協(xié)和杜斌--血流動(dòng)力學(xué)監(jiān)測(cè) Focus on PICCO[深層分析]

1、危重病患者的血流動(dòng)力學(xué)監(jiān)測(cè)危重病患者的血流動(dòng)力學(xué)監(jiān)測(cè) focus on PiCCO 北京協(xié)和醫(yī)院 杜斌 血流動(dòng)力學(xué)監(jiān)測(cè)增加患者病死率血流動(dòng)力學(xué)監(jiān)測(cè)增加患者病死率 Connors AF Jr, Speroff T, Dawson NV, Thomas C, Harrel FE Jr, Wagner D, Desbjens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ Jr, Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA. The effectiveness of right heart cathe

2、terization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 1996; 276(11): 889-897 血流動(dòng)力學(xué)監(jiān)測(cè)為何不能改善預(yù)后血流動(dòng)力學(xué)監(jiān)測(cè)為何不能改善預(yù)后 不恰當(dāng)?shù)倪m應(yīng)癥 PAC的副作用或并發(fā)癥 獲得數(shù)據(jù)的方法不正確 n儀器定標(biāo)錯(cuò)誤, 或傳感器位置錯(cuò)誤 獲得的數(shù)據(jù)不能反映血流動(dòng)力學(xué)狀態(tài) 錯(cuò)誤使用數(shù)據(jù)(對(duì)數(shù)據(jù)的解讀錯(cuò)誤) 作出治療決定前未考慮其他相關(guān)因素 nCXR, 尿量, 血清白蛋白 采用的治療措施無(wú)效或有害 無(wú)需血流動(dòng)力學(xué)監(jiān)測(cè)時(shí)未及時(shí)拔除PAC PAC的使用減少的使用

3、減少: Illinois, USA 2000年年2001年年降低降低% 出院患者數(shù)1,636,0461,684,089 PAC使用數(shù)5,9695,02215.8 PAC使用率(/1000)3.652.98 年齡0 17歲21957 65 74歲1,7391,37521 75歲1,9171,62015.5 性別男性3,4922,97015 女性2,4732,05217 Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Critical Care 2005; 9(Suppl

4、1): P69 (DOI 10.1186/cc3132) PAC的使用減少的使用減少: Illinois, USA 2000年年2001年年降低降低% 醫(yī)院大醫(yī)院87369620 其他醫(yī)院5,0924,32615 地區(qū)Chicago39.4 Rockford40 St. Louis33.6 中部15 Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Critical Care 2005; 9(Suppl 1): P69 (DOI 10.1186/cc3132) 臨床評(píng)價(jià)臨

5、床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué) 目的: 評(píng)價(jià)肺動(dòng)脈導(dǎo)管(PAC)得到的血流動(dòng)力學(xué) 指標(biāo)是否能夠改變患者的治療 設(shè)計(jì): 前瞻性觀察 患者: 103例留置PAC的患者 方法: n插管前, 請(qǐng)醫(yī)生對(duì)一些血流動(dòng)力學(xué)指標(biāo)的范圍, 診斷 及治療方案進(jìn)行預(yù)測(cè) n插管后, 復(fù)習(xí)患者病例, 記錄插管時(shí)及置管8小時(shí)內(nèi) 的血流動(dòng)力學(xué) Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of criti

6、cally ill patients. Crit Care Med 1984; 12(7): 549-553 臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué) 0% 20% 40% 60% PAWPCOSVRRAP 預(yù)測(cè)準(zhǔn)確性預(yù)測(cè)準(zhǔn)確性 Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12

7、(7): 549-553 臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué) 結(jié)果 留置PAC后 n計(jì)劃治療方案需要改變58% u應(yīng)用未預(yù)計(jì)到的治療方案30% Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553 臨床評(píng)價(jià)臨床評(píng)價(jià) vs. 血流動(dòng)力學(xué)血流動(dòng)力學(xué) 結(jié)論

8、單純根據(jù)臨床表現(xiàn)難以準(zhǔn)確預(yù)測(cè)血流動(dòng) 力學(xué)指標(biāo) PAC監(jiān)測(cè)數(shù)據(jù)通常能夠改變治療方案 Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553 血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋 臨床場(chǎng)景(n = 44) 心臟外科術(shù)后16 ARDS 9 全身性感染 9 心源性休克

9、5 其他情況 5 Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for interpreting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741 血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋 不同意見(jiàn)數(shù)目不同意見(jiàn)數(shù)目Kappa 計(jì)算機(jī)輔助診治前

10、 住院醫(yī)生與計(jì)算機(jī)5.7 2.20.64 0.14* 計(jì)算機(jī)輔助診治后 住院醫(yī)生與計(jì)算機(jī)1.9 2.00.88 0.12 住院醫(yī)生與主治醫(yī)生1.2 1.70.92 0.10 主治醫(yī)生與計(jì)算機(jī)0.9 1.20.95 0.07 *p 0.05 Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for interpreting pulmonary artery catheterization data: results of the Europe

11、an HEMODYN resident study. Intensive Care Med 2003; 29: 735-741 血流動(dòng)力學(xué)數(shù)據(jù)的解釋血流動(dòng)力學(xué)數(shù)據(jù)的解釋 計(jì)算機(jī)輔助前計(jì)算機(jī)輔助前計(jì)算機(jī)輔助后計(jì)算機(jī)輔助后 RCRCRSSC 酸堿失衡0.830.930.950.98 機(jī)械通氣0.780.950.960.98 代謝0.520.860.900.96 充盈狀態(tài)0.560.840.910.93 泵功能0.530.840.900.90 循環(huán)0.720.910.940.96 RC: 住院醫(yī)生與計(jì)算機(jī); RS: 住院醫(yī)生與主治醫(yī)生; SC: 主治醫(yī)生與計(jì)算機(jī) Squara P, Fourquet

12、 E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for interpreting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741 血流動(dòng)力學(xué)參數(shù)改變治療決定血流動(dòng)力學(xué)參數(shù)改變治療決定 Squara P, Bennett D, Perret C. Chest 2002; 121:

13、 2009-2015 ICU患者的輸液治療患者的輸液治療 輸液治療的決定因素 臨床經(jīng)驗(yàn) 中心靜脈壓或肺動(dòng)脈楔壓 Boldt J, Lenz M, Kumle B, Papsdorf M. Volume replacement strategies on intensive care units: results from a postal survey. Intensive Care Med 1998; 24: 147-151 臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性: PAWP 0101519 19 15 10 0 預(yù)計(jì)預(yù)計(jì)PAWP (mmHg) 測(cè)定測(cè)定PAWP (mmHg) Eisenber

14、g PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553 No change in planned therapy after catheterization Change in planned therapy after catheterization 0 臨床判斷缺乏準(zhǔn)確性臨床判

15、斷缺乏準(zhǔn)確性: CO 04.57.0預(yù)計(jì)預(yù)計(jì)CO (L/min) 測(cè)定測(cè)定CO (L/min) Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553 4.5 7.0 臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性 Eisenberg PL, Jaffe AS, Schust

16、er DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553 參數(shù)參數(shù)判斷正確數(shù)目判斷正確數(shù)目/測(cè)定數(shù)目測(cè)定數(shù)目正確率正確率(%) PAWP31/10230 CO49/9751 SVR39/8844 RAP54/9855 How good are our clinical skills? Cardiac output Wedge

17、pressure Connors (NEJM 83) ICU pts 44% 42% Eisenberg (CCM 84) ICU pts 50% 33% Bayliss (BMJ 83) CCU pts 71% 62% 臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性 Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients Eisenberg PR, et al. Crit Care Med 1984; 12: 349

18、 Assessing hemodynamic status in critically ill patients: Do physicians use clinical information optimally? Connors AF, et al. J Crit Care 1987; 2: 174 Therapeutic impact of PAC in the ICU Steingrub, et al. Chest 1991; 99: 1451 PAC in critically ill patients: A prospective analysis of outcome change

19、s associated with catheter-prompted changes in therapy Mimoz O et al. Crit Care Med 1994; 22: 573 Hemodynamic and pulmonary fluid status in the trauma patient: are we slipping? Veale WN Jr, et al. Am Surg.2005; 71: 621 臨床判斷缺乏準(zhǔn)確性臨床判斷缺乏準(zhǔn)確性 醫(yī)生常常相信自己的判斷, 但自信與準(zhǔn)確 性之間并無(wú)相關(guān)性 與經(jīng)驗(yàn)較少的醫(yī)生相比, 盡管有經(jīng)驗(yàn)的醫(yī) 生更為自信, 但他們的判斷

20、并不準(zhǔn)確 醫(yī)生不應(yīng)盲目根據(jù)自己對(duì)心臟功能的判 斷, 作為治療決策的依據(jù) Dawson NV et al. Hemodynamic assessment in managing the critically ill: is physician confidence warranted? Med Decis Making 1993; 13: 258-266 臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性 Clinical Setting Accurate Assessment, % Unanticipated Changes in Therapy Based on PAC, % Connor

21、s, et al62 noncardiac medical intensive care patients 4848 Eisenberg, et al103 critically ill patients5030 Tuchschmidt and Sharma 35 noncardiac medical intensive care patients 4265 Steingrub, et al154 combined medical/surgical intensive care patients 5147 Connors, et alCardiac and noncardiac medical

22、 intensive care 6647 臨床重要的血流動(dòng)力學(xué)參數(shù)臨床重要的血流動(dòng)力學(xué)參數(shù) 所有醫(yī)生所有醫(yī)生(n = 417)心內(nèi)科醫(yī)生心內(nèi)科醫(yī)生(n = 27) CO330 (79%)21 (75%) PAWP285 (68%)27 (100%) SvO2220 (53%)10 (38%) MPAP120 (37%)10 (38%) SV100 (24%)3 (13%) RAP20 (5%) RVEF20 (5%) RVEDV18 (4%) Squara P, Bennett D, Perret C. Chest 2002; 121: 2009-2015 心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測(cè)心臟手

23、術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測(cè) 問(wèn)卷調(diào)查(39個(gè)問(wèn)題) n血流動(dòng)力學(xué)監(jiān)測(cè) n容量替代 n正性肌力藥物 / 升壓藥物 n輸血 德國(guó)的80個(gè)ICU主任 問(wèn)卷回收率69% Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Groe J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a p

24、ostal survey. Acta Anaesthesiologica Scandinavica 2007; 51(3): 347- 358. 心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測(cè)心臟手術(shù)后患者的血流動(dòng)力學(xué)監(jiān)測(cè) 血流動(dòng)力學(xué)監(jiān)測(cè)血流動(dòng)力學(xué)監(jiān)測(cè)比例比例(%) 基本監(jiān)測(cè)100 肺動(dòng)脈導(dǎo)管(PAC)58.2 經(jīng)食道超聲(TEE)38.1 PICCO13.0 Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Groe J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor

25、 and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiologica Scandinavica 2007; 51(3): 347- 358. 英格蘭與威爾士英格蘭與威爾士ICU的的CO監(jiān)測(cè)技術(shù)監(jiān)測(cè)技術(shù) Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England and Wal

26、es. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131) 英格蘭與威爾士英格蘭與威爾士ICU的的CO監(jiān)測(cè)技術(shù)監(jiān)測(cè)技術(shù) CO監(jiān)測(cè)技術(shù) 2種 69% 首選經(jīng)食道多普勒監(jiān)測(cè)CO 41% 常規(guī)監(jiān)測(cè)ScvO2 20% Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England and Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131)

27、Are We Using PAC Correctly? PAWP測(cè)定中的技術(shù)問(wèn)題測(cè)定中的技術(shù)問(wèn)題 Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure. Crit Care Med 1984; 12(3): 164-170 N (%) measurements % of technical problems No problem1868 (69) Technical problems8

28、43 (31) Criterion 1 (total)(12)(38) Unable to obtain an “atrial waveform”1238 Criterion 2 (total)156 (6)19 WP waveform intermediate between the phasic PA and atrial waveforms100 (4)12 Spontaneous variation of WP56 (2)7 Criterion 3 (total)381 (14)45 Poor dynamic response184 (7)22 Damped tracing65 (2)

29、8 Overinflation42 (2)5 Cannot aspirate blood with the catheter in the PA36 (1)4 Cannot aspirate blood with the catheter in the wedge position54 (2)6 PAWP測(cè)定中的技術(shù)問(wèn)題測(cè)定中的技術(shù)問(wèn)題 Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressu

30、re. Crit Care Med 1984; 12(3): 164-170 WP Technical ProblemCorrected by InitialConfirmed 228OverinflationDeflated balloon 812Venous bloodAdvance 2 cm 308Venous bloodWithdrawn 156Venous bloodNothing 812Poor dynamic responseWithdrawn 4 cm 248Poor dynamic responseDeflated and inflated balloon 2313Poor

31、dynamic responseWithdrawn 128Poor dynamic responseFlushed 3618Partial WPPatient coughed 214Partial WPRepositioned 720Partial WPNothing 1420?Repositioned WP initial WP confirmed = 11 6 mmHg Range (-13, +22) PAWP測(cè)定中的技術(shù)問(wèn)題測(cè)定中的技術(shù)問(wèn)題 Morris AH, Chapman RH, Gardner RM. Frequency of wedge pressure errors in

32、the ICU. Crit Care Med 1985; 13(9): 705-708 ProblemDescriptionsNumber (%) Damped tracingReduced high-frequency content40 (43%) Poor dynamic responseAbsent oscillation, low frequency, or inadequate duration of oscillations after a sudden pressure decrease from approximately 300 mmHg to vascular level

33、s 58 (62%) Over inflationSlow, frequently linear increase in pressure after balloon inflation 10 (9%) Partial WPWaveform intermediate between phasic PA and atrial waveforms 22 (25%) PAWP測(cè)定中的技術(shù)問(wèn)題測(cè)定中的技術(shù)問(wèn)題 Distribution of WP measurements and frequency of a WP error 4 mmHg Trauma ICURespiratory ICU N% (

34、95%CI)N% (95%CI) Total WP attempts10917% (11 26%)17710% (6 15%) WP ultimately confirmed80158 Initial WP without technical problems468% (3 16%)1334% (1 8%) Initial WP with technical problems5326% (18 44%)4031% (17 47%) No WP obtained104 Morris AH, Chapman RH, Gardner RM. Frequency of wedge pressure e

35、rrors in the ICU. Crit Care Med 1985; 13(9): 705-708 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) 目的: 評(píng)價(jià)歐洲國(guó)家ICU醫(yī)生對(duì)PAC相關(guān)知識(shí)的 了解程度 設(shè)計(jì): 調(diào)查問(wèn)卷 背景: 86個(gè)歐洲大學(xué)及非大學(xué)醫(yī)院ICU 對(duì)象: 從兩個(gè)歐洲危重病醫(yī)學(xué)會(huì)目錄中選取134 個(gè)ICU. 其中86個(gè)ICU的535名醫(yī)生參加問(wèn)卷調(diào)查 干預(yù): 在每個(gè)ICU中, 所有醫(yī)生均被要求同時(shí)完 成一項(xiàng)調(diào)查問(wèn)卷, 包括31個(gè)多選題, 涉及床旁留 置PAC的所有方面 Gnaegi A, Feihl F, Perret C. Intensive care physic

36、ians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 199

37、7; 25: 213-220 PAC相關(guān)知識(shí)調(diào)查問(wèn)卷的內(nèi)容分類 1壓力或心輸出量測(cè)定的技術(shù)問(wèn)題 2相關(guān)指標(biāo)的計(jì)算 3血流動(dòng)力學(xué)指標(biāo)的解讀 4留置導(dǎo)管 5導(dǎo)管相關(guān)并發(fā)癥的識(shí)別, 預(yù)防及治療 6應(yīng)用PAC指導(dǎo)治療 7其他 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) In-TrainingPostgraduate Training Completed Primary Medical Specialty Anesthesiology69.9 13.777.0 12.6 Internal Medicine67.9 14.378.3 11.5 Others62.4 16.369.8 15.2 Opi

38、nion of Respondents on Their Knowledge of PACs Inadequate57.6 15.355.0 17.3 Minimal65.7 14.371.9 14.1 Adequate73.2 13.179.2 10.7 Superfluous-83.3 0 Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med

39、1997; 25: 213-220 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) 60.6 65.4 69 77.3 80.8 74.3 73.8 78.2 83.3 78.9 50 60 70 80 90 Never 10/mth Inserting PACs: Frequency in the Last 6 Mths Mean Scores In-Training Postgraduate Training Completed Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of

40、 right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) 55.8 62.6 67.9 71.1 73.6 63.9 70.2 75.2 79.5 81.9 50 60 70 80 90 Never 10/mth Using PAC Data for Guiding Therapy: Frequency in the Last 6 Mths Mean Scores In-Training Postgraduate Train

41、ing Completed Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220 ICU醫(yī)生缺乏醫(yī)生缺乏PAC的相關(guān)知識(shí)的相關(guān)知識(shí) 63.4 70.9 75.9 77.4 73.3 67.6 73 79.9 79.6 78.8 50 60 70 80 90 Never 10/mth Supervising PAC

42、 Insertion: Frequency in the Last 6 Mths Mean Scores In-Training Postgraduate Training Completed Gnaegi A, Feihl F, Perret C. Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220 Is There an Easy Alternative to T

43、his Dilemma? Central venous catheter Injectate temperature sensor 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 11

44、40 (GEDI) 625 DPT Monitor cable PMK-206 Interface cable PC80150 Connection cable to bedside monitor PMK - XXX AUX adapter cable PC81200 PiCCO的技術(shù)原理的技術(shù)原理 PiCCO技術(shù)由下列兩種技術(shù)組成, 用于更有效地 進(jìn)行血流動(dòng)力和容量治療, 使大多數(shù)病人不必 使用肺動(dòng)脈導(dǎo)管: a. 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)b. 動(dòng)脈脈搏輪廓分析技術(shù)動(dòng)脈脈搏輪廓分析技術(shù) 心輸出量的測(cè)定心輸出量的測(cè)定: 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù) 中心靜脈內(nèi)注射指示劑后, 動(dòng)脈導(dǎo)管尖端

45、的熱敏電阻測(cè)量溫度下降的變化曲線 通過(guò)分析熱稀釋曲線, 使用Stewart- Hamilton公式計(jì)算得出心輸出量(CO) Tb注射注射 t 心輸出量的測(cè)定心輸出量的測(cè)定: 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù) 經(jīng)肺熱稀釋測(cè)量只需要在中心靜脈內(nèi)注射冷( 8C)或室溫( 24C)生理鹽水 中心靜中心靜 脈注射脈注射 右心右心 左心左心 肺肺 PiCCO導(dǎo)導(dǎo) 管如插在管如插在 股動(dòng)脈內(nèi)股動(dòng)脈內(nèi) 熱稀釋法測(cè)定熱稀釋法測(cè)定CO: PiCCO vs. PAC PCCO動(dòng)脈熱稀釋動(dòng)脈熱稀釋 測(cè)量位置測(cè)量位置 靜脈注射靜脈注射 RAEDVPBV EVLW LAEDVLVEDV EVLW RVEDV 常規(guī)熱稀釋常規(guī)熱

46、稀釋 測(cè)量位置測(cè)量位置 s01020304050 0,0 0,2 0,4 0,6 C - -D DT 注射注射 熱熱 稀稀 釋釋 測(cè)測(cè) 量量 曲曲 線線 D - dtT KV)T(T CO b iib TDa Tb = 血流溫度血流溫度 Ti = 注射指示劑溫度注射指示劑溫度 Vi = 注射指示劑容積注射指示劑容積 Tb . dt = 熱稀釋曲線下面積熱稀釋曲線下面積 K = 校正系數(shù)校正系數(shù) 動(dòng)脈脈搏輪廓分析動(dòng)脈脈搏輪廓分析 動(dòng)脈脈搏輪廓分析通過(guò)動(dòng)脈壓力波型的形狀獲得連續(xù) 的每搏參數(shù) 通過(guò)經(jīng)肺熱稀釋法的初始校正后, 該公式可以在每次心 臟搏動(dòng)時(shí)計(jì)算出每搏量(SV) t s P mm Hg S

47、V 連續(xù)心輸出量測(cè)定連續(xù)心輸出量測(cè)定: PiCCO 壓力曲線壓力曲線 下面積下面積 壓力曲線型壓力曲線型 狀狀 PCCO = cal HR Systole P(t) SVR + C(p) dP dt () dt 動(dòng)脈順應(yīng)動(dòng)脈順應(yīng) 性參數(shù)性參數(shù) 心心率率與病人有關(guān)的校與病人有關(guān)的校 正因子正因子 t s P mm Hg PCCO is displayed as last 12s mean 心輸出量的測(cè)定心輸出量的測(cè)定: PiCCO vs. 熱稀釋熱稀釋 AuthorPt/Obs COTDa COTDpa Bias SD r Von Spiegel, et al. Anaesthesist 199

48、6; 45(11)21/48-4.7 1.5%.97 McLuckie, et al. Acta Paediatr 1996; 859/?0.19 0.21 L/min/m2 Goedje, et al. Chest 1998; 113(4)30/1500.16 0.31 L/min/m2.96 Goedje, et al. Thorac Cardiovasc Surg 1998; 4630/8100.26 0.71 L/min.96 Zoolner, et al. Anaesthesist 1998; 47(11)18/1600.03 1.04 L/min.91 Goedje, et al.

49、 Crit Care Med 1999; 27(11)24/216-0.29 0.66 L/min.93 Sakka, et al. Intensive Care Med 1999; 2537/4490.68 0.62 L/min.97 Sakka, et al. J Cardiothorac Vasc Anesth 2000; 14(2)12/510.73 0.38 L/min.96 Zoolner, et al. J Cardiothorac Vasc Anesth 2000; 14(2)19/760.21 0.73 L/min.96 Bindels, et al. Crit Care 2

50、000; 445/2830.49 0.45 L/min/m2.95 PiCCO的技術(shù)原理的技術(shù)原理 PiCCO技術(shù)由下列兩種技術(shù)組成, 用于更有效地 進(jìn)行血流動(dòng)力和容量治療, 使大多數(shù)病人不必 使用肺動(dòng)脈導(dǎo)管: a. 經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋技術(shù)b. 動(dòng)脈脈搏輪廓分析技術(shù)動(dòng)脈脈搏輪廓分析技術(shù) PiCCO容量參數(shù)容量參數(shù) 全心舒張末期容積GEDV 胸腔內(nèi)血容積ITBV 血管外肺水EVLW 通過(guò)對(duì)熱稀釋曲線的分析, 可以得到這些容量參數(shù) ln c (I) 注射注射 At 再循環(huán)再循環(huán) MTt t e -1 DSt c (I) 全心舒張末期容積全心舒張末期容積(GEDV) 全心舒張末期容積(GEDV

51、)是心臟4個(gè)腔室內(nèi)的 血容量 胸腔內(nèi)血容積胸腔內(nèi)血容積(ITBV) 胸腔內(nèi)血容積(ITBV)是心臟4個(gè)腔室的容積 + 肺 血管內(nèi)的血液容量 血管外肺水血管外肺水(EVLW) 血管外肺水(EVLW)是肺內(nèi)含有的水量, 可以在 床旁定量判斷肺水腫的程度 容量的測(cè)量原理容量的測(cè)量原理 ln c (I) 注射注射 At 再循環(huán)的影響再循環(huán)的影響 MTt t e-1 DSt c (I) MTt: Mean transit time平均傳輸時(shí)間平均傳輸時(shí)間 half of the indicator passed the point of detection DSt: Downslope time下降時(shí)間

52、下降時(shí)間 exponential downslope time of TD curve 容量的測(cè)量原理容量的測(cè)量原理 Vall = V1 + V2 + V3 + V4 = MTt x Flow Meier et al. J Appl Physiol. 1954 V3 = 最大腔的容積最大腔的容積 = DSt x Flow Newman et al. Circulation. 1951 指示劑由注射點(diǎn)到檢測(cè)點(diǎn)的平均傳輸指示劑由注射點(diǎn)到檢測(cè)點(diǎn)的平均傳輸 時(shí)間時(shí)間MTt由兩點(diǎn)間的總?cè)莘e決定由兩點(diǎn)間的總?cè)莘e決定 下降時(shí)間下降時(shí)間DSt由其中最大的腔室決由其中最大的腔室決 定定 (比其它腔至少大比其它腔

53、至少大 20% 成立成立!) flow V3V4V2V1 注射注射 檢測(cè)檢測(cè) 胸腔內(nèi)的容積組成胸腔內(nèi)的容積組成 GEDV PTV RAEDVPBVLAEDVLVEDVRVEDV EVLW EVLW ITTV PTV = 肺內(nèi)熱容積肺內(nèi)熱容積, 在一系列混合腔室中具有最大的熱容積在一系列混合腔室中具有最大的熱容積 (DSt 容積容積) ITTV = 胸腔內(nèi)總熱容積胸腔內(nèi)總熱容積, 從注射點(diǎn)到測(cè)量的熱容積之和從注射點(diǎn)到測(cè)量的熱容積之和 (MTt 容積容積) GEDV= 全心舒張末期容積全心舒張末期容積 = ITTV PTV 容量的測(cè)量原理容量的測(cè)量原理 RAEDVPTVLAEDVLVEDVRVED

54、V 胸腔總熱容積胸腔總熱容積(ITTV) ITTV = CO x MTtTDa 肺內(nèi)總熱容積肺內(nèi)總熱容積(PTV) PTV = CO x DStTDa 全心舒張末期容積全心舒張末期容積 GEDV = ITTV PTV RAEDVRVEDVLAEDVLVEDV RAEDVRVEDVLAEDVLVEDVPTV PTV ITBV的測(cè)量原理的測(cè)量原理 Sakka et al, Intensive Care Med 2000; 26: 180-187 ITBV = 1.25 * GEDV 28.4 ml r = 0.96 ITBVTD (ml) GEDVST (ml) GEDV vs. ITBV in

55、57 intensive care patients ITBV準(zhǔn)確性的臨床驗(yàn)證準(zhǔn)確性的臨床驗(yàn)證 Sakka et al, Intensive Care Med 26: 180-187, 2000 n = 209 r = 0.97 Bias = -7.6 ml/m2 SD = 57.4 ml/m2 ITBVIST vs. ITBVITD in 209 intensive care patients 容量測(cè)量小結(jié)容量測(cè)量小結(jié) ITTV = CO x MTtTDa PTV = CO x DStTDa ITBV = 1.25 x GEDV GEDV = ITTV PTV RAEDVRVEDVLAEDV

56、LVEDV RAEDVRVEDVLAEDVLVEDVPBV RAEDVRVEDVLAEDVLVEDVPTV PTV PiCCO前負(fù)荷指標(biāo)前負(fù)荷指標(biāo) 在反映心臟前負(fù)荷的敏感性和特異性方面, 已 經(jīng)證實(shí)ITBV和GEDV不但優(yōu)于CVP及PAWP, 也優(yōu) 于RVEDV ITBV和GEDV最主要的優(yōu)點(diǎn)是不受機(jī)械通氣的影 響而產(chǎn)生錯(cuò)誤, 因此能夠在任何情況下提供前 負(fù)荷情況的正確信息 經(jīng)由GEDV和SV計(jì)算得到的全心射血分?jǐn)?shù)(GEF), 在一定程度上反映了心肌收縮功能 nGEF = 4 x SV / GEDV 容量負(fù)荷反應(yīng)組與無(wú)反應(yīng)組的容量負(fù)荷反應(yīng)組與無(wú)反應(yīng)組的CVP 擴(kuò)容治療前的肺動(dòng)脈楔壓擴(kuò)容治療前的

57、肺動(dòng)脈楔壓 PAOP (mmHg) 有反應(yīng)者有反應(yīng)者無(wú)反應(yīng)者無(wú)反應(yīng)者 Calvin et al8 17 2 Schneider et al10 110 1 Reuse et al10 410 3 Diebel et al14 77 2 Diebel et al16 615 5 Wagner and Leatherman10 314 4 Tavernier et al10 412 3 Tousignant et al12 316 3 Michard et al10 311 2 p 0.05 擴(kuò)容治療前的右室舒張末容積指數(shù)擴(kuò)容治療前的右室舒張末容積指數(shù) 擴(kuò)容治療前的右室舒張末面積擴(kuò)容治療前的右室舒

58、張末面積 LVEDA (cm2/m2) 有反應(yīng)者有反應(yīng)者無(wú)反應(yīng)者無(wú)反應(yīng)者 Tavernier et al9 312 4 Tousignant et al15 520 5 Feissel et al10 410 2 p 100%時(shí), 胸片才會(huì)發(fā)生改變 Bongard FS, Surgery 1984 胸片對(duì)EVLW的改變并不敏感 Helperin BD, Chest 1984 確定患者是否符合ARDS影像學(xué)表現(xiàn)時(shí), 醫(yī)生之間存在非常明顯的差異 Rubenfeldet al, Chest 1999 容量測(cè)量小結(jié)容量測(cè)量小結(jié) ITTV = CO x MTtTDa PTV = CO x DStTDa

59、ITBV = 1.25 x GEDV EVLW = ITTV ITBV GEDV = ITTV PTV RAEDVRVEDVLAEDVLVEDV RAEDVRVEDVLAEDVLVEDVPBV RAEDVRVEDVLAEDVLVEDVPTV PTV EVLW EVLW EVLW: PiCCO vs. 重力法測(cè)定重力法測(cè)定 Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-1

60、39 血管外肺水的臨床驗(yàn)證血管外肺水的臨床驗(yàn)證 Sakka et al, Intensive Care Med 26: 180-187, 2000 Bias = -0.2 ml/kg SD = 1.4 ml/kg n = 209 r = 0.96 EVLWIST vs. EVLWITD in 209 intensive care patients 減少血管外肺水減少血管外肺水: 臨床試驗(yàn)臨床試驗(yàn) Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992 血管外肺水血管外肺水 血管外肺水(EVLW)通過(guò)經(jīng)肺熱稀釋法得到, 已 被染料稀釋法和重量法證實(shí)