1、,PiCCO plus 容量监护仪,,临床价值,,2. PiCCO技术的临床价值,内容,1. 什么是PiCCO,2. PiCCO技术的临床价值,1. 什么是PiCCO,3. PiCCO应用中的护理,,什么是PiCCO技术?,3次热稀释校准,两种技术,经热稀释方法得到的非连续性参数心输出量 CO全心舒张末期容积 GEDV胸腔内血容量 ITBV血管外肺水 EVLW*肺血管通透性指数 PVPI*心功能指数 CFI全心射血分数 GEF,动脉轮廓分析法得到的连续性参数连续心输出量 PCCO动脉压 AP心率 HR每搏量 SV每搏量变异 SVV脉压变异 PPV系统血管阻力 SVR左心室收缩力指数 dPmx*
2、,血液动力学和容量进行监护管理 对心肺功能进行评价,两部分参数,PiCCO,,什么是PiCCO技术?,同时进行心肺功能监测！,,中心静脉导管,注射液温度探头容纳管 PV4046,PCCI,AP,13.03 16.28 TB37.0,AP 140 117 92 (CVP) 5 SVRI 2762 PC CI 3.24 HR 78 SVI 42 SVV 5% dPmx 1140 (GEDI) 625,压力线 206PMK,动脉热稀释导管,PULSION 一次性压力传感器 PV8115 （包括PV4046）,温度测量电缆 PC80150,注射液温度电缆 PC80109,什么是PiCCO技术?,血流动
3、力学,Swan和Ganz发明通过血流引导的气囊漂浮导管（漂浮导管 或 Swan-Ganz 导管 或 肺动脉导管）继中心静脉压（CVP）之后临床监测的一大新进展,经食管超声技术（TEE）,原理 物体（红细胞）移动的速度和已知频率超声波的反射频率成正比 HemoSonicTM100的超声多普勒探头 通过测定红细胞移动的速度来推算降主动脉的血流量,TEE,优势：准确性高降主动脉的血流量是CO的70% 劣势：误差多，对操作者经验要求高，需严格培训，费用高,9,监测生命体征,Monitoring,Respiration Rate,Temperature,10,一些重要的指标,Monitoring,Blo
4、od Pressure (NiBP), no correlation with CO no correlation with oxygen delivery,ECG,Respiration Rate,Temperature,PiCCO Technology,液体管理所需要的指标,Introduction to the PiCCO-Technology,CO,前负荷,EVLW,收缩力指数,个性化的容量管理,static - dynamic,PiCCO 技术监测,功能原理 热稀释技术 脉搏轮廓分析技术 收缩力指数 前、后负荷参数 血管外肺水 肺部通透性指数,血流动力学监测,PiCCO 技术 依据经
5、肺热稀释技术以及脉搏轮廓分析技术,原理,Left Heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATH arterial thermodilution catheter,central venous bolus injection,Introduction to the PiCCO-Technology Function,Bolus injection,concentration changes over time (Thermodilution c
6、urve),中心静脉处注入冰盐水，依次经过胸腔内各腔室,股动脉导管内有热敏电阻，会记录温度的变化,Introduction to the PiCCO-Technology Function,Left heart,Right heart,Lungs,原理,胸腔内各腔室,Introduction to the PiCCO-Technology Function,肺内热容积 (PTV),胸腔内热容积 (ITTV),Total of mixing chambers,最大混合腔室,血流动力学监测,Introduction to PiCCO Technology,功能原理 热稀释技术 脉搏轮廓分析技术 收
7、缩力指数 后负荷参数 血管外肺水 肺部通透性指数,Tb x dt,(Tb - Ti) x Vi x K,Tb,Injection,t,D,=,COTD a,Tb = Blood temperature Ti = Injectate temperature Vi = Injectate volume Tb . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate,CO的计算是通过对热稀
8、释曲线分析， 使用 Stewart-Hamilton 方程式,心排的计算,Introduction to the PiCCO-Technology Thermodilution,热稀释曲线下面积反比例反映CO,36,5,37,5,10,热稀释曲线,Normal CO: 5.5l/min,Introduction to the PiCCO-Technology Thermodilution,36,5,37,36,5,37,Time,low CO: 1.9l/min,High CO: 19l/min,Time,Time,Temperature,Temperature,Temperature,经肺热
9、稀释 vs. 肺动脉导管,Left heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH arterial thermo-dilution catheter,central venous bolus injection,RA,RV,PA,LA,LV,Aorta,Transpulmonary TD (PiCCO),Pulmonary Artery TD (PAC),In both procedures only part of the injected indicator passes the ther
10、mistor. Nonetheless the determination of CO is correct, as it is not the amount of the detected indicator but the difference in temperature over time that is relevant!,Introduction to the PiCCO Technology Thermodilution,Comparison with the Fick Method,0,97,0,68 0,62,37/449,Sakka SG et al., Intensive
11、 Care Med 25, 1999,- / -,0,19 0,21,9/27,McLuckie A. et a., Acta Paediatr 85, 1996,0,96,0,16 0,31,30/150,Gdje O et al., Chest 113 (4), 1998,0.98,0,32 0,29,23/218,Holm C et al., Burns 27, 2001,0,93,0,13 0,52,60/180,Della Rocca G et al., Eur J Anaest 14, 2002,0,95,-0,04 0,41,17/102,Friedman Z et al., E
12、ur J Anaest, 2002,0,95,0,49 0,45,45/283,Bindels AJGH et al., Crit Care 4, 2000,0,98,0,03 0,17,18/54,Pauli C. et al., Intensive Care Med 28, 2002,24/120,n (Pts / Measurements),0,99,0,03 0,24,Tibby S. et al., Intensive Care Med 23, 1997,r,bias SD(l/min),Comparison with Pulmonary Artery Thermodilution,
13、经肺热稀释技术的有效性,Introduction to the PiCCO Technology Thermodilution,MTt: Mean Transit time the mean time required for the indicator to reach the detection point,DSt: Down Slope time the exponential downslope time of the thermodilution curve,Recirculation,t,e-1,Tb,From the characteristics of the thermodi
14、lution curve it is possible to determine certain time parameters,对热稀释曲线做进一步分析,Introduction to the PiCCO-Technology Thermodilution,Injection,In Tb,MTt,DSt,Tb = blood temperature; lnTb = logarithmic blood temperature; t = time,Pulmonary Thermal Volume PTV = Dst x CO,By using the time parameters from t
15、he thermodilution curve and the CO ITTV and PTV can be calculated,计算 ITTV 与 PTV,Introduction to the PiCCO-Technology Thermodilution,Recirculation,t,e-1,Tb,Injection,In Tb,Intrathoracic Thermal Volume ITTV = MTt x CO,MTt,DSt,Pulmonary Thermal Volume (PTV),Intrathoracic Thermal Volume (ITTV),Calculati
16、on of ITTV and PTV,Einfhrung in die PiCCO-Technologie Thermodilution,ITTV = MTt x CO,PTV = Dst x CO,GEDV is the difference between intrathoracic and pulmonary thermal volumes,Global End-diastolic Volume (GEDV),Volumetric preload parameters GEDV,ITTV,GEDV,PTV,Introduction to the PiCCO Technology Ther
17、modilution,Volumetric preload parameters ITBV,Intrathoracic Blood Volume (ITBV),GEDV,ITBV,PBV,Introduction to the PiCCO Technology Thermodilution,ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV),ITBVTD (ml),ITBV = 1.25 * GEDV 28.4 ml,GEDV vs. I
18、TBV in 57 Intensive Care Patients,Intrathoracic Blood Volume (ITBV),Introduction to the PiCCO-Technology Thermodilution,ITBV is calculated from the GEDV by the PiCCO Technology,GEDV (ml),Sakka et al, Intensive Care Med 26: 180-187, 2000,Summary and Key Points - Thermodilution,PiCCO 技术是一种微创的方法，用以监测容量
19、状态和心血管功能 根据经肺热稀释技术可以计算出各种容积参数. CO 由热稀释曲线形状描记.心脏前负荷相关的容积参数可以通过对热稀释曲线进一步分析获得。,Introduction to the PiCCO-Technology,Haemodynamic Monitoring,Introduction to PiCCO Technology,功能原理 热稀释技术 脉搏轮廓分析技术 收缩力指数 后负荷参数 血管外肺水 肺部通透性指数,Transpulmonary Thermodilution,The pulse contour analysis is calibrated through the t
20、ranspulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve,Calibration of the Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,Injection,Pulse Contour Analysis,T = blood temperaturet = time P = blood pressure,COTPD,= SVTD,HR
21、,PCCO = cal HR ,P(t),SVR,+ C(p) ,dP,dt,(,),dt,Cardiac Output,Heart rate,Systole,Introduction to the PiCCO-Technology Pulse contour analysis,Parameters of Pulse Contour Analysis,n (Pts / Measurements),0,94,0,03 0,63,12 / 36,Buhre W et al., J Cardiothorac Vasc Anesth 13 (4), 1999,19 / 76,24 / 517,62 /
22、 186,20 / 360,25 / 380,22 / 96,- / -,-0,40 1,3,Mielck et al., J Cardiothorac Vasc Anesth 17 (2), 2003,0,88,0,31 1,25,Zllner C et al., J Cardiothorac Vasc Anesth 14 (2), 2000,0,88,-0,2 1,15,Gdje O et al., Crit Care Med 30 (1), 2002,0,94,-0,02 0,74,Della Rocca G et al., Br J Anaesth 88 (3), 2002,0,93,
23、-0,14 0,33,Felbinger TW et al., J Clin Anesth 46, 2002,- / -,0,14 0,58,Rauch H et al., Acta Anaesth Scand 46, 2002,r,bias SD (l/min),Comparison with pulmonary artery thermodilution,Validation of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,SVmax SVmin,SVV =,SVme
24、an,The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.,Parameters of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Stroke Volume Variati
25、on,The increase of preload volume is equal: EDV1 = EDV2 SV1 SV2,SVV 提示心脏对容量治疗的反应好坏,EDV,SV,SVV small,SVV large, EDV1, EDV2, SV1, SV2,PPmax PPmin,PPV =,PPmean,The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.,Parame
26、ters of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Pulse Pressure Variation,PPmax,PPmean,PPmin,Summary pulse contour analysis - CO and volume responsiveness,PiCCO脉搏轮廓分析技术是由经肺热稀释技术计算进一步获得PiCCO 技术分析动脉压力曲线每次的搏动，可以提供实时的参
27、数CO之外， 反映容积相关的血流动力学参数SVV (stroke volume variation) 和PPV (pulse pressure variation) 可以持续获得,Introduction to the PiCCO-Technology Pulse contour analysis,Haemodynamic Monitoring,Introduction to PiCCO Technology,功能原理 热稀释技术 脉搏轮廓分析技术 收缩力指数 后负荷参数 血管外肺水 肺部通透性指数,Contractility is a measure for the performance
28、of the heart muscle,Contractility parameters of PiCCO technology:dPmx (maximum rate of the increase in pressure)GEF (Global Ejection Fraction)CFI (Cardiac Function Index),Contractility,Introduction to the PiCCO-Technology Contractility parameters,kg,Contractility parameter from the pulse contour ana
29、lysis,Introduction to the PiCCO-Technology Contractility parameters,dPmx = maximum velocity of pressure increase,The contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.,Contractility parameter from the pulse contour analysis,Introduction to the PiCCO-T
30、echnology Contractility parameters,femoral dP/max mmHg/s,LV dP/dtmax mmHg/s,dPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients,de Hert et al., JCardioThor&VascAnes 2006,n = 220 y = -120 + (0,8* x) r = 0,82 p 0,001
31、,0,500,1000,1500,0,1000,1500,2000,2000,500,dPmx = maximum velocity of pressure increase,is calculated as 4 times the stroke volume divided by the global end-diastolic volumereflects both left and right ventricular contractility,GEF = Global Ejection Fraction,Contractility parameters from the thermod
32、ilution measurement,Introduction to the PiCCO-Technology Contractility parameters,4 x SV,GEF =,GEDV,LA,LV,RA,RV,Combes et al, Intensive Care Med 30, 2004,GEF = Global Ejection Fraction,Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure,sen
33、sitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1 specifity,22,20,19,18,16,12,8,D FAC, %,D GEF, %,5,10,-5,-20,-10,10,20,15,-15,-10,r=076, p0,0001 n=47,Introduction to the PiCCO-Technology Contractility parameters,Contractility parameters from the thermodilution measurement,is the CI divided by global
34、 end-diastolic volume indexis - similar to the GEF a parameter of both left and right ventricular contractility,CFI = Cardiac Function Index,CI,CFI =,GEDVI,Introduction to the PiCCO-Technology Contractility parameters,Contractility parameters from the thermodilution measurement,Combes et al, Intensi
35、ve Care Med 30, 2004,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1 specificity,6,5,4,3,5,3,2,D FAC, %,D GEF, %,5,10,-5,-20,-10,10,20,15,-15,-10,r=079, p0,0001 n=47,CFI = Cardiac Function Index,Introduction to the PiCCO-Technology Contractility parameters,CFI was compared to the gold standard T
36、EE measured contractility in patients without right heart failure,Contractility parameters from the thermodilution measurement,Haemodynamic Monitoring,Introduction to PiCCO technology,功能原理 热稀释技术 脉搏轮廓分析技术 收缩力指数 后负荷参数 血管外肺水 肺部通透性,is calculated as the difference between MAP and CVP divided by COas an a
37、fterload parameter it represents a further determinant of the cardiovascular situation is an important parameter for controlling volume and catecholamine therapies,(MAP CVP) x 80,SVR =,CO,Afterload parameter,SVR = Systemic Vascular Resistance,MAP = Mean Arterial Pressure CVP = Central Venous Pressur
38、e CO = Cardiac Output 80 = Factor for correction of units,Introduction to the PiCCO Technology Afterload parameter,收缩力指数 dPmx 由脉搏轮廓分析技术获得， 用于评估左室心肌功能， 给出了心功能重要的信息， 可以指导治疗收缩力指数 GEF 和 CFI 是评估全心功能的重要参数 ，支持心衰的早期诊断外周血管阻力 SVR 由血压和心排获得，是一个进一步评估心血管功能的指数， 对于容量的控制和血管活性药物的应用提供了重要信息。,Summary and Key Points,Intr
39、oduction to the PiCCO Technology Contractility and Afterload,Haemodynamic Monitoring,Introduction to PiCCO technology,功能原理 热稀释技术 脉搏轮廓分析技术 收缩力指数 后负荷参数 血管外肺水 肺部通透性指数,To Dry or Not to Dry,ITTV ITBV= EVLW,The Extravascular Lung Water is the difference between the intrathoracic thermal volume and the int
40、rathoracic blood volume. It represents the amount of water in the lungs outside the blood vessels.,Calculation of Extravascular Lung Water (EVLW),Introduction to the PiCCO Technology Extravascular Lung Water,容量测量小结,ITTV = CO * MTtTDa,PTV = CO * DStTDa,ITBV = 1.25 * GEDV,EVLW = ITTV - ITBV,GEDV = ITT
41、V - PTV,Katzenelson et al,Crit Care Med 32 (7), 2004,Sakka et al, Intensive Care Med 26: 180-187, 2000,Gravimetry,Dye dilution,EVLW from the PiCCO technology has been shown to have a good correlation with the measurement of extravascular lung water via the gravimetry and dye dilution reference metho
42、ds,Validation of Extravascular Lung Water,n = 209 r = 0.96,ELWI by gravimetry,ELWI by PiCCO,R = 0,97 P 0,001,Y = 1.03x + 2.49,0,10,20,30,20,30,40,10,ELWITD (ml/kg),0,5,10,20,15,25,25,5,0,10,0,20,15,ELWIST (ml/kg),Introduction to the PiCCO Technology Extravascular Lung Water,Boeck J, J Surg Res 1990;
43、 254-265,High extravascular lung water is not reliably identified by blood gas analysis,EVLW as a quantifier of lung edema,PaO2 /FiO2,10,20,550,30,150,250,0,450,ELWI (ml/kg),0,50,350,Introduction to the PiCCO Technology Extravascular Lung Water,ELWI = 7 ml/kg,ELWI = 8 ml/kg,ELWI = 14 ml/kg,ELWI = 19
44、 ml/kg,Extravascular lung water index (ELWI) normal range: 3 7 ml/kg,Pulmonary oedema,Normal range,EVLW as a quantifier of lung oedema,Introduction to the PiCCO Technology Extravascular Lung Water,40,Halperin et al, 1985, Chest 88: 649,Chest x ray does not reliably quantify pulmonary oedema and is difficult to judge, particularly in critically ill patients,
