重要的血流動(dòng)力學(xué)參數(shù)臨床重要的血流動(dòng)力學(xué)參數(shù)所有醫(yī)生所有醫(yī)生(n = 417)心內(nèi)科醫(yī)生心內(nèi)科醫(yī)生(n = 27)CO330 (79%)21 (75%)PAWP285 (68%)27 (100%)SvO2220 (53%)10 (38%)MPAP120 (37%)10 (38%)SV100 (24

22、%)3 (13%)RAP20 (5%)RVEF20 (5%)RVEDV18 (4%)Squara P, Bennett D, Perret C. Chest 2002; 121: 2009-2015心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測問卷調(diào)查(39個(gè)問題)n血流動(dòng)力學(xué)監(jiān)測n容量替代n正性肌力藥物 / 升壓藥物n輸血德國的80個(gè)ICU主任問卷回收率69%Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Groe J, Schirmer U. Current practice of hemodynamic monitoring

23、and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiologica Scandinavica 2007; 51(3): 347-358.心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測血流動(dòng)力學(xué)監(jiān)測血流動(dòng)力學(xué)監(jiān)測比例比例(%)基本監(jiān)測100肺動(dòng)脈導(dǎo)管(PAC)58.2經(jīng)食道超聲(TEE)38.1PICCO13.0Kastrup M, Markewitz A, S

24、pies C, Carl M, Erb J, Groe J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiologica Scandinavica 2007; 51(3): 347-358.英格蘭與威爾士英格蘭與威爾士ICU的的CO監(jiān)測技術(shù)監(jiān)測技術(shù)Esdai

25、le B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England and Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131)英格蘭與威爾士英格蘭與威爾士ICU的的CO監(jiān)測技術(shù)監(jiān)測技術(shù)CO監(jiān)測技術(shù) 2種69%首選經(jīng)食道多普勒監(jiān)測CO41%常規(guī)監(jiān)測ScvO220%Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive

26、care units in England and Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131)Are We Using PAC Correctly?PAWP測定中的技術(shù)問題測定中的技術(shù)問題Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure. Crit Care Med 1984; 12(3): 164

27、-170N (%) measurements% of technical problemsNo problem1868 (69)Technical problems843 (31)Criterion 1 (total)(12)(38)Unable to obtain an “atrial waveform”1238Criterion 2 (total)156 (6)19WP waveform intermediate between the phasic PA and atrial waveforms100 (4)12Spontaneous variation of WP56 (2)7Crit

28、erion 3 (total)381 (14)45Poor dynamic response184 (7)22Damped tracing65 (2)8Overinflation42 (2)5Cannot aspirate blood with the catheter in the PA36 (1)4Cannot aspirate blood with the catheter in the wedge position54 (2)6PAWP測定中的技術(shù)問題測定中的技術(shù)問題Morris AH, Chapman RH, Gardner RM. Frequency of technical pr

29、oblems encountered in the measurement of pulmonary artery wedge pressure. Crit Care Med 1984; 12(3): 164-170WPTechnical ProblemCorrected byInitialConfirmed228OverinflationDeflated balloon812Venous bloodAdvance 2 cm308Venous bloodWithdrawn156Venous bloodNothing812Poor dynamic responseWithdrawn 4 cm24

30、8Poor dynamic responseDeflated and inflated balloon2313Poor dynamic responseWithdrawn128Poor dynamic responseFlushed3618Partial WPPatient coughed214Partial WPRepositioned720Partial WPNothing1420?RepositionedWP initial WP confirmed = 11 6 mmHgRange (-13, +22)PAWP測定中的技術(shù)問題測定中的技術(shù)問題Morris AH, Chapman RH,

31、 Gardner RM. Frequency of wedge pressure errors in the ICU. Crit Care Med 1985; 13(9): 705-708ProblemDescriptionsNumber (%)Damped tracingReduced high-frequency content40 (43%)Poor dynamic responseAbsent oscillation, low frequency, or inadequate duration of oscillations after a sudden pressure decrea

32、se from approximately 300 mmHg to vascular levels58 (62%)Over inflationSlow, frequently linear increase in pressure after balloon inflation10 (9%)Partial WPWaveform intermediate between phasic PA and atrial waveforms22 (25%)PAWP測定中的技術(shù)問題測定中的技術(shù)問題Distribution of WP measurements and frequency of a WP er

33、ror 4 mmHgTrauma ICURespiratory ICUN% (95%CI)N% (95%CI)Total WP attempts10917% (11 26%)17710% (6 15%)WP ultimately confirmed80158Initial WP without technical problems468% (3 16%)1334% (1 8%)Initial WP with technical problems5326% (18 44%)4031% (17 47%)No WP obtained104Morris AH, Chapman RH, Gardner

34、RM. Frequency of wedge pressure errors in the ICU. Crit Care Med 1985; 13(9): 705-708ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)目的: 評(píng)價(jià)歐洲國家ICU醫(yī)生對(duì)PAC相關(guān)知識(shí)的了解程度設(shè)計(jì): 調(diào)查問卷背景: 86個(gè)歐洲大學(xué)及非大學(xué)醫(yī)院ICU對(duì)象: 從兩個(gè)歐洲危重病醫(yī)學(xué)會(huì)目錄中選取134個(gè)ICU. 其中86個(gè)ICU的535名醫(yī)生參加問卷調(diào)查干預(yù): 在每個(gè)ICU中, 所有醫(yī)生均被要求同時(shí)完成一項(xiàng)調(diào)查問卷, 包括31個(gè)多選題, 涉及床旁留置PAC的所有方面Gnaegi A, Feihl F, Perret C.

35、 Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to ac

36、t? Crit Care Med 1997; 25: 213-220PAC相關(guān)知識(shí)調(diào)查問卷的內(nèi)容分類1壓力或心輸出量測定的技術(shù)問題2相關(guān)指標(biāo)的計(jì)算3血流動(dòng)力學(xué)指標(biāo)的解讀4留置導(dǎo)管5導(dǎo)管相關(guān)并發(fā)癥的識(shí)別, 預(yù)防及治療6應(yīng)用PAC指導(dǎo)治療7其他ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)In-TrainingPostgraduate Training CompletedPrimary Medical SpecialtyAnesthesiology69.9 13.777.0 12.6Internal Medicine67.9 14.378.3 11.5Others62.4 16.369.8 15

37、.2Opinion of Respondents on Their Knowledge of PACsInadequate57.6 15.355.0 17.3Minimal65.7 14.371.9 14.1Adequate73.2 13.179.2 10.7Superfluous-83.3 0Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med

38、1997; 25: 213-220ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)60.665.46977.380.874.373.878.283.378.95060708090Never 10/mthInserting PACs: Frequency in the Last 6 MthsMean ScoresIn-TrainingPostgraduate Training CompletedGnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheteri

39、zation at the bedside: time to act? Crit Care Med 1997; 25: 213-220ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)55.862.667.971.173.663.970.275.279.581.95060708090Never 10/mthUsing PAC Data for Guiding Therapy: Frequency in the Last 6 MthsMean ScoresIn-TrainingPostgraduate Training CompletedGnaegi A, Feihl F, Perret C. I

40、ntensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí)63.470.975.977.473.367.67379.979.678.85060708090Never 10/mthSupervising PAC Insertion: Frequency in the Last 6 MthsMean ScoresIn-Training

41、Postgraduate Training CompletedGnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220Is There an Easy Alternative to This Dilemma?Central venous catheterInjectate temperature sensor hou

42、sing PV4046 Arterial thermodilution catheter Injectate temperature sensor cablePC80109 PULSION disposable pressure transducer PV8115PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP) 5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI) 625 DPT Monitor cablePMK-206Interface cablePC80150 Connection cableto beds

43、ide monitorPMK - XXX AUX adaptercable PC81200 PiCCO的技術(shù)原理的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成, 用于更有效地進(jìn)行血流動(dòng)力和容量治療, 使大多數(shù)病人不必使用肺動(dòng)脈導(dǎo)管:a. 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)b. 動(dòng)脈脈搏輪廓分析技術(shù)動(dòng)脈脈搏輪廓分析技術(shù)心輸出量的測定心輸出量的測定: 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)中心靜脈內(nèi)注射指示劑后, 動(dòng)脈導(dǎo)管尖端的熱敏電阻測量溫度下降的變化曲線通過分析熱稀釋曲線, 使用Stewart-Hamilton公式計(jì)算得出心輸出量(CO)Tb注射注射t心輸出量的測定心輸出量的測定: 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)經(jīng)

44、肺熱稀釋測量只需要在中心靜脈內(nèi)注射冷( 8C)或室溫( 24C)生理鹽水中心靜中心靜脈注射脈注射右心右心左心左心肺肺PiCCO導(dǎo)導(dǎo)管如插在管如插在股動(dòng)脈內(nèi)股動(dòng)脈內(nèi)熱稀釋法測定熱稀釋法測定CO: PiCCO vs. PACPCCO動(dòng)脈熱稀釋動(dòng)脈熱稀釋測量位置測量位置靜脈注射靜脈注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常規(guī)熱稀釋常規(guī)熱稀釋測量位置測量位置s010203040500,00,20,40,6 C- -D DT注射注射熱熱稀稀釋釋測測量量曲曲線線D-dtTKV)T(TCObiibTDa Tb = 血流溫度血流溫度Ti = 注射指示劑溫度注射指示劑溫度Vi = 注射

45、指示劑容積注射指示劑容積 Tb . dt = 熱稀釋曲線下面積熱稀釋曲線下面積K = 校正系數(shù)校正系數(shù)動(dòng)脈脈搏輪廓分析動(dòng)脈脈搏輪廓分析動(dòng)脈脈搏輪廓分析通過動(dòng)脈壓力波型的形狀獲得連續(xù)的每搏參數(shù)通過經(jīng)肺熱稀釋法的初始校正后, 該公式可以在每次心臟搏動(dòng)時(shí)計(jì)算出每搏量(SV)t sP mm HgSV連續(xù)心輸出量測定連續(xù)心輸出量測定: PiCCO壓力曲線壓力曲線下面積下面積壓力曲線型壓力曲線型狀狀PCCO = cal HR SystoleP(t)SVR+ C(p) dPdt() dt動(dòng)脈順應(yīng)動(dòng)脈順應(yīng)性參數(shù)性參數(shù)心心率率與病人有關(guān)的校與病人有關(guān)的校正因子正因子 t sP mm HgPCCO is disp

46、layed as last 12s mean心輸出量的測定心輸出量的測定: PiCCO vs. 熱稀釋熱稀釋AuthorPt/ObsCOTDa COTDpaBias SDrVon Spiegel, et al. Anaesthesist 1996; 45(11)21/48-4.7 1.5%.97McLuckie, et al. Acta Paediatr 1996; 859/?0.19 0.21 L/min/m2Goedje, et al. Chest 1998; 113(4)30/1500.16 0.31 L/min/m2.96Goedje, et al. Thorac Cardiovasc

47、 Surg 1998; 4630/8100.26 0.71 L/min.96Zoolner, et al. Anaesthesist 1998; 47(11)18/1600.03 1.04 L/min.91Goedje, et al. Crit Care Med 1999; 27(11)24/216-0.29 0.66 L/min.93Sakka, et al. Intensive Care Med 1999; 2537/4490.68 0.62 L/min.97Sakka, et al. J Cardiothorac Vasc Anesth 2000; 14(2)12/510.73 0.38

48、 L/min.96Zoolner, et al. J Cardiothorac Vasc Anesth 2000; 14(2)19/760.21 0.73 L/min.96Bindels, et al. Crit Care 2000; 445/2830.49 0.45 L/min/m2.95PiCCO的技術(shù)原理的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成, 用于更有效地進(jìn)行血流動(dòng)力和容量治療, 使大多數(shù)病人不必使用肺動(dòng)脈導(dǎo)管:a. 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)b. 動(dòng)脈脈搏輪廓分析技術(shù)動(dòng)脈脈搏輪廓分析技術(shù)PiCCO容量參數(shù)容量參數(shù)全心舒張末期容積GEDV胸腔內(nèi)血容積ITBV血管外肺水EVLW通過

49、對(duì)熱稀釋曲線的分析, 可以得到這些容量參數(shù)ln c (I)注射注射At再循環(huán)再循環(huán)MTtte-1DStc (I)全心舒張末期容積全心舒張末期容積(GEDV)全心舒張末期容積(GEDV)是心臟4個(gè)腔室內(nèi)的血容量胸腔內(nèi)血容積胸腔內(nèi)血容積(ITBV)胸腔內(nèi)血容積(ITBV)是心臟4個(gè)腔室的容積 + 肺血管內(nèi)的血液容量血管外肺水血管外肺水(EVLW)血管外肺水(EVLW)是肺內(nèi)含有的水量, 可以在床旁定量判斷肺水腫的程度容量的測量原理容量的測量原理ln c (I)注射注射At再循環(huán)的影響再循環(huán)的影響MTtte-1DStc (I)MTt: Mean transit time平均傳輸時(shí)間平均傳輸時(shí)間 ha

50、lf of the indicator passed the point of detection DSt: Downslope time下降時(shí)間下降時(shí)間 exponential downslope time of TD curve容量的測量原理容量的測量原理Vall = V1 + V2 + V3 + V4 = MTt x FlowMeier et al. J Appl Physiol. 1954V3 = 最大腔的容積最大腔的容積 = DSt x FlowNewman et al. Circulation. 1951指示劑由注射點(diǎn)到檢測點(diǎn)的平均傳輸指示劑由注射點(diǎn)到檢測點(diǎn)的平均傳輸時(shí)間時(shí)間MTt

51、由兩點(diǎn)間的總?cè)莘e決定由兩點(diǎn)間的總?cè)莘e決定下降時(shí)間下降時(shí)間DSt由其中最大的腔室決由其中最大的腔室決定定 (比其它腔至少大比其它腔至少大 20% 成立成立!)flowV3V4V2V1注射注射檢測檢測胸腔內(nèi)的容積組成胸腔內(nèi)的容積組成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV = 肺內(nèi)熱容積肺內(nèi)熱容積, 在一系列混合腔室中具有最大的熱容積在一系列混合腔室中具有最大的熱容積 (DSt 容積容積)ITTV = 胸腔內(nèi)總熱容積胸腔內(nèi)總熱容積, 從注射點(diǎn)到測量的熱容積之和從注射點(diǎn)到測量的熱容積之和 (MTt 容積容積)GEDV= 全心舒張末期容積全心舒張末期容

52、積 = ITTV PTV容量的測量原理容量的測量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔總熱容積胸腔總熱容積(ITTV)ITTV = CO x MTtTDa肺內(nèi)總熱容積肺內(nèi)總熱容積(PTV)PTV = CO x DStTDa全心舒張末期容積全心舒張末期容積GEDV = ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTVITBV的測量原理的測量原理Sakka et al, Intensive Care Med 2000; 26: 180-187ITBV = 1.25 * GEDV 28.4 mlr = 0.96ITBVTD

53、(ml)GEDVST (ml)GEDV vs. ITBV in 57 intensive care patientsITBV準(zhǔn)確性的臨床驗(yàn)證準(zhǔn)確性的臨床驗(yàn)證Sakka et al, Intensive Care Med 26: 180-187, 2000n = 209r = 0.97Bias = -7.6 ml/m2SD = 57.4 ml/m2ITBVIST vs. ITBVITD in 209 intensive care patients容量測量小結(jié)容量測量小結(jié)ITTV = CO x MTtTDaPTV = CO x DStTDaITBV = 1.25 x GEDVGEDV = ITTV

54、 PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVPiCCO前負(fù)荷指標(biāo)前負(fù)荷指標(biāo)在反映心臟前負(fù)荷的敏感性和特異性方面, 已經(jīng)證實(shí)ITBV和GEDV不但優(yōu)于CVP及PAWP, 也優(yōu)于RVEDVITBV和GEDV最主要的優(yōu)點(diǎn)是不受機(jī)械通氣的影響而產(chǎn)生錯(cuò)誤, 因此能夠在任何情況下提供前負(fù)荷情況的正確信息經(jīng)由GEDV和SV計(jì)算得到的全心射血分?jǐn)?shù)(GEF), 在一定程度上反映了心肌收縮功能nGEF = 4 x SV / GEDV容量負(fù)荷反應(yīng)組與無反應(yīng)組的容量負(fù)荷反應(yīng)組與無反應(yīng)組的CVP擴(kuò)容治療前的肺動(dòng)脈楔壓擴(kuò)

55、容治療前的肺動(dòng)脈楔壓PAOP (mmHg)有反應(yīng)者有反應(yīng)者無反應(yīng)者無反應(yīng)者Calvin et al8 17 2Schneider et al10 110 1Reuse et al10 410 3Diebel et al14 77 2 Diebel et al16 615 5Wagner and Leatherman10 314 4 Tavernier et al10 412 3Tousignant et al12 316 3 Michard et al10 311 2 p 0.05擴(kuò)容治療前的右室舒張末容積指數(shù)擴(kuò)容治療前的右室舒張末容積指數(shù)擴(kuò)容治療前的右室舒張末面積擴(kuò)容治療前的右室舒張末面積L

56、VEDA (cm2/m2)有反應(yīng)者有反應(yīng)者無反應(yīng)者無反應(yīng)者Tavernier et al9 312 4 Tousignant et al15 520 5 Feissel et al10 410 2 p 100%時(shí), 胸片才會(huì)發(fā)生改變Bongard FS, Surgery 1984胸片對(duì)EVLW的改變并不敏感Helperin BD, Chest 1984確定患者是否符合ARDS影像學(xué)表現(xiàn)時(shí), 醫(yī)生之間存在非常明顯的差異Rubenfeldet al, Chest 1999容量測量小結(jié)容量測量小結(jié)ITTV = CO x MTtTDaPTV = CO x DStTDaITBV = 1.25 x GED

57、VEVLW = ITTV ITBVGEDV = ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWEVLW: PiCCO vs. 重力法測定重力法測定Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139血管外肺水的臨床驗(yàn)證血管外肺水的臨床驗(yàn)證Sakka

58、 et al, Intensive Care Med 26: 180-187, 2000Bias = -0.2 ml/kgSD = 1.4 ml/kgn = 209r = 0.96EVLWIST vs. EVLWITD in 209 intensive care patients減少血管外肺水減少血管外肺水: 臨床試驗(yàn)臨床試驗(yàn)Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992血管外肺水血管外肺水血管外肺水(EVLW)通過經(jīng)肺熱稀釋法得到, 已被染料稀釋法和重量法證實(shí)已證實(shí)血管外肺水(EVLW)與ARDS的嚴(yán)重程度, 病人機(jī)械通氣的天數(shù), 住IC

59、U的時(shí)間及死亡率明確相關(guān), 其評(píng)估肺水腫遠(yuǎn)遠(yuǎn)優(yōu)于胸部X線肺血管通透性指數(shù)(PVPI)一定程度上反映了肺水腫形成的原因nPVPI = EVLW / PBV隱匿性肺水腫的檢測隱匿性肺水腫的檢測指標(biāo)指標(biāo)EVLW增加增加臨床癥狀100 200%胸片100 200%氧合(機(jī)械通氣時(shí))300%EVLW (PiCCO)10 15%原發(fā)性與繼發(fā)性原發(fā)性與繼發(fā)性ARDS/ALI的鑒別的鑒別患者人群(n = 10)n原發(fā)性ARDS/ALI (n = 4): 肺炎, 誤吸n繼發(fā)性ARDS/ALI (n = 6): 全身性感染評(píng)價(jià)指標(biāo)nITBVInEVLWInPVPI (EVLW/ITBV)Morisawa K, T

60、aira Y, Takahashi H, Matsui K, Ouchi M, Fujinawa N, Noda K. Do the data obtained by the PiCCO system enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS? Critical Care 2006, 10(Suppl 1):P326 (doi: 10.1186/cc4673)原發(fā)性與繼發(fā)性原發(fā)性與繼發(fā)性ARDS/ALI的鑒別的鑒別Morisawa K, Taira Y, Takahashi H, Mats