PiCCO原理以及計算過程課件

IntroductiontoPiCCOTechnology

PiCCO技術(shù)的介紹Principlesoffunction

理論知識Thermodilution

熱稀釋法Pulsecontouranalysis

脈搏輪廓分析法Contractilityparameters

收縮力參數(shù)Afterloadparameters

后負(fù)荷參數(shù)Extravascularlungwater

血管外肺水Pulmonarypermeability

肺通透性指數(shù)血流動力學(xué)監(jiān)測TheoryandPracticePiCCOTechnologyParametersforguidingvolumetherapyIntroductiontothePiCCO-TechnologyCO心排量Volumetricpreload容量負(fù)荷EVLW肺水Contractility收縮力DifferentiatedVolumeManagement

-static-dynamic

-PiCCOTechnologyisacombinationoftranspulmonarythermodilutionandpulsecontouranalysisPiCCO技術(shù)是經(jīng)肺熱稀釋法和脈搏輪廓分析法的結(jié)合PrinciplesofMeasurementLeftHeartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHPULSIOCATHCVCPULSIOCATHarterialthermodilutioncathetercentralvenousbolusinjectionIntroductiontothePiCCO-Technology–FunctionBolusinjectionconcentrationchangesovertime(Thermodilutioncurve)Aftercentralvenousinjectionthecoldbolussequentiallypassesthroughthevariousintrathoraciccompartments中心靜脈彈丸注射后，冰鹽水會通過胸腔內(nèi)的各個腔室。Thetemperaturechangeovertimeisregisteredbyasensoratthetipofthearterialcatheter動脈導(dǎo)管尖端的感受器探測到注射液溫度的改變。IntroductiontothePiCCO-Technology–FunctionLeftheartRightheartLungsRARVLALVPBVEVLWEVLWPrinciplesofMeasurementIntrathoracicCompartments(mixingchambers)IntroductiontothePiCCO-Technology–FunctionPulmonaryThermalVolume(PTV)

肺內(nèi)熱稀釋容積IntrathoracicThermalVolume(ITTV)胸腔內(nèi)熱容積Totalofmixingchambers

所有的混合腔室RARVLALVPBVEVLWEVLWLargestsinglemixingchamber最大的單一混合腔室HaemodynamicMonitoringE.IntroductiontoPiCCOTechnologyPrinciplesoffunction

ThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeabilityTb

x

dt(Tb-Ti)xVix

K

TbInjectiont∫D=COTDaTb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫?Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectateTheCOiscalculatedbyanalysisofthethermodilutioncurveusingthemodifiedStewart-Hamiltonalgorithm

心排量是通過分析熱稀釋曲線得來的，應(yīng)用Stewart-Hamilton定律。CalculationoftheCardiacOutputIntroductiontothePiCCO-Technology–ThermodilutionTheareaunderthethermodilutioncurveisinverselyproportionaltotheCO.熱稀釋曲線下的面積是與CO呈反比的。

36,537510ThermodilutioncurvesNormalCO:5.5l/minIntroductiontothePiCCO-Technology–Thermodilution36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperatureTranspulmonaryvs.PulmonaryArteryThermodilutionLeftheartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHarterialthermo-dilutioncathetercentralvenousbolusinjectionRARVPALALVAortaTranspulmonaryTD(PiCCO)PulmonaryArteryTD(PAC)Inbothproceduresonlypartoftheinjectedindicatorpassesthethermistor.在這兩種方式中只有一部分注射液會通過熱敏感受器。NonethelessthedeterminationofCOiscorrect,asitisnottheamountofthedetectedindicatorbutthedifferenceintemperatureovertimethatisrelevant!

但是CO正確與否的決定性因素，并不是指示劑的量，而是隨著時間變化導(dǎo)致的溫度變化，這兩者相關(guān)的。IntroductiontothePiCCO–Technology–ThermodilutionComparisonwiththeFickMethod0,970,68±0,6237/449SakkaSGetal.,IntensiveCareMed25,1999-/-0,19±0,219/27McLuckieA.eta.,Acta

Paediatr85,19960,960,16±0,3130/150G?djeOetal.,Chest113(4),19980.980,32±0,2923/218HolmCetal.,Burns27,20010,930,13±0,5260/180DellaRoccaGetal.,EurJAnaest14,20020,95-0,04±0,4117/102FriedmanZetal.,EurJAnaest,20020,950,49±0,4545/283BindelsAJGHetal.,CritCare4,20000,980,03±0,1718/54PauliC.etal.,IntensiveCareMed28,200224/120n(Pts/Measurements)0,990,03±0,24TibbyS.etal.,IntensiveCareMed23,1997rbias±SD(l/min)ComparisonwithPulmonaryArteryThermodilutionValidationofthe

Transpulmonary

ThermodilutionIntroductiontothe

PiCCO–Technology–ThermodilutionMTt:MeanTransittime

themeantimerequiredfortheindicatortoreachthedetectionpointDSt:DownSlopetime

theexponentialdownslopetimeofthethermodilutioncurveRecirculationte-1TbFromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters

從熱稀釋曲線的特點來看，它是可以決定某些時間參數(shù)的。ExtendedanalysisofthethermodilutioncurveIntroductiontothePiCCO-Technology–ThermodilutionInjectionInTbMTtDStTb=bloodtemperature;lnTb=logarithmicbloodtemperature;t=timePulmonaryThermalVolumePTV=DstxCOByusingthetimeparametersfromthethermodilutioncurveandtheCOITTVandPTVcanbecalculated

通過熱稀釋曲線的時間參數(shù)，可以計算出ITTV和PTV.CalculationofITTVandPTVIntroductiontothePiCCO-Technology–ThermodilutionRecirculationte-1TbInjectionInTbIntrathoracicThermalVolumeITTV=MTtxCOMTtDStPulmonaryThermalVolume(PTV)IntrathoracicThermalVolume(ITTV)CalculationofITTVandPTVEinführungindiePiCCO-Technologie–ThermodilutionITTV=MTtxCOPTV=DstxCORARVLALVPBVEVLWEVLWGEDVisthedifferencebetweenintrathoracicandpulmonarythermalvolumes.GEDV就是胸腔內(nèi)熱容積和肺內(nèi)熱容積的差值。GlobalEnd-diastolicVolume(GEDV)Volumetricpreloadparameters–GEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroductiontothePiCCO–Technology–ThermodilutionVolumetricpreloadparameters–ITBVIntrathoracicBloodVolume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroductiontothePiCCO–Technology–ThermodilutionITBVisthetotaloftheGlobalEnd-DiastolicVolumeandthebloodvolumeinthepulmonaryvessels(PBV)ITBVTD(ml)ITBV=1.25*GEDV–28.4[ml]GEDVvs.ITBVin57IntensiveCare

PatientsIntrathoracic

Blood

Volume(ITBV)Volumetric

preload

parameters–ITBVIntroductiontothe

PiCCO-Technology–ThermodilutionITBVis

calculated

from

theGEDVby

the

PiCCOTechnology01000200030000100020003000GEDV

(ml)Sakkaetal,IntensiveCareMed26:180-187,2000SummaryandKeyPoints-Thermodilution

PiCCOTechnologyisalessinvasivemethodformonitoringthe

volumestatusandcardiovascularfunction.

PiCCO技術(shù)是一種監(jiān)測容量狀態(tài)和心肌功能的微創(chuàng)技術(shù)。 Transpulmonarythermodilutionallowscalculationofvariousvolumetricparameters.經(jīng)肺熱稀釋法可以計算各種容量參數(shù)。 TheCOiscalculatedfromtheshapeofthethermodilutioncurve.CO是通過熱稀釋曲線的面積計算而得的。 Thevolumetricparametersofcardiacpreloadcanbecalculatedthroughadvanced analysisofthethermodilutioncurve.心臟前負(fù)荷的容量參數(shù)是通過進(jìn)一步分析熱稀釋曲線獲得的。Forthethermodilutionmeasurementonlyafractionofthetotalinjectedindicator needstopassthedetectionsite,asitisonlythechangeintemperatureovertimethat isrelevant.

對于熱稀釋測量來講，只需要一部分的指示劑通過監(jiān)測點，同樣只需要在相關(guān)的時間里面溫度有所改變即可。IntroductiontothePiCCO-TechnologyHaemodynamicMonitoringE.IntroductiontoPiCCOTechnologyPrinciplesoffunctionThermodilutionPulsecontour

analysisContractility

parametersAfterload

parametersExtravascular

LungWaterPulmonary

PermeabilityTranspulmonaryThermodilutionThepulsecontouranalysisiscalibratedthroughthetranspulmonarythermodilutionandisabeattobeatrealtimeanalysisofthearterialpressurecurve.脈搏輪廓分析法是通過經(jīng)肺熱稀釋法計算，同時也是實時分析動脈壓力曲線得出的。CalibrationofthePulseContourAnalysisIntroductiontothePiCCO-Technology–PulsecontouranalysisInjectionPulseContourAnalysisT=bloodtemperaturet=timeP=bloodpressureCOTPD=SVTDHRPCCO=cal?HR?P(t)SVR+C(p)?dPdt()dtCardiacOutputPatient-specificcalibrationfactor(determinedbythermodilution)

HeartrateAreaunderthepressurecurveShapeofthepressurecurveAorticcomplianceSystoleIntroductiontothePiCCO-Technology–PulsecontouranalysisParametersofPulseContourAnalysis

n(Pts/Measurements)0,940,03±0,6312/36BuhreW

etal.,JCardiothorac

Vasc

Anesth13(4),199919/7624/51762/18620/36025/38022/96-/--0,40±1,3Mielck

etal.,JCardiothorac

Vasc

Anesth17(2),20030,880,31±1,25Z?llnerC

etal.,JCardiothorac

Vasc

Anesth14(2),20000,88-0,2±1,15G?djeO

etal.,CritCareMed30(1),20020,94-0,02±0,74DellaRoccaG

etal.,BrJAnaesth88(3),20020,93-0,14±0,33FelbingerTW

etal.,JClin

Anesth46,2002-/-0,14±0,58RauchH

etal.,Acta

AnaesthScand46,2002r

bias±SD(l/min)ComparisonwithpulmonaryarterythermodilutionValidationofPulseContourAnalysisIntroductiontothePiCCO-Technology–PulsecontouranalysisSVmax–SVminSVV=SVmeanSVmaxSVminSVmeanTheStrokeVolumeVariationisthevariationinstrokevolumeovertheventilatorycycle,measuredovertheprevious30secondperiod.

每博量變異是每博量在一個呼吸周期中的變異，它所測量的是之前30秒的值。ParametersofPulseContourAnalysisIntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–StrokeVolumeVariationPPmax–PPminPPV=PPmeanThepulsepressurevariationisthevariationinpulsepressureovertheventilatorycycle,measuredovertheprevious30secondperiod.

脈壓變異是在一個呼吸周期里面脈搏壓力的變異，它測得的是之前30秒的值。ParametersofPulseContourAnalysisIntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–PulsePressureVariationPPmaxPPmeanPPminSummarypulsecontouranalysis-COandvolumeresponsiveness ThePiCCOtechnologypulsecontouranalysisiscalibratedbytranspulmonary

thermodilution

PiCCO技術(shù)脈搏輪廓分析基于熱稀釋法來計算的

PiCCOtechnologyanalysesthearterialpressurecurvebeatbybeat therebyprovidingrealtimeparameters.

PiCCO技術(shù)分析實時動脈壓力曲線，因此它提供了實時的監(jiān)測數(shù)據(jù)。 Besidescardiacoutput,thedynamicparametersofvolumeresponsiveness SVV(strokevolumevariation)andPPV(pulsepressurevariation)aredetermined continuously.

除了心輸出量，SVV和PPV都是連續(xù)性的參數(shù)。IntroductiontothePiCCO-Technology–PulsecontouranalysisHaemodynamicMonitoringE.IntroductiontoPiCCOTechnologyPrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeabilityContractilityisameasurefortheperformanceoftheheartmuscle收縮力指數(shù)是評估心肌功能的參數(shù)ContractilityparametersofPiCCOtechnology:PiCCO技術(shù)監(jiān)測心肌收縮力的參數(shù):

dPmx(maximumrateoftheincreaseinpressure)GEF(GlobalEjectionFraction)CFI(CardiacFunctionIndex)ContractilityIntroductiontothePiCCO-Technology–ContractilityparameterskgContractilityparameterfromthepulsecontouranalysisIntroductiontothePiCCO-Technology–ContractilityparametersdPmx=maximumvelocityofpressureincreaseThecontractilityparameterdPmxrepresentsthemaximumvelocityofleftventricularpressureincrease.

收縮力參數(shù)dPmx指的是左心室壓力曲線上的最大值。ContractilityparameterfromthepulsecontouranalysisIntroductiontothePiCCO-Technology–ContractilityparametersfemoraldP/max[mmHg/s]LVdP/dtmax[mmHg/s]dPmxwasshowntocorrelatewellwithdirectmeasurementofvelocityofleftventricularpressureincrease

in70cardiacsurgerypatientsdPmx的值與左心室壓力的測量值在70個心臟手術(shù)的病例中，呈現(xiàn)很好的正相關(guān)。deHertetal.,JCardioThor&VascAnes2006

n=220y=-120+(0,8*x)r=0,82p<0,00105001000150001000150020002000500dPmx=maximumvelocityofpressureincrease iscalculatedas4timesthestrokevolumedividedbytheglobalend-diastolic volume

GEF是4倍的SV除以全心舒張末期容量 reflectsbothleftandrightventricularcontractility它反應(yīng)的是全心功能參數(shù)GEF=GlobalEjectionFractionContractilityparametersfromthethermodilutionmeasurementIntroductiontothePiCCO-Technology–Contractilityparameters4xSVGEF=GEDVLALVRARVCombesetal,IntensiveCareMed30,2004GEF=GlobalEjectionFractionComparisonoftheGEFwiththegoldstandardTEEmeasuredcontractilityinpatientswithoutrightheartfailure.GEF和金標(biāo)準(zhǔn)TEE同時在右心功能正常的病例中的對比。sensitivity00,40,60,8010,20,20,40,60,81specifity2220191816128DFAC,%DGEF,%510-5-20-10102015-15-10r=076,p<0,0001n=47IntroductiontothePiCCO-Technology–ContractilityparametersContractilityparametersfromthethermodilutionmeasurement istheCIdividedbyglobalend-diastolicvolumeindexCFI是CI除以全心舒張末期容量指數(shù) is-similartotheGEF–aparameterofbothleftandrightventricular contractility它與GEF相似，是反映全心功能的參數(shù)CFI=CardiacFunctionIndexCICFI=GEDVIIntroductiontothePiCCO-Technology–ContractilityparametersContractilityparametersfromthethermodilutionmeasurementCombesetal,IntensiveCareMed30,2004sensitivity00,40,60,8010,20,20,40,60,81specificity6543,532DFAC,%DGEF,%510-5-20-10102015-15-10r=079,p<0,0001n=47CFI=Cardiac

FunctionIndexIntroductiontothePiCCO-Technology–ContractilityparametersCFIwascomparedtothegoldstandardTEEmeasuredcontractilityinpatientswithoutrightheartfailure.CFI與金標(biāo)準(zhǔn)的TEE在右心功能正常病人中的對比ContractilityparametersfromthethermodilutionmeasurementHaemodynamicMonitoringE.IntroductiontoPiCCOtechnologyFunctionsThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability iscalculatedasthedifferencebetweenMAPandCVPdividedbyCO asanafterloadparameteritrepresentsafurtherdeterminantofthecardiovascularsituation

作為一個后負(fù)荷指數(shù)，它是心血管狀況更深層的決定性因素。 isanimportantparameterforcontrollingvolumeandcatecholaminetherapies這是一個非常重要的參數(shù)，它可以提示容量控制和兒茶酚胺的治療。(MAP–CVP)x80SVR=COAfterloadparameterSVR=SystemicVascularResistanceMAP=MeanArterialPressureCVP=CentralVenousPressureCO=CardiacOutput80=FactorforcorrectionofunitsIntroductiontothePiCCO–Technology–Afterloadparameter TheparameterdPmxfromthepulsecontouranalysisasameasureoftheleft ventricularmyocardialcontractilitygivesimportantinformationregarding cardiacfunctionandtherapyguidance.脈搏輪廓分析得出的參數(shù)dPmx能提示左心室心肌收縮力的重要信息，這關(guān)乎心肌的功能和治療方向。 ThecontractilityparametersGEFandCFIareimportantparametersfor assessingtheglobalsystolicfunctionandsupportingtheearlydiagnosisof myocardialinsufficiency.心功能指數(shù)GEF和CFI是非常重要的參數(shù)，可以用來評估整體收縮期的心肌功能以及對于心肌損傷的早期診斷。 TheSystemicVascularResistanceSVRcalculatedfrombloodpressureand cardiacoutputisafurtherparameterofthecardiovascularsituation,andgives additionalinformationforcontrollingvolumeandcatecholaminetherapies.SVR是基于血壓和心輸出量來分析的，這是評估心血管功能重要的參數(shù)，能提示容量管理和兒茶酚胺類藥物的治療。SummaryandKeyPointsIntroductiontothePiCCO–Technology–ContractilityandAfterloadHaemodynamicMonitoringE.IntroductiontoPiCCOtechnologyPrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparametersAfterloadparametersExtravascularLungWaterPulmonaryPermeability ITTV

– ITBV= EVLWTheExtravascularLungWateristhedifferencebetweentheintrathoracicthermalvolumeandtheintrathoracicbloodvolume.Itrepresentstheamountofwaterinthelungsoutsidethebloodvessels.EVLW是胸腔內(nèi)熱容積和胸腔內(nèi)血容積的差值。它反應(yīng)肺血管外的水有多少。CalculationofExtravascularLungWater(EVLW)IntroductiontothePiCCO–Technology–ExtravascularLungWaterKatzenelsonetal,CritCareMed32(7),2004Sakkaetal,IntensiveCareMed26:180-187,2000GravimetryDyedilutionEVLWfromthePiCCOtechnologyhasbeenshowntohaveagoodcorrelationwiththemeasurementofextravascularlungwaterviathegravimetryanddyedilutionreferencemethods.PiCCO技術(shù)測得的EVLW與通過重力實驗與染料稀釋法測得的血管外肺水有很好的相關(guān)性ValidationofExtravascularLungWatern=209r=0.96ELWIbygravimetryELWIbyPiCCOR=0,97P<0,001Y=1.03x+2.49010203020304010ELWITD(ml/kg)051020152525501002015ELWIST(ml/kg)IntroductiontothePiCCO–Technology–ExtravascularLungWaterBoeckJ,JSurgRes1990;254-265Highextravascularlungwaterisnotreliablyidentifiedbybloodgasanalysis高血管外肺水與血氣分析沒有相關(guān)性。EVLWasaquantifieroflungedemaPaO2/FiO21020550301502500450ELWI(ml/kg)050350IntroductiontothePiCCO–Technology–ExtravascularLungWaterELWI=7ml/kgELWI=8ml/kgELWI=14ml/kgELWI=19ml/kgExtravascularlung

waterindex

(ELWI)

normalrange:

3–7ml/kgPulmonaryoedemaNormalrangeEVLWasaquantifieroflungoedemaIntroductiontothePiCCO–Technology–ExtravascularLungWater40Halperinetal,1985,Chest88:649Chestxray–doesnotreliablyquantifypulmonaryoedemaandisdifficulttojudge,particularlyincriticallyillpatients.X線檢查——并不能量化肺水腫，對于嚴(yán)重的病人尤其難以評估。r=0.1p>0.050208015-10-151060D

radiographicscore-80-60-40-20D

ELWIEVLWasaquantifieroflungoedemaIntroductiontothePiCCO–Technology–ExtravascularLungWaterELWI(ml/kg)>21 n=5414-21 n=1007-14 n=174<7 n=45Mortality(%)1000n=373*p=0.00220304050607080SturmJin:Lewis,Pfeiffer(eds):PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139RelevanceofEVLWAssessmentTheamountofextravascularlungwaterisapredictorformortalityintheintensivecarepatient.肺水的量在ICU病人中，可以提示死亡率。ELWI(ml/kg)4-6300Mortality(%)20n=8140506070806-88-1010-1212-1616-20>2090100Sakkaetal,Chest2002IntroductiontothePiCCO–Technology–ExtravascularLungWaterIntensiveCaredaysMitchelletal,AmRevResp

Dis145:990-998,1992RelevanceofEVLWAssessmentVolumemanagementguidedbyEVLWcansignificantlyreducetimeonventilationandICUlengthofstayincriticallyillpatients,whencomparedtoPCWPorientedtherapy.通過肺水指導(dǎo)液體管理可以縮短患者上呼吸機(jī)的時間和住ICU時間VentilationDaysPACGroupn=101*p≤0,05PACGroupEVLWGroupEVLWGroup22days15days9days7days*p≤0,05IntroductiontothePiCCO–Technology–ExtravascularLungWaterHaemodynamicMonitoringE.IntroductiontoPiCCOTechnologyPrinciplesoffunctionThermodilutionPulsecontouranalysisContractilityparameters