picco的監(jiān)測與護(hù)理課件

什么是PiCCO技術(shù)？

PulseindicatorContinousCardiacOutputpicco的監(jiān)測與護(hù)理a.經(jīng)肺熱稀釋技術(shù)（TPTD）b.動脈脈搏輪廓分析技術(shù)（PC）兩者的結(jié)合：PiCCOpicco的監(jiān)測與護(hù)理中心靜脈導(dǎo)管頸內(nèi)靜脈鎖骨下靜脈溫度指示劑注射大部分血流動力學(xué)不穩(wěn)定的病人都會做以下監(jiān)測?中心靜脈導(dǎo)管(用作補(bǔ)液，血管活性藥物的使用，中心靜脈壓的監(jiān)測)?動脈導(dǎo)管(持續(xù)監(jiān)測動脈血壓、動脈抽血等)動脈導(dǎo)管股動脈腋動脈肱動脈持續(xù)監(jiān)測動脈血壓、波形、血溫監(jiān)測picco的監(jiān)測與護(hù)理PiCCO

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

溫度測量電纜壓力電纜picco的監(jiān)測與護(hù)理彈丸注射肺PiCCO導(dǎo)管如：股動脈

經(jīng)肺熱稀釋技術(shù)需要在中心靜脈注射冷鹽水(<8°C)或室溫鹽水(<24°C)A.熱稀釋參數(shù)左心右心RAPBVEVLWLALVEVLWRVA.熱稀釋參數(shù)的測量picco的監(jiān)測與護(hù)理

熱稀釋參數(shù)

心輸出量 CO

全心舒張末期容積 GEDV

胸腔內(nèi)血容積 ITBV

血管外肺水 EVLW

肺血管通透性指數(shù) PVPI

心功能指數(shù) CFI

全心射血分?jǐn)?shù) GEFpicco的監(jiān)測與護(hù)理t[s]P[mmHg]B.脈搏輪廓分析picco的監(jiān)測與護(hù)理

脈搏輪廓參數(shù)

脈搏連續(xù)心輸出量 PCCO

每搏量 SV

心率 HR

每搏量變異 SVV

脈壓變異 PPV

動脈壓力 AP

系統(tǒng)血管阻力 SVR

左心室收縮指數(shù) dPmxpicco的監(jiān)測與護(hù)理如何測量心輸出量（CO）picco的監(jiān)測與護(hù)理傳統(tǒng)的漂浮導(dǎo)管（swan-ganz）采用熱稀釋法來測定COpicco的監(jiān)測與護(hù)理TbinjectiontFemoralarterycatheter股動脈導(dǎo)管(e.g.PV2014L16)Axillaryarterycatheter腋動脈導(dǎo)管(e.g.PV2014L08)Centralvenousinjection經(jīng)肺熱稀釋法:CardiacOutputStewart-Hamiltonmethod1.用經(jīng)肺熱稀釋法測量COTb=血液溫度Ti=注射液溫度Vi=注射液容積∫?Tb.

dt=熱稀釋曲線下面積K=校正系數(shù)，與體重、血溫和注射液溫度相關(guān)picco的監(jiān)測與護(hù)理與肺動脈熱稀釋對比COTDavs.

COTDpan(pat./measurements)bias±SD(l/min)rFriedmanZetal.,EurJAnaest,200217/102-0,04±0,410,95DellaRoccaGetal.,EurJAnaest14,200260/1800,13±0,520,93HolmCetal.,Burns27,200123/2180,32±0,290.98BindelsAJGHetal.,CritCare4,200045/2830,49±0,450,95SakkaSGetal.,IntensiveCareMed25,199937/4490,68±0,620,97G?djeOetal.,Chest113(4),199830/1500,16±0,310,96McLuckieA.eta.,ActaPaediatr85,19969/270,19±0,21-/-與Fick方法對比COTDavs.

COFickPauliC.etal.,IntensiveCareMed28,200218/540,03±0,170,98TibbyS.etal.,IntensiveCareMed23,199724/1200,03±0,240,99經(jīng)肺熱稀釋法的驗(yàn)證picco的監(jiān)測與護(hù)理B.動脈脈搏輪廓分析t[s]P[mmHg]壓力曲線下面積壓力曲線型狀PCCO=cal?HR?

SystoleP(t)SVR+C(p)?dPdt()dt動脈順應(yīng)性心率病人相關(guān)的校正因子（通過熱稀釋法得到）2.用脈搏輪廓分析法測量COpicco的監(jiān)測與護(hù)理

通過對分析每一次心臟跳動（beatbybeat）時的動脈壓力波型，得到連續(xù)的參數(shù)t-?Tt-?T校正t[s]P[mmHg]SV脈搏輪廓分析－原理熱稀釋法測量得到CO測量血壓(P(t),MAP,CVP)

經(jīng)過經(jīng)肺熱稀釋校正后，可以測量每一次心臟跳動的每搏量（SV）picco的監(jiān)測與護(hù)理與肺動脈熱稀釋對比PCCO–COTDpa

n(pat./measurements)

bias±SD(l/min)rMielcketal.,JCardiothoracVascAnesth17(2),200322/96-0,40±1,3-/-RauchH*etal.ActaAnaesthScand46,200225/3800,14±0,58-/-FelbingerTWetal.JClinAnesth46,200220/360-0,14±0,330,93DellaRoccaG*etal.BrJAnaesth88(3),200262/186-0,02±0,740,94G?djeO*etal.CritCareMed30(1),200224/517-0,2±1,150,88Z?llnerCetal.JCardiothoracVascAnesth14(2),200019/760,31±1,250,88BuhreWetal.,JCardiothoracVascAnesth13(4),199912/360,03±0,630,94脈搏輪廓分析驗(yàn)證Thesetablesareonlyanexcerptofpublications,intotaltherearemorethan200articlesaboutthePiCCOTechnology.picco的監(jiān)測與護(hù)理Goedjeetal,ThoracCardiovascSurg46:242-249,1998

PiCCOvsCOTDPain30patientsaftercardiacsurgerypicco的監(jiān)測與護(hù)理容量的監(jiān)測picco的監(jiān)測與護(hù)理目前判斷心臟前負(fù)荷的標(biāo)準(zhǔn)Centrolvenouspressure(CVP)Pulmonarycapillarywedgepressure

(PCWP)

但是?壓力=容量

?前負(fù)荷的量化值是LVEDV（左室舒張末的容積），是容量值而非壓力值。picco的監(jiān)測與護(hù)理

壓力數(shù)據(jù)并不是在任何時候都可以正確反映心臟前負(fù)荷和容量水平Erroneousreadingsofpressuretracings

Ibertietal.JAMA1990 Al-Kharratetal.AmJRespirCritCareMed1999Discrepancybetweenmeasuredandtransmuralpressures

Pinskyetal.AmRevRespirDis1992 Tebouletal.CritCareMed1999壓力和容量之間并不成線性關(guān)系picco的監(jiān)測與護(hù)理Lichtwarck-Aschoffetal,IntensiveCareMed18:142-147,1992picco的監(jiān)測與護(hù)理Lichtwarck-Aschoffetal,IntensiveCareMed18:142-147,1992picco的監(jiān)測與護(hù)理lnc(I)injectionAtrecirculationMTtte-1DStc(I)At: Appearancetime MTt: Meantransittime DSt: Downslopetime出現(xiàn)時間平均通過時間下斜時間PiCCO容量監(jiān)測的方法（一）picco的監(jiān)測與護(hù)理COxMTt=volumeofdistribution=1+2+3+4+53COxDst=largestmixingchamber=33IndicatorinjectionIndicatordilutioncurve14253picco的監(jiān)測與護(hù)理CVbolusinjectionArterialTDcatheter

(e.g.PV2014L16)ITTV =Intrathoracicthermalvolume PTV =PulmonarythermalvolumeGEDV =Globalend-diastolicvolume EVLW

=ExtravascularlungwaterITBV =Intrathoracicbloodvolume

RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDVPTVGEDVITTVITBVPiCCO容量監(jiān)測的方法（二）picco的監(jiān)測與護(hù)理ITTV=CO*MTtTDaPTV=CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=

ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPBVEVLWEVLWPBVEVLWEVLWEVLWEVLWPiCCO容量監(jiān)測的方法（三）picco的監(jiān)測與護(hù)理RAEDVRVEDVLAEDVLVEDV全心舒張末期容積GEDVGEDV

=ITTV-PTVITTV=CO*MTtTDaPTV=CO*DStTDapicco的監(jiān)測與護(hù)理Changesinstrokevolumeindex(%)Changesinglobalend-diastolicvolumeindex(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM2002picco的監(jiān)測與護(hù)理胸內(nèi)血容量ITBVRAEDVRVEDVLAEDVLVEDVPBVITBV

=1.25*GEDVpicco的監(jiān)測與護(hù)理RelationshipbetweenITBVandGEDVSakkaetal:IntensiveCareMed26:180-187,2000GEDVvs.ITBVin57intensivecarepatientsr=0.96ITBV=1.25*GEDV–28.4[ml]picco的監(jiān)測與護(hù)理

Lichtwarck-AschoffM.etal,IntensivCareMed18:142-147,1992ITBVasindicatorofcardiacpreloadpicco的監(jiān)測與護(hù)理GEF

=GEDV4xSV心臟腔室射血分?jǐn)?shù)GlobalejectionfractionPiCCO所特有心肺功能指數(shù)臨床上常用的EF(射血分?jǐn)?shù))=ejectionfractionSvLVEDVGlobalEjectionFraction(GEF)(transpulmonarythermodilution)=GEFSVGEDV/4picco的監(jiān)測與護(hù)理dPmax=壓力曲線上最快的變化速度dP/dtmax反映了左室內(nèi)壓力上升的加速度t[s]P[mmHg]PiCCO用于評價心肌收縮力的指數(shù)picco的監(jiān)測與護(hù)理血管外肺水EVLWEVLWEVLWEVLW=ITTV-ITBVpicco的監(jiān)測與護(hù)理Sakkaetal:IntensiveCareMed26:180-187,2000Bias = -0.2ml/kg

SD = 1.4ml/kgn=209r=0.96EVLWISTvs.EVLWITDin209intensivecarepatients熱稀釋法和熱-染料稀釋法測量EVLW的相關(guān)性picco的監(jiān)測與護(hù)理PICCO測量的EVLW和動物實(shí)驗(yàn)中活體肺重量的相關(guān)性Katzenelsonetal.SCCM2002EVLWPiCCOEVLWGrav.picco的監(jiān)測與護(hù)理Source Comparison CorrelationHalperinetal,1985

X-rayscorevs.

r=0,51Chest88:649

EVLWBaudendisteletal,1982

X-rayscorevs.EVLW

77%JTrauma22:983Sibbaldetal,1983

comparisoncardiacedema

r=0,66Chest83:725 comparisonnoncardiacedema

r=0,7Sivaketal,1983

X-rayscorevsEVLW

64%CritCareMed.11:498

X-rayscorevs.

EVLW

42%Laggneretal,1984

X-rayscorevs.EVLW

r=0,84IntensiveCareMed.10:309Halleretal,1985

X-rayscorevs.EVLW

66%Fortschr.R?ntgenstr.142:68Eisenbergetal,1987

X-rayscorevs.EVLW

76%AmRevRespDis136:662Takedaetal,1995

X-rayscorevs.EVLW X-rayinsensitive

J

VetMedSci57(3):481 ComparisonofEVLWandchestX-raypicco的監(jiān)測與護(hù)理PVPI=EVLW/PBVPVPI=EVLW/PBV>>>>PulmonaryVascularPermeabilityIndex=PVPIPBV血管通透性增高的肺水腫流體壓力增高的肺水腫EVLW*PBV=0.25xGEDV Sakkaetal.IntensiveCareMed2000*picco的監(jiān)測與護(hù)理肺血管通透性指數(shù)216位充血性心力衰竭（CHF）與社區(qū)獲得性肺炎（CAP）病人的肺血管通透性指數(shù)（PVPI）。兩組的EVLWI都是16ml/kg，但是PVPI不同。fromBenedikzetalESICM20024PVPI*CHFCAP32picco的監(jiān)測與護(hù)理在81個重癥ICU病人中EVLW與死亡率的關(guān)系Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork199