PiCCO技術(shù)的臨床應(yīng)用

PiCCO容量監(jiān)護儀的臨床應(yīng)用前茂企業(yè)付家紅1PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

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參數(shù)進行監(jiān)測的工具。2PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心靜脈導管?頸內(nèi)靜脈?鎖骨下靜脈?股靜脈大多數(shù)血流動力學不穩(wěn)定的患者都會置?中心靜脈導管(給血管活性藥物…)?動脈導管(監(jiān)測動脈壓、動脈血氣分析…)連接動脈熱稀釋導管股動脈導管腋動脈導管3PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02中心靜脈導管?頸內(nèi)靜脈?鎖骨下靜脈?股靜脈4PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO

plus

連接示意圖中心靜脈導管注射液溫度探頭容納管（T型管）動脈熱稀釋導管注射液溫度電纜PULSION一次性壓力傳感器PCCIAP13.0316.28

TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625

溫度測量電纜壓力電纜5PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO技術(shù)可以監(jiān)測心輸出量第一：6PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02什么是PiCCO技術(shù)?3次熱稀釋校準

經(jīng)肺熱稀釋曲線injectiontT

動脈脈搏輪廓分析Pt

＝兩種技術(shù)

經(jīng)熱稀釋方法得到的非連續(xù)性參數(shù)

心輸出量 CO

全心舒張末期容積 GEDV

胸腔內(nèi)血容量ITBV

血管外肺水 EVLW*

肺血管通透性指數(shù)PVPI*

心功能指數(shù)CFI

全心射血分數(shù)GEF

動脈輪廓分析法得到的連續(xù)性參數(shù)

連續(xù)心輸出量PCCO

動脈壓AP

心率HR

每搏量SV

每搏量變異SVV

脈壓變異PPV

系統(tǒng)血管阻力SVR

左心室收縮力指數(shù)dPmx*血液動力學和容量進行監(jiān)護管理＋兩部分參數(shù)PiCCO7PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Tb=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行分析所得熱稀釋方法所得心輸出量的計算Tb

x

dt(Tb-Ti)xVix

K

TbInjectiont∫D=COTDa8PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02熱稀釋曲線下的面積與心輸出量成反比

36,537510熱稀釋曲線NormalCO:5.5l/min36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperature9PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02經(jīng)肺熱稀釋法測量CO(vs肺動脈導管)Author

Bias

(L/min) SD

rGodje

Chest1998

0.16

0.35

0.96Sakka

ICM1999 0.68 0.62 0.97Goedje

CCM1999 0.29 0.60 0.93Bindels

CC2000 0.49 0.78

0.95Goedje

Chest2000 0.35 0.72 0.98DellaRoccaBJA2002 0.15 0.870.93SanderCC2005 0.00 0.70 0.95Ostergaard

AAS2006 0.46 0.55

10PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02脈搏輪廓分析Cal=校準系數(shù)來自經(jīng)肺熱稀釋方法Surface

=Cal.x

Strokevolume11PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PCCO=cal.HR.

(P(t)/SVR+C(p).

dP/dt)dtsystolePatient-specific

calibrationfactor(determined

with

thermodilution)complianceshape

of

pressurecurveareaof

pressurecurveP(mmHg)t(s)12PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO所得連續(xù)心排量數(shù)值準確性論證Roedig

Getal.

BrJAnaesth1999;82:525-530GoedjeOetal.

AnnThorac

Surg1999;68:1532-1536Buhre

Wetal.

JCardiothorac

Vasc

Anesth1999;13:437-440GoedjeOetal.

CritCareMed1999;27:2407-2412ZollnerCetal.

JCardiothorac

Vasc

Anesth2000;14:125-129GoedjeOetal.

MedSci

Monit2001;7:1344-1350FelbingerTWetal.

JClin

Anaesth2002;14:296-301GoedjeOetal.

CritCareMed2002;30:52-58RauchHetal.

Acta

AnaesthesiolScand2002;46:426-429Felbingeretal.JClin

Anaesth2005;17:241-248Ostergaardetal.

Acta

AnaesthesiolScand2006;50:1044-104913PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

PiCCO不僅是心排量監(jiān)測儀14PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

GEDV(全心舒張末期容量）—評估心臟前負荷容量第二：15PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02目前醫(yī)學界判斷心臟前負荷的標準中心靜脈壓

(CVP)肺動脈楔壓

(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

PULSIONMedicalSystems16PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02壓力不是容量壓力不代表容積壓力與流量相關(guān)

---壓力就是壓力

北京協(xié)和醫(yī)院劉大為17PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Prospective,nonrandomized,nonblindedinterventionalstudy.Cardiaccatheterizationandechocardiographylaboratories.NormalhealthyvolunteersGroups:Group1:Pulmonarycatheterizationandradionuclidecineangiographyn=12Group2:volumetricechocardiographyn=32Volumeload:3Lsalinivover3hrsCritCareMed.2004;32:691–699.18PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0219PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CritCareMed2004;32:691–69920PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CVP/PAWP對容量試驗的反應(yīng)擇期心臟手術(shù)患者n=20監(jiān)測GEDVI:PiCCOCEDVIPAC:PACLVpreloadassessment:TEEHemodynamicmeasurements:before(T0)and20min(T1)and40min(T2)afteravolumeloadVolumeload:HES10ml/kgover20min

BritishJournalofAnaesthesia.2005,94(6):748–755.21PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0222PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02BritishJournalofAnaesthesia94(6):748–55(2005)23PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,Crit

CareMed2004;32:691-69924灌注壓CVP/PCWP反映前負荷中心靜脈壓和每搏輸出量的關(guān)聯(lián)監(jiān)測前負荷24PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Kumaretal.,Crit

CareMed2004;32:691-69925肺動脈嵌壓和每搏輸出量的關(guān)聯(lián)監(jiān)測前負荷灌注壓CVP/PCWP反映前負荷25PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02GEDV可以作為心臟前負荷的指標全心舒張末容量GEDV26PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02每搏量的變化指數(shù)(%)全心舒張末容量的變化指數(shù)(%)r=0.72p<0.001Transpulmonarythermodilutionasaguidetofluidtherapyinsepticpatientswithacutecirculatoryfailure.Michardetal.SCCM200227PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02%*fluid

loadingdobutamine**

GEDV是反映前負荷的指標Chest2003;124:1900-190828PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02治療指南－SurvivingSepsisCampaignGuidelines2008:?灌注壓在評估擴容治療中已經(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)29PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02SVV（每搏量變異）---預測容量反應(yīng)30PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02SVmaxSVminSVmeanSVmax–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)律的完全機械通氣病人31PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Intrathoracicpressure 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)測前負荷32PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02SVV

反映了心臟對因機械通氣導致的前負荷周期性變化的敏感性。1,15,18,19,20SVV

可用于預測擴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械通氣病人而言，每搏量變異-SVV33PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_0200.511-specificitysensitivitySVVCVP00.60.410.80.210%Strokevolumevariationasapredictoroffluid

responsivenessinpatientsundergoing

brain

surgery

BerkenstadtH.MargalitN,HadaniM,FriedmanZ,SegalE,VilaY,PerelA.Anesth

Analg2001;92:984-9sensitivity=79%specificity=93%34PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02心肌收縮狀況FORCE-FREQUENCYRELATIONDIGITALIS,OTHERINONOTROPICAGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATINGCATECHOLAMINESSYMPATHETICNERVEIMPULSESLOSSOFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRINSICDEPRESSION左室舒張末容量每搏量FromBraunwaldEetal.Mechanismsofcontractionofthenormalandfailingheart2nded.Boston,Little,Brown,197635PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI（心功能指數(shù)）—心肌收縮功能第三：36PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02CFI=CI/GEDVI37PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

TEEFACPiCCOCFI38PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Jabotetal(submitted)r=0.8039PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02-15-551525354555VolumeexpansionDobutamine*percentchangesinCFI(%)

CFIbehavesasamarkerofsystolic

functionJabotetal(submitted)AlowCFI(<4)canalerttheclinicianandincitetoperformanechoCFI(<4)提醒醫(yī)生應(yīng)當進一步使用超聲技術(shù)診斷

RepetitivemeasurementsofCFIallowfollowingthechangesofcardiacfunctionwiththerapy多次監(jiān)測CFI可以用來跟蹤治療方案實施以后心臟功能的改變40PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02t[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)41PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO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)42PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLW（血管外肺水）—肺水腫指數(shù)第四：43PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PulmonarycirculationLeftHeartRightHeartLungs血管外肺水EVLW在管理前負荷中的作用EVLW=Extravascular

LungWater（血管外肺水）Bodycirculation監(jiān)測前負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充有預警功能44PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02373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]45PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02EVLWp00.5100.51PaO2/FiO2sensitivity1-specificity16mL/kgEVLW46PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02利用EVLW治療病人101位肺水腫病人隨時分成肺動脈導管（PAC）組與血管外肺水組（EVLW），分別依據(jù)PCWP和EVLW的測量結(jié)果進行治療。在EVLW組的病人在ICU的時間和機械通氣時間都顯著降低。Mitchelletal,AmRev

RespDis145:990-998,1992

22天15天9天7天**機械通氣天數(shù)住ICU天數(shù)n=101EVLW組PAC組EVLW組PAC組47PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫Incaseofdoubtful

diagnosis

basedonconventional

criteria

尤其當傳統(tǒng)的標準產(chǎn)生不確定診斷時

如何應(yīng)用EVLW指標？48PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02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49PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema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）

如何應(yīng)用EVLW指標？

50PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02PiCCO肺相關(guān)指標

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Pulmonarv

Blood

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

Lung

Water51PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02109876543210PVPIALI/ARDSHydrostatic

pulmonary

edema*Se=85%Sp=100%cut-off

value=352PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02Incriticallyillpatientsforidentifyingpatientswithpulmonaryedema針對危重病人，甄別病人是否有肺水腫Inpatientswithpulmonaryedema

fordiagnosinghydrostatic

vs

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）InALI/ARDSpatientsforidentifyingpatientswithhighdegreeofpulmonaryedema針對ALI/ARDS的病人群，從中甄別嚴重肺水腫的病人如何應(yīng)用EVLW指標？

53PMAN\FREIDOKU\SCHULUNG\PiCCO\high_level\PiCCO_highLevelV05_04_02

44patientshospitalizedinBicetre

HospitalforALI/ARDS

accordingtostandarddefinitions(bilateral

infiltrates,P/F,etc)35%65%EVLW<7EVLW>7Michardetal.Chest2004Managementcould

be

different

intermsofvolumeexpansionanddiureticsuseaccordingtolung