1、PiCCO容量 监护仪在 ICU中的应用1PiCCO Technology容量管理Introduction to the PiCCO-TechnologyCOVolumetric preload EVLWContractilityDifferentiated Volume Management- static - dynamic2正确的监测才能进行正确的治疗3什么是 PiCCO？4PiCCO是一种技术，是一种简便、微创、高效费比的，对重症病人主要血流动力学参数进行监测的工具。5Central venous catheter jugular subclavian femoral大多数血流动力学不
2、稳定的患者都会置 中心静脉导管(vasoactive agents administration) 动脉导管(monitoring of blood pressure, blood samples)Thermodilution arterial catheter femoral axillary long radial连接6Central venous catheter jugular subclavian femoral7PiCCO技术可以监测心输出量8PiCCO Technology is a combination of transpulmonary thermodilution and
3、 pulse contour analysisPrinciples of MeasurementLeft HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology Function9Transpulmonary thermodilution methodArterial TD
4、 catheter动脉热稀释导管 (e.g. PV2014L16)CV bolus injection中心静脉一次注射RAEDV右房舒张末容量PBV肺血容量EVLWLAEDV左房舒张末容量LVEDV左室舒张末容量EVLW血管外肺水RVEDV右室舒张末容量0 10 20 30 40 500,00,20,40,6C-D TInjectionsLungsCVCAortaV. cavasup.RAArterial TD catheter10Tb = Blood temperatureTi = Injectate temperatureVi = Injectate volume Tb . dt = Ar
5、ea under the thermodilution curveK = Correction constant, made up of specific weight and specific heat of blood and injectate心输出量是利用 Stewart-Hamilton 公式对热稀释曲线进行分析所得热 稀 释 方法所得心 输 出量的 计 算Tb x dt(Tb - Ti) x Vi x K TbInjectiont D=COTD a11The area under the thermodilution curve is inversely proportional
6、to the CO.36,5375 10Thermodilution curvesNormal CO: 5.5l/minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO: 1.9l/minHigh CO: 19l/minTimeTimeTemperatureTemperatureTemperature12经 肺 vs. 肺 动 脉 热 稀 释Left heartRight HeartPulmonary Circulation LungsBody CirculationPULSIOCATH arte
7、rial thermo-dilution cathetercentral venous bolus injection RARVPALALVAortaTranspulmonary TD (PiCCO) Pulmonary Artery TD (PAC)这 两种方法所得 CO都是准确的，因 为热 稀 释 方法关注的只是时间 以及温度改 变 ！13Transpulmonary thermodilutionCO measurement(vs PA thermodilution)Author Bias (L/min) SD rGodje Chest 1998 0.16 0.35 0.96Sakka I
8、CM 1999 0.68 0.62 0.97Goedje CCM 1999 0.29 0.60 0.93Bindels CC 2000 0.49 0.78 0.95Goedje Chest 2000 0.35 0.72 0.98Della Rocca BJA 2002 0.15 0.87 0.93Sander CC 2005 0.00 0.70 0.95Ostergaard AAS 2006 0.46 0.5514Pulse contour analysis脉搏脉搏 轮轮 廓分析廓分析Cal = calibration factor obtained from transpulmonary t
9、hermodilution (cold bolus injection)校准系数来自校准系数来自 经经 肺肺 热热 稀稀 释释 方法方法Surface = Cal. x Stroke volume15PCCO = cal . HR . (P(t)/SVR + C(p) . dP/dt) dtsystolePatient-specific calibration factor(determined with thermodilution)compliance shape of pressure curvearea of pressure curveP (mmHg)t (s)16Validatio
10、n of continuous cardiac output measurement by thepulse contour analysis (PiCCO system)PiCCO所得所得 连续连续 心排量数心排量数 值值 准确性准确性 论证论证Roedig G et al. Br J Anaesth 1999; 82: 525-530Goedje O et al. Ann Thorac Surg 1999; 68: 1532-1536Buhre WW et al. J Cardiothorac Vasc Anesth 1999; 13: 437-440Goedje O et al. Cri
11、t Care Med 1999; 27: 2407-2412Zollner C et al. J Cardiothorac Vasc Anesth 2000;14: 125-129Goedje O et al. Med Sci Monit 2001; 7: 1344-1350Felbinger TW et al. J Clin Anaesth 2002; 14: 296-301Goedje O et al. Crit Care Med 2002; 30:52-58Rauch H et al. Acta Anaesthesiol Scand 2002; 46: 426-429Felbinger
12、et al. J Clin Anaesth 2005; 17: 241-248Ostergaard et al. Acta Anaesthesiol Scand 2006; 50: 1044-104917PiCCO不仅是不仅是心排量监测仪心排量监测仪18PiCCO technologyGEDV评估心脏前负荷容量19目前目前 医学界医学界 判斷心判斷心 脏脏 前負荷的前負荷的 标准标准 Centrol venous pressure (CVP) Pulmonary capillary wedge pressure (PCWP)但是這是基於以下的假設“ 压力 = 容 量 “但這種假設並非完全正確
13、PULSIONMedical Systems 20Kumar et al., Crit Care Med 2004;32: 691-699 21灌注 压 CVP / PCWP反映前 负 荷中心静脉 压 和每搏 输 出量的关 联监测 前 负 荷21Kumar et al., Crit Care Med 2004;32: 691-69922肺 动 脉嵌 压 和每搏 输 出量的关 联Measuring Preload 监测 前 负 荷灌注 压 CVP / PCWP反映前 负 荷22Raper R and Sibbald WJ. Chest 1986 Misled by the wedge ? The
14、 Swan-Ganz catheter and left ventricular preload.23GEDV可以作为心脏前负荷的指标Global End-Diastolic Volume evaluated by transpulmonary thermodilutionGEDV24CO x MTt = volume of distribution = 1 + 2 + 3 + 4 + 53Indicator injectionIndicator dilutioncurve1 42 525CO x MTt = volume of distribution = 1 + 2 + 3 + 4 + 5
15、3CO x Dst = largest mixing chamber = 33Indicator injectionIndicator dilutioncurve1 42 526CO x MTt = volume of distribution = GEDV + PBV + EVLWRA LARV LVPBVEVLWMeier et al. J Appl Physiol 1954RA LARV LVGEDVNewman et al. Circulation 1951CO x DSt= largest mixing chamber= PBV + EVLW PBVEVLW27Changes ins
16、troke volumeindex (%)Changes in global end-diastolic volume index (%)r = 0.72p 0.001Transpulmonary thermodilution as a guide to fluid therapy in septic patients with acute circulatory failure. Michard et al. SCCM 200228治疗指南 Surviving Sepsis Campaign Guidelines 2008: 灌注压在评估扩容治疗中已经被证实有局限性 . 使用血流量或者容量参
17、数指导容量管理或许更有优势 这些技术已经能够在 ICU内实现 PiCCO技术29Intrathoracic pressureVenous return to left and right ventricleLeft ventricular preloadLeft ventricular stroke volumeSystolic arterial blood pressureIntrathoracic pressureSqueezing “ of the pulmonary bloodLeft ventricular preloadLeft ventricular stoke volumeSystolic arterial blood pressurePPmax PPminPPmaxPPmin吸气Reuter et al., Ansthesist 2003;52: 1005-1013容量反映 值 的生理学意 义呼气 吸气 呼气吸气早期 吸气晚期呼吸周期中血 压 的波 动监测 前 负 荷30
