PiCCO在ICU中的應(yīng)用課件

PiCCO容量監(jiān)護(hù)儀在ICU中的應(yīng)用PiCCO在ICU中的應(yīng)用PiCCOTechnology容量管理IntroductiontothePiCCO-TechnologyCOVolumetricpreloadEVLWContractilityDifferentiatedVolumeManagementstatic-dynamic2PiCCO在ICU中的應(yīng)用正確的監(jiān)測才能進(jìn)行正確的治療3PiCCO在ICU中的應(yīng)用什么是PiCCO？4PiCCO在ICU中的應(yīng)用

PiCCO是一種技術(shù)，是一種簡便、微創(chuàng)、高效費比的，對重癥病人主要血流動力學(xué)參數(shù)進(jìn)行監(jiān)測的工具。5PiCCO在ICU中的應(yīng)用Centralvenouscatheter?jugular?subclavian?femoral大多數(shù)血流動力學(xué)不穩(wěn)定的患者都會置?中心靜脈導(dǎo)管(vasoactiveagentsadministration…)?動脈導(dǎo)管(monitoringofbloodpressure,bloodsamples…)Thermodilutionarterialcatheter?femoral?axillary?longradial連接6PiCCO在ICU中的應(yīng)用Centralvenouscatheter?jugular?subclavian?femoral7PiCCO在ICU中的應(yīng)用PiCCO技術(shù)可以監(jiān)測心輸出量8PiCCO在ICU中的應(yīng)用PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysisPrinciplesofMeasurementLeftHeartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHPULSIOCATHCVCPULSIOCATHarterialthermodilutioncathetercentralvenousbolusinjectionIntroductiontothePiCCO-Technology–Function9PiCCO在ICU中的應(yīng)用TranspulmonarythermodilutionmethodArterialTDcatheter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EVLWLAEDV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010203040500,00,20,40,6[°C]-DTInjection[s]LungsCVCAortaV.cava

sup.RAArterialTDcatheter10PiCCO在ICU中的應(yīng)用Tb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫?Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate心輸出量是利用Stewart-Hamilton公式對熱稀釋曲線進(jìn)行分析所得熱稀釋方法所得心輸出量的計算Tb

xdt(Tb-Ti)xVix

KTbInjectiont∫D=COTDa11PiCCO在ICU中的應(yīng)用TheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.

36,537510ThermodilutioncurvesNormalCO:5.5l/minIntroductiontothePiCCO-Technology–Thermodilution36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperature12PiCCO在ICU中的應(yīng)用經(jīng)肺vs.肺動脈熱稀釋LeftheartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHarterialthermo-dilutioncathetercentralvenousbolusinjectionRARVPALALVAortaTranspulmonaryTD(PiCCO)PulmonaryArteryTD(PAC)這兩種方法所得CO都是準(zhǔn)確的，因為熱稀釋方法關(guān)注的只是時間以及溫度改變！13PiCCO在ICU中的應(yīng)用TranspulmonarythermodilutionCOmeasurement(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

14PiCCO在ICU中的應(yīng)用Pulsecontouranalysis脈搏輪廓分析Cal=calibrationfactorobtainedfromtranspulmonarythermodilution(coldbolusinjection)

校準(zhǔn)系數(shù)來自經(jīng)肺熱稀釋方法Surface

=Cal.x

Strokevolume15PiCCO在ICU中的應(yīng)用PCCO=cal.HR.

(P(t)/SVR+C(p).dP/dt)dtsystolePatient-specificcalibrationfactor(determinedwiththermodilution)complianceshapeofpressurecurveareaofpressurecurveP(mmHg)t(s)PiCCO在ICU中的應(yīng)用Validationofcontinuouscardiacoutputmeasurementbythepulsecontouranalysis(PiCCOsystem)PiCCO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;50:1044-104917PiCCO在ICU中的應(yīng)用

PiCCO不僅是

心排量監(jiān)測儀18PiCCO在ICU中的應(yīng)用

PiCCO?technologyGEDV—評估心臟前負(fù)荷容量19PiCCO在ICU中的應(yīng)用目前醫(yī)學(xué)界判斷心臟前負(fù)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

PULSIONMedicalSystems20PiCCO在ICU中的應(yīng)用Kumaretal.,CritCareMed2004;32:691-69921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)測前負(fù)荷21PiCCO在ICU中的應(yīng)用Kumaretal.,CritCareMed2004;32:691-69922肺動脈嵌壓和每搏輸出量的關(guān)聯(lián)MeasuringPreload監(jiān)測前負(fù)荷灌注壓CVP/PCWP反映前負(fù)荷22PiCCO在ICU中的應(yīng)用RaperRandSibbaldWJ.Chest1986

Misledbythewedge?TheSwan-Ganzcatheterandleftventricularpreload.23PiCCO在ICU中的應(yīng)用GEDV可以作為心臟前負(fù)荷的指標(biāo)GlobalEnd-DiastolicVolume

evaluatedbytranspulmonarythermodilutionGEDV24PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=1+2+3+4+53IndicatorinjectionIndicatordilutioncurve1425325PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=1+2+3+4+53COxDst=largestmixingchamber=33IndicatorinjectionIndicatordilutioncurve1425326PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVGEDVNewmanetal.Circulation1951COxDSt=largestmixingchamber=PBV+EVLWPBVEVLW27PiCCO在ICU中的應(yīng)用Changesinstrokevolumeindex(%)Changesinglobalend-diastolicvolumeindex(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM200228PiCCO在ICU中的應(yīng)用治療指南－SurvivingSepsisCampaignGuidelines2008:?

灌注壓在評估擴(kuò)容治療中已經(jīng)被證實有局限性

...使用血流量或者容量參數(shù)指導(dǎo)容量管理或許更有優(yōu)勢

…

這些技術(shù)已經(jīng)能夠在ICU內(nèi)實現(xiàn)

…?

PiCCO技術(shù)29PiCCO在ICU中的應(yīng)用Intrathoracicpressure 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監(jiān)測前負(fù)荷30PiCCO在ICU中的應(yīng)用SVmaxSVminSVmeanSVmax–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秒的測量結(jié)果…只適用于心律規(guī)律的完全機(jī)械通氣病人31PiCCO在ICU中的應(yīng)用SVV

反映了心臟對因機(jī)械通氣導(dǎo)致的前負(fù)荷周期性變化的敏感性。1,15,18,19,20

SVV

可用于預(yù)測擴(kuò)容治療對每搏量的提高程度。1,15,18,19,20對于沒有心律失常的完全機(jī)械通氣病人而言，每搏量變異-SVV32PiCCO在ICU中的應(yīng)用00.511-specificitysensitivitySVVCVP00.60.410.80.210%StrokevolumevariationasapredictoroffluidresponsivenessinpatientsundergoingbrainsurgeryBerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.AnesthAnalg2001;92:984-9sensitivity=79%specificity=93%33PiCCO在ICU中的應(yīng)用心肌收縮狀況FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSIONVENTRICULAREDVVENTRICULARSTROKEVOLUMEFromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,197634PiCCO在ICU中的應(yīng)用CFI—心臟收縮功能指數(shù)35PiCCO在ICU中的應(yīng)用

TEEFACPiCCOCFIPiCCO在ICU中的應(yīng)用Jabotetal(submitted)r=0.80PiCCO在ICU中的應(yīng)用t[s]P[mmHg]左心室收縮力指數(shù)dPmx

=

動脈壓力曲線的上升枝PiCCO心肌收縮力參數(shù)38PiCCO在ICU中的應(yīng)用PiCCO心肌收縮力參數(shù)dPmx反映了左心室最大壓力增加的速度，是心肌收縮力的參數(shù)39PiCCO在ICU中的應(yīng)用全心射血分?jǐn)?shù)（GEF）（經(jīng)肺熱稀釋導(dǎo)管）GEF=GEDV4xSVRVEF=RVEDVSVLVEF=LVEDVSV右心室射血分?jǐn)?shù)（RVEF）（肺動脈熱稀釋導(dǎo)管）左心室射血分?jǐn)?shù)（LVEF）（心臟超聲）12&

3全心射血分?jǐn)?shù)GEF右心左心肺PBVEVLWEVLWRAEDVRVEDVLVEDV每搏量（SV）LAEDV

射血分?jǐn)?shù)：與每搏量和舒張末期容積相關(guān)40PiCCO在ICU中的應(yīng)用EVLW—肺水腫指數(shù)41PiCCO在ICU中的應(yīng)用ExtravascularwatercontentofthelungPulmonarycirculationLeftHeartRightHeartLungs血管外肺水EVLW在管理前負(fù)荷中的作用EVLW=ExtravascularLungWaterBodycirculation監(jiān)測前負(fù)荷分辨以及量化肺水腫僅有的一個在床邊獲得肺水量化值的方法對容量過度補(bǔ)充有預(yù)警功能42PiCCO在ICU中的應(yīng)用RALARVLVGEDVRALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDV43PiCCO在ICU中的應(yīng)用COxMTt=volumeofdistribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeieretal.JApplPhysiol1954RALARVLVPBVSakkaetal.IntensiveCareMed2000ITBV=1.25xGEDVEVLW=(COxMTt)-ITBVEVLW44PiCCO在ICU中的應(yīng)用COxMTtcold=coldindicatorvolumeofdistributionRALARVLVPBVEVLWCOxMTtICG=ICGvolumeofdistributionEVLWEVLWRALARVLVPBV45PiCCO在ICU中的應(yīng)用46PiCCO在ICU中的應(yīng)用EVLWmeasuredwiththePiCCOsystemcomparedwithgravimetricsindogswithcardiogenicandnon-cardiogenicpulmonaryedemaKatzenelsonetal.SCCM2002EVLWPiCCOEVLWGrav.47PiCCO在ICU中的應(yīng)用Source 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.R?ntgenstr.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光片的對比

胸部X光片常受到胸腔內(nèi)滲出的影響，并受到床旁拍攝X光片技術(shù)方面的限制48PiCCO在ICU中的應(yīng)用監(jiān)測ELWI能夠發(fā)現(xiàn)肺水10-15%的增加X-ray只有在肺水100-300%增長時才能甄別49PiCCO在ICU中的應(yīng)用373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]50PiCCO在ICU中的應(yīng)用利用EVLW治療病人101位肺水腫病人隨時分成肺動脈導(dǎo)管（PAC）組與血管外肺水組（EVLW），分別依據(jù)PCWP和EVLW的測量結(jié)果進(jìn)行治療。在EVLW組的病人在ICU的時間和機(jī)械通氣時間都顯著降低。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51PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，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HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標(biāo)？PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedemafordiagnosinghydrostaticvs.increasedpermeabilitypulmonaryedema針對已經(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）HowtouseEVLWmeasurements?如何應(yīng)用EVLW指標(biāo)？

PiCCO在ICU中的應(yīng)用PiCCO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

LungWater54PiCCO在ICU中的應(yīng)用Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedema

fordiagnosinghydrostaticvsincreasedpermeabilitypulmonaryedema針對已經(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ALI/ARDS的病人群，從