1、持续脉搏轮廓分析及跨肺心输出量测定 Continuous Pulse Contour Analysis and Transpulmonary Cardiac Output,北京协和医院 MICU 翁利,“The basic task of the cardiorespiratory system is to distribute enough oxygen to the cells”Pflger 1872,组织灌注的决定因素,OPS image of a healthy volunteer,OPS image of unresponsive microcirculatory septic sh
2、ock,Spronk PE, Ince C, Gardien MJ, et al. Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 2002;360:1395-1396,组织灌注的决定因素,血压 NBP或ABP 血流 心输出量（ CO ）,0,临床判断缺乏准确性: CO,0,4.5,7.0,预计CO (L/min),测定CO (L/min),Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulm
3、onary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553,4.5,7.0,CO的测定方法,The French Way,NiCO,CCO,LiDCO,PiCCO,Monitor,PAC,英格兰与威尔士ICU的CO监测技术,Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England
4、and Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131),热稀释法CO-PAC,PAC增加患者病死率,Connors AF, Jr., Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. Support investigators. JAMA 1996;276:889-897.,PAC为何不能改善预后,不恰当的适应症 P
5、AC的副作用或并发症 获得数据的方法不正确 仪器定标错误, 或传感器位置错误 获得的数据不能反映血流动力学状态 错误使用数据(对数据的解读错误) 作出治疗决定前未考虑其他相关因素 CXR, 尿量, 血清白蛋白 采用的治疗措施无效或有害 无需血流动力学监测时未及时拔除PAC,Is There an Easy Alternative to This Dilemma?,PiCCO的技术原理,PiCCO技术由下列两种技术组成, 用于更有效地进行血流动力和容量治疗, 使大多数病人不必使用肺动脉导管:,Central venous catheter,Injectate temperature sensor
6、 housing PV4046,Arterial thermodilution catheter,Injectate temperature sensor cable PC80109,PULSION disposable pressure transducer PV8115,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,DPT Monitor cable PMK-206,Interface cable PC80150,C
7、onnection cable to bedside monitor PMK - XXX,AUX adapter cable PC81200,心输出量的测定: 经肺热稀释技术,热稀释法测定CO: TPTD vs. PAC,CO(PAC) vs CO(TPTD),Sakka SG, Reinhart K, Meier-Hellmann A. Comparison of pulmonary artery and arterial thermodilution cardiac output in critically ill patients. Intensive Care Med 1999;25:
8、843-846.,Bland-Altman Mean Bias=0.68L/min SD=0.62L/min,+2SD,-2SD,Mean Bias,CO(PAC) vs CO(TPTD),Sakka SG, Reinhart K, Wegscheider K, et al. Is the placement of a pulmonary artery catheter still justified solely for the measurement of cardiac output? J Cardiothorac Vasc Anesth 2000;14:119-124.,“For th
9、e measurement of CO alone, a PAC seems no longer justified because CO can be obtained with comparable accuracy from transpulmonary thermodilution”,PiCCO的技术原理,PiCCO技术由下列两种技术组成, 用于更有效地进行血流动力和容量治疗, 使大多数病人不必使用肺动脉导管:,连续心输出量测定: PCCO,压力曲线下面积,压力曲线型状,动脉顺应性参数,心率,与病人有关的校正因子,t s,P mm Hg,PCCO is displayed as las
10、t 12s mean,PCCO与PAC比较,目的： 比较PiCCO的PCCO与PAC测定CO的相关性 方法: 心脏外科术后患者19名 同时放置PAC及PiCCO 观察3Hr 共228组数据,Zollner C, Haller M, Weis M, et al. Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: A prospective criterion standard study in patients after cardiac surgery. J Cardiotho
11、rac Vasc Anesth 2000;14:125-129.,PCCO与PAC比较,Zollner C, Haller M, Weis M, et al. Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: A prospective criterion standard study in patients after cardiac surgery. J Cardiothorac Vasc Anesth 2000;14:125-129.,PCCO与PAC比较,Zollner
12、 C, Haller M, Weis M, et al. Beat-to-beat measurement of cardiac output by intravascular pulse contour analysis: A prospective criterion standard study in patients after cardiac surgery. J Cardiothorac Vasc Anesth 2000;14:125-129.,PCCO 可靠性-sepsis,目的： 评价在感染性休克的情况下PCCO的可靠性 方法： 17只感染性休克的猪，3只正常对照。 同时联接2
13、台PiCCO 1台PiCCO定期校正（1次/小时），1台不校正。 比较2台PiCCO所测CO的差别。,Schuerholz T, Meyer MC, Friedrich L, et al. Reliability of continuous cardiac output determination by pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006;50:407-413.,PCCO 可靠性,（A）感染性休克前,（B）感染性休克3Hr后,Schuerholz T, Meyer MC, Fr
14、iedrich L, et al. Reliability of continuous cardiac output determination by pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006;50:407-413.,PCCO 可靠性,（C）感染性休克5hr后,（D）感染性休克9hr后,Schuerholz T, Meyer MC, Friedrich L, et al. Reliability of continuous cardiac output determination b
15、y pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006;50:407-413.,PCCO 可靠性,“we demonstrated that continuous CO determination by pulse-contour analysis is a reliable method to assess CO up to 5 h without recalibration in porcine septic shock. ”,Schuerholz T, Meyer MC, Friedri
16、ch L, et al. Reliability of continuous cardiac output determination by pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006;50:407-413.,如何判断PCCO 可靠性？,Linton NW, Linton RA. Is comparison of changes in cardiac output, assessed by different methods, better than only comparing ca
17、rdiac output to the reference method? Br J Anaesth 2002;89:336-337; author reply 337-339.,绝对值,改变值,如何判断PCCO 可靠性？,“PCO methods are designed to track changes in CO. Therefore only changes in CO should be pooled from different patients.”,Linton NW, Linton RA. Is comparison of changes in cardiac output,
18、assessed by different methods, better than only comparing cardiac output to the reference method? Br J Anaesth 2002;89:336-337; author reply 337-339.,PCCO vs TPTD相关性及影响因素,目的：PiCCO持续监测心输出量(PCCO)与跨肺心输出量(TPTD)相关性及影响因素。 方法： 北京协和医院MICU 2006/12/102007/10/8 34名危重病患者(17男17女，平均7313岁) 261次测定, TPTD测定值=3次测量均值(1
19、0%) 平均每名患者7.76.5次 比较PCCO与TPTD,PCCO vs TPTD,方法：,TPTD1,TPTD2,PCCO,PCCO=(PCCO-TPTD1)/TPTD1 TPTD=(TPTD2-TPTD1)/TPTD1,time,PCCO vs TPTD,y = 0.2121 + 0.9380 x R2 =0.71 P0.0001,PCCO vs TPTD,热稀释法测定CO方法学误差,热稀释法测定CO的误差-方法学,Stetz CW, Miller RG, Kelly GE, et al. Reliability of the thermodilution method in the d
20、etermination of cardiac output in clinical practice. Am Rev Respir Dis 1982;126:1001-1004.,SEM%=(Standard error of mean CO)/average CO,热稀释法测定CO的误差-方法学,评价CO测量的可重复性 2SEM (Standard error of mean CO) = 95% CI of CO (测定值) 综合考虑各种因素后，大于3SEM 则表示两次测定值之差有临床意义。 例如： 1次CO测定值=3次测量平均值 SEM=5, CO1=4.2L/min, CO2=3.8L
21、/min 3SEM%=15%, CO(1+2)/24L/min CO1-CO2=0.4 15%CO(1+2)/20.6 CO2与CO1的差别无临床意义,Stetz CW, Miller RG, Kelly GE, et al. Reliability of the thermodilution method in the determination of cardiac output in clinical practice. Am Rev Respir Dis 1982;126:1001-1004.,热稀释法测定CO的误差-方法学,Stetz CW, Miller RG, Kelly GE,
22、 et al. Reliability of the thermodilution method in the determination of cardiac output in clinical practice. Am Rev Respir Dis 1982;126:1001-1004.,12%15%,热稀释法测定CO的可靠性,“The clinician must observe a change in measured CO of at least 10% to 15% before concluding that the observed response was actually
23、 due to a specific intervention.”,Hall JB, Schmidt GA, Wood LDH. Principles of critical care. New York: McGraw-Hill, 2005.158,PCCO vs TPTD,PCCO vs TPTD,PCCO 准确性的影响因素,Logistic Regression,(PCCO-TPTD2)/TPTD2 and SVR,PCCO准确性影响因素,PiCCO的校正,PCCO 准确性的影响因素,Logistic Regression,结 论,跨肺热稀释法测量CO 与PAC相关性好 创伤小 持续脉搏轮廓分析测量CO 不受时间长短影响 血管阻力变化小于20%的情况下与跨肺热稀释法CO相关性好 PiCCO校正 目前尚无准确的床旁指标提示校正 可以根据现有文献5-8小时校正,谢 谢！,
