PiCCO參數(shù)的臨床意義1課件

PiCCO監(jiān)護(hù)儀的臨床應(yīng)用前茂企業(yè)付家紅1PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02血流動(dòng)力不穩(wěn)定的綜合分析

急性循環(huán)衰竭可能源于心輸出量降低或系統(tǒng)低血壓（壓力和流量對(duì)于防止器官衰竭都是非常重要的）。系統(tǒng)低血壓可能源于血管張力的降低（血管麻痹）或心輸出量降低。除非有嚴(yán)重的心動(dòng)過緩，病人的低心輸出量與低每搏輸出量密切相關(guān)，其原因可能是前負(fù)荷不足、心肌收縮功能下降或后負(fù)荷增加。急性循環(huán)衰竭時(shí)了解病理生理反應(yīng)需要的所有血流動(dòng)力學(xué)參數(shù)PiCCOplus都能夠提供。對(duì)于帶有中心靜脈導(dǎo)管和動(dòng)脈導(dǎo)管的病人（如大多數(shù)血流動(dòng)力不穩(wěn)定的ICU病人），PiCCO技術(shù)足以獲得這些參數(shù)并用于指導(dǎo)治療.2PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_023PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心靜脈導(dǎo)管?頸內(nèi)靜脈?鎖骨下靜脈?股靜脈大多數(shù)血流動(dòng)力學(xué)不穩(wěn)定的患者都會(huì)置?中心靜脈導(dǎo)管(給血管活性藥物…)?動(dòng)脈導(dǎo)管(監(jiān)測(cè)動(dòng)脈壓、動(dòng)脈血?dú)夥治觥?連接動(dòng)脈熱稀釋導(dǎo)管股動(dòng)脈導(dǎo)管腋動(dòng)脈導(dǎo)管5PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心靜脈導(dǎo)管?頸內(nèi)靜脈?鎖骨下靜脈?股靜脈6PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO

plus

連接示意圖中心靜脈導(dǎo)管注射液溫度探頭容納管（T型管）動(dòng)脈熱稀釋導(dǎo)管注射液溫度電纜PULSION一次性壓力傳感器PCCIAP13.0316.28

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

溫度測(cè)量電纜壓力電纜7PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO技術(shù)可以監(jiān)測(cè)心輸出量第一：8PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Tb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫?Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate心輸出量是利用Stewart-Hamilton公式對(duì)熱稀釋曲線進(jìn)行分析所得熱稀釋方法所得心輸出量的計(jì)算Tb

xdt(Tb-Ti)xVix

KTbInjectiont∫D=COTDa10PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02經(jīng)肺熱稀釋法測(cè)量CO(vs肺動(dòng)脈導(dǎo)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所得連續(xù)心排量數(shù)值準(zhǔn)確性論證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不僅是心排量監(jiān)測(cè)儀16PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

GEDV(全心舒張末期容量）

ITBV(胸腔內(nèi)的血容量）

—評(píng)估心臟前負(fù)荷容量

----是充足CO的必要前提----GEDIisindexedto“理想體表面積”第二：17PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02全心舒張末期容積（GEDV）是整個(gè)心臟四個(gè)腔室血量總合，即：在舒張末期心房和心室的血量總和。胸腔內(nèi)血容積（ITBV）代表整個(gè)胸腔血管內(nèi)血量的總合。全心舒張末期容積（GEDV）和胸腔內(nèi)血容積（ITBV）反映了循環(huán)容量狀態(tài)，是心臟前負(fù)荷良好的指標(biāo)。全心舒張末期容積（GEDV）和胸腔內(nèi)血容積（ITBV）用于管理患者血管充盈狀態(tài)以及指導(dǎo)容量治療。18PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,CritCareMed2004;32:691-69920灌注壓CVP/PCWP反映前負(fù)荷中心靜脈壓和每搏輸出量的關(guān)聯(lián)監(jiān)測(cè)前負(fù)荷20PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,CritCareMed2004;32:691-69921肺動(dòng)脈嵌壓和每搏輸出量的關(guān)聯(lián)監(jiān)測(cè)前負(fù)荷灌注壓CVP/PCWP反映前負(fù)荷21PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02GEDV和ITBV的（病理）生理意義證明了GEDV指數(shù)（GEDI）和每搏輸出量指數(shù)（SVI）之間存在的關(guān)系。實(shí)驗(yàn)總共包括36位感染性休克病人，這些病人均需容量治療或給予更大劑量的多巴酚丁胺。血流動(dòng)力學(xué)參數(shù)通過經(jīng)肺熱稀釋法重復(fù)三次測(cè)量得到?？偣苍?7位病人中進(jìn)行了66次液體治療，在9位病人中28次提高了多巴酚丁胺的輸注速度。補(bǔ)充容量顯著增加了中心靜脈壓（CVP）、全心舒張末期容積指數(shù)（GEDI）、每搏量指數(shù)（SVI）、以及心指數(shù)（CI）。GEDI的變化與SVI相關(guān)，而CVP的變化則與SVI無關(guān)。灌注前GEDI赿低的病例中正性反應(yīng)越明顯，灌注前GEDI的高低與治療后GEDI和SVI提升的百分比呈負(fù)相關(guān)。輸入多巴酚丁胺可以增加SVI和CI，但不會(huì)顯著改變CVP和GEDI。此結(jié)果證實(shí)GEDI是心臟前負(fù)荷的指標(biāo)[46]。

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

GEDV是反映前負(fù)荷的指標(biāo)Chest2003;124:1900-190824PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

SVV（每搏量變異）---預(yù)測(cè)容量反應(yīng)26PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02SVmaxSVminSVmeanSVmax–SVminSVV=SVmean每搏量變異SVV

每搏量變異（StrokeVolumeVariation，SVV）反映了每搏量隨通氣周期變化的情況。SVV是...…過去30秒的測(cè)量結(jié)果…只適用于心律規(guī)律的完全機(jī)械通氣病人27PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Intrathoracicpressure Venousreturntoleftandrightventricle Leftventricularpreload Leftventricularstrokevolume SystolicarterialbloodpressureIntrathoracicpressure ?Squeezing“ofthepulmonaryblood Leftventricularpreload Leftventricularstokevolume SystolicarterialbloodpressurePPmaxPPminPPmaxPPmin吸氣Reuteretal.,An?sthesist2003;52:1005-1013容量反映值的生理學(xué)意義呼氣吸氣呼氣吸氣早期吸氣晚期呼吸周期中血壓的波動(dòng)監(jiān)測(cè)前負(fù)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心肌收縮狀況FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSION左室舒張末容量

每搏量FromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,197631PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI（心功能指數(shù)）—心肌收縮功能第三：32PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI=CI/GEDVI33PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI是一種反映心臟肌力情況的變量，與前負(fù)荷無關(guān)[33,34]。正性肌力刺激會(huì)使CI/GEDVI曲線變得更陡峭，收縮力降低則使代表心功能指數(shù)的曲線斜率變得平緩。（見圖8）CFI的（病理）生理意義34PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02-15-551525354555VolumeexpansionDobutamine*percentchangesinCFI(%)

CFIbehavesasamarkerofsystolicfunctionJabotetal(submitted)AlowCFI(<4)canalerttheclinicianandincitetoperformanechoCFI(<4)提醒醫(yī)生應(yīng)當(dāng)進(jìn)一步使用超聲技術(shù)診斷

RepetitivemeasurementsofCFIallowfollowingthechangesofcardiacfunctionwiththerapy多次監(jiān)測(cè)CFI可以用來跟蹤治療方案實(shí)施以后心臟功能的改變35PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI和GEF的（病理）生理意義右心室和左心室射血分?jǐn)?shù)的影響因素都會(huì)對(duì)CFI和GEF造成影響（心室射血分?jǐn)?shù)是每搏輸出量除以心室舒張末期容積）。因此，CFI和GEF不但依賴于心肌收縮力，還受右心室和左心室后負(fù)荷的影響。在這方面，實(shí)驗(yàn)性正性肌力刺激可以成比例增加左心室dp/dtmax（左心室收縮功能最好的指標(biāo)，但是無法在床旁測(cè)量）和CFI[60]。最近有報(bào)告發(fā)現(xiàn)心電圖測(cè)量得到的左心室收縮時(shí)間百分比與CFI之間有非常密切的相關(guān)性[61]。總的來說，CFI和GEF主要依賴于右心室和左心室收縮力，可以用來檢測(cè)右心和左心室功能障礙[59-62]。36PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02t[s]P[mmHg]左心室收縮力指數(shù)dPmx

=

動(dòng)脈壓力曲線的上升枝PiCCO心肌收縮力參數(shù)37PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02在基礎(chǔ)生理學(xué)中，左心室的收縮力通過左心室（LV）壓力曲線的最大速度來評(píng)估。大部分的最大壓力上升速度都位于LV的射血期內(nèi)，即動(dòng)脈壓力曲線的上升枝。因此，動(dòng)脈壓曲線的最大變化速度可以用來反映左心的最大收縮力。嚴(yán)格地說，LVdP/dtmax只能在心室收縮的等電相作為定量測(cè)量收縮力的參數(shù)。因?yàn)闊o法直接在病人左心室內(nèi)連續(xù)測(cè)量，建議在大動(dòng)脈內(nèi)測(cè)量壓力變化的速度，以獲得較好的LVdP/dtmax指標(biāo)。38PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLW（血管外肺水）—肺水腫指數(shù)第四：39PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02床邊直接量化肺水腫包括細(xì)胞內(nèi)液，間質(zhì)液以及肺泡內(nèi)液(不受胸腔積液的影響)

ELWIisindexedto“PredictedBodyWeight”(theoreticalbodyweight)40PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02肺水腫severelyincreasedLungWaterELWI21ml/kgBWmoderatelyincreasedLungWaterELWI11ml/kgBWnoLungWaterincreaseELWI5ml/kgBWPulmonaryOedemaInfiltrationofwaterintothelungtissuecausedbyinflammatoryorcardiacprocessesdisablesthegasexchange(oxygenationofblood)andisdifficulttoquantifybyconventionalmethods41PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLW的（病理）生理意義肺內(nèi)所含的水份可因左心衰竭、肺炎、膿毒癥、中毒、燒傷等原因而增加。EVLW的增加是因?yàn)橐后w向組織間隙滲出增加，后者可由血管內(nèi)濾過壓的升高（左心衰竭，容量過多）或肺血管血漿蛋白通透性增加引起，血漿蛋白產(chǎn)生的膠體滲透壓會(huì)將水份拉向組織間隙（內(nèi)毒素休克，肺炎，膿血癥，醉酒，燒傷）。EVLW是唯一可以在床旁定量監(jiān)測(cè)肺部狀態(tài)和肺通透性損傷情況的參數(shù)，特別是當(dāng)肺水腫由肺血管通透性增加引起時(shí)。上述情況下得出的血?dú)夂头喂δ苤笜?biāo)沒有器官特異性，因?yàn)樗鼈儾粌H受肺部狀態(tài)的影響，而且受到肺灌流和通氣狀況的影響。EVLW與氧合指標(biāo)之間的相關(guān)性在r=0.5左右[55,63,66]。肺部X線顯示的是整個(gè)胸腔的密度，它不僅受血管外肺水的影響，而且受到空氣和血液含量的影響。另外，肌肉和脂肪層也會(huì)對(duì)定量評(píng)價(jià)肺部X線顯影造成影響[45,51-54,56,63]。因此，血?dú)夂托仄荒苡糜诖才詼?zhǔn)確判斷病人肺水腫的情況。肺順應(yīng)性是肺表面活性膜的參數(shù)，與肺水含量沒有相關(guān)性[40]。42PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02根據(jù)EVLW判斷什么樣的病人

可以從限液中受益Schuster及其合作者在一些研究中發(fā)現(xiàn)[64,69,70]，在容量管理過程中是否考慮EVLW會(huì)對(duì)重癥監(jiān)護(hù)室病人的病程有所影響。所有的研究都表明，治療醫(yī)生了解血管外肺水的準(zhǔn)確數(shù)值和變化趨勢(shì)會(huì)有積極影響。一個(gè)包含100位病人的前瞻性隨機(jī)對(duì)照研究表明，通過監(jiān)測(cè)和控制EVLW，可以縮短機(jī)械通氣和呆在ICU的時(shí)間[69]。因此，在循環(huán)容量管理過程中同時(shí)考慮EVLW可以減少肺水腫、減少機(jī)械通氣天數(shù)及重癥監(jiān)護(hù)的天數(shù)。43PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02根據(jù)EVLW選擇特定的通氣模式近期有關(guān)PULSIONCOLD系統(tǒng)的兩個(gè)實(shí)驗(yàn)，研究了急性呼吸衰竭病人通氣模式的選擇。Zeravik等人[65]發(fā)現(xiàn)，當(dāng)ARDS的病人肺水含量較高時(shí)，聯(lián)合高頻通氣只提高氧合。另一個(gè)研究表明，對(duì)肺水正?；蚵杂猩叩募毙院粑ソ卟∪硕?，壓力支持通氣比控制通氣的效果更好[68]。這些結(jié)果說明，通過對(duì)肺水的測(cè)量，醫(yī)生可以清楚病人是從聯(lián)合高頻通氣受益，還是從壓力支持自主通氣受益更多。這種認(rèn)識(shí)無法通過傳統(tǒng)的評(píng)估項(xiàng)目獲得，如氧合指標(biāo)、順應(yīng)性或其它參數(shù)。44PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02ITBV和EVLW的關(guān)系過去幾年內(nèi)大量研究顯示，根據(jù)容量測(cè)量治療重癥病人的血管內(nèi)容積，比根據(jù)壓力測(cè)量進(jìn)行治療有更多的優(yōu)點(diǎn)[23-45]。EVLW的水平與病人能否出院有關(guān)[66,75]，任何降低EVLW的方法都很有可能縮短病人機(jī)械通氣的時(shí)間和住在ICU的時(shí)間[68]，并且減少可能的并發(fā)癥（肺炎、氣胸等）。因靜水壓造成的EVLW增加部分，可以通過容量控制的方式來降低。下圖顯示當(dāng)ITBV處于“正常范圍”之下時(shí)，EVLW就無法再降低了。因此，代表心臟前負(fù)荷的ITBV，不能低于這個(gè)“正常范圍”，以避免使心輸出量進(jìn)一步降低從而導(dǎo)致身體供氧不足。45PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0246PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02373位重癥ICU病人中EVLWI與死亡率的關(guān)系：其中193人感染，49人ARDS，48人頭部創(chuàng)傷，83人出血性休克。根據(jù)EVLW的數(shù)值病人分成四組。Sakkaetal,Chest2002EVLW與死亡率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治療病人101位肺水腫病人隨時(shí)分成肺動(dòng)脈導(dǎo)管（PAC）組與血管外肺水組（EVLW），分別依據(jù)PCWP和EVLW的測(cè)量結(jié)果進(jìn)行治療。在EVLW組的病人在ICU的時(shí)間和機(jī)械通氣時(shí)間都顯著降低。Mitchelletal,AmRevRespDis145:990-998,1992

22天15天9天7天**機(jī)械通氣天數(shù)住ICU天數(shù)n=101EVLW組PAC組EVLW組PAC組49PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Incaseofdoubtfuldiagnosisbasedonconventionalcriteria尤其當(dāng)傳統(tǒng)的標(biāo)準(zhǔn)產(chǎn)生不確定診斷時(shí)

如何應(yīng)用EVLW指標(biāo)？50PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02監(jiān)測(cè)ELWI能夠發(fā)現(xiàn)肺水10-15%的增加X-ray只有在肺水100-300%增長時(shí)才能甄別51PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema針對(duì)已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）

如何應(yīng)用EVLW指標(biāo)？

52PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO肺相關(guān)指標(biāo)

肺血管通透性指數(shù)（PulmonaryVascularPermeabilityIndex，PVPI）=血管外肺水（EVLW）與肺血容積（PBV），反映了肺水腫的類型PulmonarvBlood

Volume靜水壓肺水腫通透性肺水腫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、心電圖和楔壓測(cè)量可能會(huì)混淆由靜水壓引起的肺水腫病人和由通透性增加引起的肺水腫病人。事實(shí)上，心電圖顯示左心室收縮功能障礙并不意味著肺水腫一定是由容量過多引起的（心衰可以合并急性肺損傷）。在急性肺損傷的病人，液體過多可能會(huì)伴隨肺楔壓升高。在靜水壓型肺水腫中，可以發(fā)現(xiàn)EVLW增加但PVPI正常；而在通透性肺水腫中，EVLW和PVPI都增加。此外，對(duì)于通透性肺水腫而言，PVPI與肺損傷的嚴(yán)重程度相關(guān)[74]。56PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLWPulmonarycapillaryhydrostaticpressurePcritnormallungcapillarypermeabilityIncreasedlungcapillarypermeability14mmHgPAPO:1057PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對(duì)危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedema

fordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema針對(duì)已經(jīng)確診肺水腫的病人，診斷肺水腫的類型（靜水壓型，高滲透型）InALI/ARDSpatientsforidentifyingpatientswithhighdegreeofpulmonaryedema針對(duì)ALI/ARDS的病人群，從中甄別嚴(yán)重肺水腫的病人如何應(yīng)用EVLW指標(biāo)？

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

44patientshospitalizedinBicetreHospitalforALI/ARDSaccordingtostandarddefinitions(bilateralinfiltrates,P/F,etc)35%65%EVLW<7EVLW>7Michardetal.Chest2004Managementcouldbedifferentintermsofvolumeexpansionanddiureticsuseaccordingtolungwatermeasurements根據(jù)肺水量的不同，采取擴(kuò)容或者利尿的不同治療手段59PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02心內(nèi)右向左分流的檢測(cè)和量化PiCCOplusV7.0可以校正可能存在的右向左分流。在有嚴(yán)重右向左分流的情況下CO、GEDV和EVLW都可以被準(zhǔn)確測(cè)量，分流比例自動(dòng)計(jì)算?！奥褕A孔未閉的情況并非少見。尸檢發(fā)現(xiàn)在一般人群中這種情況的比例在25%到35%之間。”[135]“當(dāng)右心房和左心房之間的壓力梯度是正時(shí)，這種未閉的卵圓孔就是心內(nèi)右向左分流的潛在途徑……”[136]“對(duì)于ARDS的病人，通過未閉卵圓孔的心臟內(nèi)右向左分流，導(dǎo)致使用機(jī)械通氣和肺內(nèi)高壓可能會(huì)加重低氧血癥?！盵137]“早期發(fā)現(xiàn)這種低氧血癥的機(jī)制就可以進(jìn)行相應(yīng)治療，如吸入一氧化氮或去除PEEP。這些治療措施的效果可以立即通過注射冷鹽水進(jìn)行評(píng)估?！?0PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_027.文獻(xiàn)經(jīng)肺指示劑稀釋技術(shù)（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經(jīng)肺指示劑稀釋技術(shù)（TPID）的有效性動(dòng)脈心輸出量（COa）B?ckJC,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.IntensiveCareMed23:987-991,1997G?djeO,PeyerlM,SeebauerT,DewaldO,ReichartB:Reproducibilityofdoubleindicatordilutionmeasurementsofintrathoracicbloodvolumecompartments,extravascularlungwater,andliverfunction.Chest,113:1070-1077,1998

TibbySM,HatherillM,JonesG,MudochA:Measurementofcardiacoutputininfantslessthan10kg:AccurancyoffemoralarterythermodilutionascomparedwithdirectFick.CritCare2(Suppl1):P79,37,1998Z?llnerC,BriegelJ,KilgerE,HallerM:RetrospektiveAnalysedesHerzzeitvolumensmitdertranspulmonalenThermodilutionsmethodebeiARDS-Patienten.[Determinationofcardiacoutputusingthetranspulmonarythermodilutiontechniqueinpatientswithacuterespiratorydistresssyndrome]An?sthesist47(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胸腔內(nèi)血容積（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.23:651-657,1997G?djeO,PeyerlM,SeebauerT,LammP,MairH,ReichartB:Centralvenouspressure,pulmonarycapillarywedgepressureandintrathoracicbloodvolumesaspreloadindicatorsincardiacsurgerypatients.EurJCardiothoracSurg13(5):533-539;discussion539-540,1998

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