協(xié)和杜斌血流動(dòng)力學(xué)監(jiān)測(cè)-Focus-on-PICCO-課件

危重病患者的血流動(dòng)力學(xué)監(jiān)測(cè)

focusonPiCCO危重病患者的血流動(dòng)力學(xué)監(jiān)測(cè)

focusonPiCCO血流動(dòng)力學(xué)監(jiān)測(cè)增加患者病死率ConnorsAFJr,SperoffT,DawsonNV,ThomasC,HarrelFEJr,WagnerD,DesbjensN,GoldmanL,WuAW,CaliffRM,FulkersonWJJr,VidailletH,BrosteS,BellamyP,LynnJ,KnausWA.Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA1996;276(11):889-897血流動(dòng)力學(xué)監(jiān)測(cè)增加患者病死率ConnorsAFJr,S精品資料精品資料你怎么稱呼老師？如果老師最后沒有總結(jié)一節(jié)課的重點(diǎn)的難點(diǎn)，你是否會(huì)認(rèn)為老師的教學(xué)方法需要改進(jìn)？你所經(jīng)歷的課堂，是講座式還是討論式？教師的教鞭“不怕太陽(yáng)曬，也不怕那風(fēng)雨狂，只怕先生罵我笨，沒有學(xué)問(wèn)無(wú)顏見爹娘……”“太陽(yáng)當(dāng)空照，花兒對(duì)我笑，小鳥說(shuō)早早早……”協(xié)和杜斌血流動(dòng)力學(xué)監(jiān)測(cè)-Focus-on-PICCO-ppt課件血流動(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CXR,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的使用減少:Illinois,USA2000年2001年降低%出院患者數(shù)1,636,0461,684,089PAC使用數(shù)5,9695,02215.8PAC使用率(/1000)3.652.98年齡0–17歲2195765–74歲1,7391,37521>75歲1,9171,62015.5性別男性3,4922,97015女性2,4732,05217AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)PAC的使用減少:Illinois,USA2000年20PAC的使用減少:Illinois,USA2000年2001年降低%醫(yī)院大醫(yī)院87369620其他醫(yī)院5,0924,32615地區(qū)Chicago39.4Rockford40St.Louis33.6中部15AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)PAC的使用減少:Illinois,USA2000年20臨床評(píng)價(jià)vs.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: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)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)EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)目的:評(píng)價(jià)肺動(dòng)脈導(dǎo)管(PAC)臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)EisenbergPR,Ja臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)結(jié) 果留置PAC后計(jì)劃治療方案需要改變 58%應(yīng)用未預(yù)計(jì)到的治療方案 30%EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)結(jié) 果EisenbergPR,臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)結(jié) 論單純根據(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EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553臨床評(píng)價(jià)vs.血流動(dòng)力學(xué)結(jié) 論EisenbergPR,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 16ARDS 9全身性感染 9心源性休克 5其他情況 5SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741血流動(dòng)力學(xué)數(shù)據(jù)的解釋臨床場(chǎng)景(n=44)SquaraP血流動(dòng)力學(xué)數(shù)據(jù)的解釋不同意見數(shù)目Kappa計(jì)算機(jī)輔助診治前住院醫(yī)生與計(jì)算機(jī)5.72.20.64

0.14*計(jì)算機(jī)輔助診治后住院醫(yī)生與計(jì)算機(jī)1.92.00.88

0.12住院醫(yī)生與主治醫(yī)生1.21.70.92

0.10主治醫(yī)生與計(jì)算機(jī)0.91.20.95

0.07*p<0.05SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741血流動(dòng)力學(xué)數(shù)據(jù)的解釋不同意見數(shù)目Kappa計(jì)算機(jī)輔助診治前住血流動(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)0.720.910.940.96RC: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)SquaraP,FourquetE,JacquetL,BroccardA,UhligT,RhodesA,BakkerJ,PerretC.Acomputerprogramforinterpretingpulmonaryarterycatheterizationdata:resultsoftheEuropeanHEMODYNresidentstudy.IntensiveCareMed2003;29:735-741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)輔助后RCRCRSSC血流動(dòng)力學(xué)參數(shù)改變治療決定SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015血流動(dòng)力學(xué)參數(shù)改變治療決定SquaraP,BennettICU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BoldtJ,LenzM,KumleB,PapsdorfM.Volumereplacementstrategiesonintensivecareunits:resultsfromapostalsurvey.IntensiveCareMed1998;24:147-151ICU患者的輸液治療輸液治療的決定因素BoldtJ,Le臨床判斷缺乏準(zhǔn)確性:PAWP01015191915100預(yù)計(jì)PAWP(mmHg)測(cè)定PAWP(mmHg)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553NochangeinplannedtherapyaftercatheterizationChangeinplannedtherapyaftercatheterization臨床判斷缺乏準(zhǔn)確性:PAWP01015191915100預(yù)0臨床判斷缺乏準(zhǔn)確性:CO04.57.0預(yù)計(jì)CO(L/min)測(cè)定CO(L/min)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5534.57.00臨床判斷缺乏準(zhǔn)確性:CO04.57.0預(yù)計(jì)CO(L/m臨床判斷缺乏準(zhǔn)確性EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553參數(shù)判斷正確數(shù)目/測(cè)定數(shù)目正確率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855臨床判斷缺乏準(zhǔn)確性EisenbergPL,JaffeAHowgoodareourclinicalskills?CardiacoutputWedgepressureConnors(NEJM‘83)ICUpts44%

42%Eisenberg(CCM‘84)ICUpts50%33%Bayliss(BMJ‘83)CCUpts71%62%Howgoodareourclinicalskil臨床判斷缺乏準(zhǔn)確性ClinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatientsEisenbergPR,etal.CritCareMed1984;12:349Assessinghemodynamicstatusincriticallyillpatients:Dophysiciansuseclinicalinformationoptimally?ConnorsAF,etal.JCritCare1987;2:174TherapeuticimpactofPACintheICUSteingrub,etal.Chest1991;99:1451PACincriticallyillpatients:Aprospectiveanalysisofoutcomechangesassociatedwithcatheter-promptedchangesintherapyMimozOetal.CritCareMed1994;22:573Hemodynamicandpulmonaryfluidstatusinthetraumapatient:areweslipping?VealeWNJr,etal.AmSurg.2005;71:621臨床判斷缺乏準(zhǔn)確性Clinicalevaluationc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)DawsonNVetal.Hemodynamicassessmentinmanagingthecriticallyill:isphysicianconfidencewarranted?MedDecisMaking1993;13:258-266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)確性之臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性ClinicalSettingAccurateAssessment,%UnanticipatedChangesinTherapyBasedonPAC,%Connors,etal62noncardiacmedicalintensivecarepatients4848Eisenberg,etal103criticallyillpatients5030TuchschmidtandSharma35noncardiacmedicalintensivecarepatients<4265Steingrub,etal154combinedmedical/surgicalintensivecarepatients<5147Connors,etalCardiacandnoncardiacmedicalintensivecare<6647臨床判斷血流動(dòng)力學(xué)的準(zhǔn)確性ClinicalSettingA臨床重要的血流動(dòng)力學(xué)參數(shù)所有醫(yī)生(n=417)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%)SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015臨床重要的血流動(dòng)力學(xué)參數(shù)所有醫(yī)生(n=417)心內(nèi)科醫(yī)生心臟手術(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)血流動(dòng)力學(xué)監(jiān)測(cè)容量替代正性肌力藥物/升壓藥物輸血德國(guó)的80個(gè)ICU主任問(wèn)卷回收率69%KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,Gro?eJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.心臟手術(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)Kast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)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)38.1PICCO13.0KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,Gro?eJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.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)比例(%)基本監(jiān)英格蘭與威爾士ICU的CO監(jiān)測(cè)技術(shù)EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)英格蘭與威爾士ICU的CO監(jiān)測(cè)技術(shù)EsdaileB,Ra英格蘭與威爾士ICU的CO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)CO41%常規(guī)監(jiān)測(cè)ScvO220%EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)英格蘭與威爾士ICU的CO監(jiān)測(cè)技術(shù)CO監(jiān)測(cè)技術(shù)2種EsdAreWeUsingPACCorrectly?AreWeUsingPACCorrectly?PAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170N(%)measurements%oftechnicalproblemsNoproblem1868(69)Technicalproblems843(31)Criterion1(total)(12)(38)Unabletoobtainan“atrialwaveform”1238Criterion2(total)156(6)19WPwaveformintermediatebetweenthephasicPAandatrialwaveforms100(4)12SpontaneousvariationofWP56(2)7Criterion3(total)381(14)45Poordynamicresponse184(7)22Dampedtracing65(2)8Overinflation42(2)5CannotaspiratebloodwiththecatheterinthePA36(1)4Cannotaspiratebloodwiththecatheterinthewedgeposition54(2)6PAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanPAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170WPTechnicalProblemCorrectedbyInitialConfirmed228OverinflationDeflatedballoon812VenousbloodAdvance2cm308VenousbloodWithdrawn156VenousbloodNothing812PoordynamicresponseWithdrawn4cm248PoordynamicresponseDeflatedandinflatedballoon2313PoordynamicresponseWithdrawn128PoordynamicresponseFlushed3618PartialWPPatientcoughed214PartialWPRepositioned720PartialWPNothing1420?RepositionedWPinitial–WPconfirmed=116mmHgRange(-13,+22)PAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanPAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708ProblemDescriptionsNumber(%)DampedtracingReducedhigh-frequencycontent40(43%)PoordynamicresponseAbsentoscillation,lowfrequency,orinadequatedurationofoscillationsafterasuddenpressuredecreasefromapproximately300mmHgtovascularlevels58(62%)OverinflationSlow,frequentlylinearincreaseinpressureafterballooninflation10(9%)PartialWPWaveformintermediatebetweenphasicPAandatrialwaveforms22(25%)PAWP測(cè)定中的技術(shù)問(wèn)題MorrisAH,ChapmanPAWP測(cè)定中的技術(shù)問(wèn)題DistributionofWPmeasurementsandfrequencyofaWPerror4mmHgTraumaICURespiratoryICUN%(95%CI)N%(95%CI)TotalWPattempts10917%(11–26%)17710%(6–15%)WPultimatelyconfirmed80158InitialWPwithouttechnicalproblems468%(3–16%)1334%(1–8%)InitialWPwithtechnicalproblems5326%(18–44%)4031%(17–47%)NoWPobtained104MorrisAH,ChapmanRH,GardnerRM.FrequencyofwedgepressureerrorsintheICU.CritCareMed1985;13(9):705-708PAWP測(cè)定中的技術(shù)問(wèn)題DistributionofWPICU醫(yī)生缺乏PAC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GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)目的:評(píng)價(jià)歐洲國(guó)家ICU醫(yī)生ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220PAC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PAC的相關(guān)知識(shí)GnaegiA,FeihlICU醫(yī)生缺乏PAC的相關(guān)知識(shí)In-TrainingPostgraduateTrainingCompletedPrimaryMedicalSpecialtyAnesthesiology69.9

13.777.0

12.6InternalMedicine67.9

14.378.3

11.5Others62.4

16.369.8

15.2OpinionofRespondentsonTheirKnowledgeofPACsInadequate57.6

15.355.0

17.3Minimal65.7

14.371.9

14.1Adequate73.2

13.179.2

10.7Superfluous--83.3

0GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)In-TrainingPostICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlF,PerretC.Intensivecarephysician’sinsufficientknowledgeofright-heartcatheterizationatthebedside:timetoact?CritCareMed1997;25:213-220ICU醫(yī)生缺乏PAC的相關(guān)知識(shí)GnaegiA,FeihlIsThereanEasyAlternativetoThisDilemma?IsThereanEasyAlternativetCentralvenouscatheterInjectatetemperaturesensorhousingPV4046ArterialthermodilutioncatheterInjectatetemperaturesensorcablePC80109PULSIONdisposablepressuretransducerPV8115PCCIAP13.0316.28

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

DPTMonitorcablePMK-206InterfacecablePC80150ConnectioncabletobedsidemonitorPMK-XXXAUXadaptercablePC81200CentralvenouscatheterInjectaPiCCO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)b.動(dòng)脈脈搏輪廓分析技術(shù)PiCCO的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成,用于心輸出量的測(cè)定: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t心輸出量的測(cè)定:經(jīng)肺熱稀釋技術(shù)中心靜脈內(nèi)注射指示劑后,動(dòng)心輸出量的測(cè)定: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(<8

C)或室溫(<24

C)生理鹽水中心靜脈注射右心左心肺PiCCO導(dǎo)管如插在股動(dòng)脈內(nèi)心輸出量的測(cè)定:經(jīng)肺熱稀釋技術(shù)經(jīng)肺熱稀釋測(cè)量只需要在中心靜熱稀釋法測(cè)定CO:PiCCOvs.PACPCCO動(dòng)脈熱稀釋測(cè)量位置靜脈注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常規(guī)熱稀釋測(cè)量位置[s]010203040500,00,20,40,6[°C]-DT注射熱稀釋測(cè)量曲線Tb=血流溫度Ti=注射指示劑溫度Vi=注射指示劑容積∫?Tb.

dt=熱稀釋曲線下面積K=校正系數(shù)熱稀釋法測(cè)定CO:PiCCOvs.PACPCCO動(dòng)脈熱動(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[mmHg]SV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連續(xù)心輸出量測(cè)定:PiCCO壓力曲線下面積壓力曲線型狀PCCO=cal?HR?

SystoleP(t)SVR+C(p)?dPdt()dt動(dòng)脈順應(yīng)性參數(shù)心率與病人有關(guān)的校正因子t[s]P[mmHg]PCCOisdisplayedaslast12smean連續(xù)心輸出量測(cè)定:PiCCO壓力曲線下面積壓力曲線型狀PC心輸出量的測(cè)定:PiCCOvs.熱稀釋AuthorPt/ObsCOTDa–COTDpaBiasSDrVonSpiegel,etal.Anaesthesist1996;45(11)21/48-4.71.5%.97McLuckie,etal.ActaPaediatr1996;859/?0.190.21L/min/m2Goedje,etal.Chest1998;113(4)30/1500.160.31L/min/m2.96Goedje,etal.ThoracCardiovascSurg1998;4630/8100.260.71L/min.96Zoolner,etal.Anaesthesist1998;47(11)18/1600.031.04L/min.91Goedje,etal.CritCareMed1999;27(11)24/216-0.290.66L/min.93Sakka,etal.IntensiveCareMed1999;2537/4490.680.62L/min.97Sakka,etal.JCardiothoracVascAnesth2000;14(2)12/510.730.38L/min.96Zoolner,etal.JCardiothoracVascAnesth2000;14(2)19/760.210.73L/min.96Bindels,etal.CritCare2000;445/2830.490.45L/min/m2.95心輸出量的測(cè)定:PiCCOvs.熱稀釋AuthorPtPiCCO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)b.動(dòng)脈脈搏輪廓分析技術(shù)PiCCO的技術(shù)原理PiCCO技術(shù)由下列兩種技術(shù)組成,用于PiCCO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)lnc(I)注射At再循環(huán)MTtte-1DStc(I)PiCCO容量參數(shù)全心舒張末期容積 GEDVlnc(I全心舒張末期容積(GEDV)全心舒張末期容積(GEDV)是心臟4個(gè)腔室內(nèi)的血容量全心舒張末期容積(GEDV)全心舒張末期容積(GEDV)是心胸腔內(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)的血液容量胸腔內(nèi)血容積(ITBV)胸腔內(nèi)血容積(ITBV)是心臟4個(gè)腔血管外肺水(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血管外肺水(EVLW)血管外肺水(EVLW)是肺內(nèi)含有的水量容量的測(cè)量原理lnc(I)注射At再循環(huán)的影響MTtte-1DStc(I)

MTt:Meantransittime平均傳輸時(shí)間

≈halfoftheindicatorpassedthepointofdetection DSt:Downslopetime下降時(shí)間≈exponentialdownslopetimeofTDcurve容量的測(cè)量原理lnc(I)注射At再循環(huán)的影響MTtte容量的測(cè)量原理Vall=

V1+V2+V3+V4

=MTtxFlowMeieretal.JApplPhysiol.1954V3=

最大腔的容積 =DStx

FlowNewmanetal.Circulation.1951指示劑由注射點(diǎn)到檢測(cè)點(diǎn)的平均傳輸時(shí)間MTt由兩點(diǎn)間的總?cè)莘e決定下降時(shí)間DSt由其中最大的腔室決定(比其它腔至少大

20%成立!)flowV3V4V2V1注射檢測(cè)容量的測(cè)量原理Vall=V1+V2+V3+胸腔內(nèi)的容積組成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV=肺內(nèi)熱容積,在一系列混合腔室中具有最大的熱容積(DSt–容積)ITTV=胸腔內(nèi)總熱容積,從注射點(diǎn)到測(cè)量的熱容積之和(MTt–容積)GEDV =全心舒張末期容積=ITTV–PTV胸腔內(nèi)的容積組成GEDVPTVRAEDVPBVLAEDVLV容量的測(cè)量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔總熱容積(ITTV)ITTV=COxMTtTDa肺內(nèi)總熱容積(PTV)PTV=COxDStTDa全心舒張末期容積GEDV=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTV容量的測(cè)量原理RAEDVPTVLAEDVLVEDVRVEDVITBV的測(cè)量原理Sakkaetal,IntensiveCareMed2000;26:180-187ITBV=1.25*GEDV–28.4[ml]r=0.96ITBVTD(ml)GEDVST(ml)GEDVvs.ITBVin57intensivecarepatientsITBV的測(cè)量原理Sakkaetal,IntensivITBV準(zhǔn)確性的臨床驗(yàn)證Sakkaetal,IntensiveCareMed26:180-187,2000n=209r=0.97Bias = -7.6ml/m2

SD = 57.4ml/m2ITBVISTvs.ITBVITDin209intensivecarepatientsITBV準(zhǔn)確性的臨床驗(yàn)證Sakkaetal,Inten容量測(cè)量小結(jié)ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTV容量測(cè)量小結(jié)ITTV=COxMTtTDaPTV=PiCCO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RVEDVITBV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GEF=4xSV/GEDVPiCCO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,容量負(fù)荷反應(yīng)組與無(wú)反應(yīng)組的CVP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PAOP(mmHg)有反應(yīng)者無(wú)反應(yīng)者Calvinetal8172Schneideretal101101Reuseetal104103Diebeletal14772?Diebeletal166155WagnerandLeatherman103144?Tavernieretal104123Tousignantetal123163?Michardetal103112?p<0.05擴(kuò)容治療前的肺動(dòng)脈楔壓PAOP(mmHg)有反應(yīng)者無(wú)反應(yīng)者擴(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LVEDA(cm2/m2)有反應(yīng)者無(wú)反應(yīng)者Tavernieretal93124?Tousignantetal155205?Feisseletal104102?p<0.05擴(kuò)容治療前的右室舒張末面積LVEDA(cm2/m2)有反應(yīng)CVP/PAWP不能預(yù)測(cè)擴(kuò)容反應(yīng)

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147CVP/PAWP不能預(yù)測(cè)擴(kuò)容反應(yīng)Lichtwarck-AsITBV能夠更好地反映前負(fù)荷

Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147ITBV能夠更好地反映前負(fù)荷Lichtwarck-Asch預(yù)測(cè)擴(kuò)容反應(yīng):PAWP/CVPvs.ITBV1.MichardF,BoussatS,ChemlaD,AnguelN,MercatA,LecarpentierY,RichardC,PinskyMR,TeboulJL.RelationbetweenRespiratoryChangesinArterialPulsePressureandFluidResponsivenessinSepticPatientswithAcuteCirculatoryFailure.AmJRespirCritCareMed2000;162:134-138.2.RexS,BroseS,MetzelderS,HunekeR,SchalteG,AutschbachR,RossaintR,BuhreW.Predictionoffluidresponsivenessinpatientsduringcardiacsurgery.BrJAnaesth2004;93:782-788預(yù)測(cè)擴(kuò)容反應(yīng):PAWP/CVPvs.ITBV1.Mi前負(fù)荷指標(biāo)與

SV/CI的相關(guān)性所有患者單一患者相關(guān)系數(shù),rSVIartCIartCIart(最低值–最高值)CVP-0.090.00-0.01–0.33PAWP-0.02-0.01-0.36–0.03RAEDVI0.28-0.11-0.02–0.37RVEDVI0.03-0.020.02–0.03ITBVI0.760.830.67–0.91GEDVI0.820.870.70–0.93Goedjeetal,EurJCardiothoracSurg1998;13(5):533-539;discussion539-540前負(fù)荷指標(biāo)與SV/CI的相關(guān)性所有患者單一患者相關(guān)系心輸出量和全身循環(huán)阻力由于脈搏輪廓分析連續(xù)測(cè)量每搏量和動(dòng)脈壓,可以如下計(jì)算得到心輸出量(CO)和全身循環(huán)阻力(SVR):CO=每搏量x心率SVR=(平均動(dòng)脈壓–中心靜脈壓)/CO心輸出量和全身循環(huán)阻力由于脈搏輪廓分析連續(xù)測(cè)量每搏量和動(dòng)脈壓每搏量變異(SVV)對(duì)于沒有心律失常的機(jī)械通氣患者SVV反映了心臟對(duì)因機(jī)械通氣導(dǎo)致的心臟前負(fù)荷周期性變化的敏感性SVV可以用于預(yù)測(cè)擴(kuò)容治療是否會(huì)使每搏量增加SVmaxSVminSVmeanSVmax–SVminSVV(30秒)=SVmean每搏量變異(SVV)對(duì)于沒有心律失常的機(jī)械通氣患者SVmax對(duì)擴(kuò)容反應(yīng)的預(yù)測(cè)性:CVPvs.SVVSensitivity1–SpecificityBerkenstadtetal,AnesthAnalg2001;92:984-989---CVP__SVV對(duì)擴(kuò)容反應(yīng)的預(yù)測(cè)性:CVPvs.SVVSensitiv血管外肺水的測(cè)定:EVLW放射影像學(xué)(radiology)指示劑稀釋技術(shù)(indicatordilutiontechnique)顯像技術(shù)(imagingtechnique)重力測(cè)定技術(shù)(gravimetrictechnique)血管外肺水的測(cè)定:EVLW放射影像學(xué)(radiology)氧合與肺水腫靜水壓升高引起肺水腫CMVFiO20.4ScilliaP,DelcroixM,LejeuneP,MelotC,StruyvenJ,NaeijeR,GevenoisPA.Hydrostaticpulmonaryedema:evaluationwiththin-sectionCTindogs.Radiology1999;211:161-168氧合與肺水腫靜水壓升高引起肺水腫ScilliaP,Del血管外肺水與氧合MartinGS,EatonS,MealerM,MossM.Extravascularlungwaterinpatientswithseveresepsis:aprospectivecohortstudy.CritCare2005;9:R74-R82(DOI10.1186/cc3025)血管外肺水與氧合MartinGS,EatonS,Me血管外肺水與病死率Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139血管外肺水與病死率Sturm,In:Practical血管外肺水的測(cè)定當(dāng)EVLW增加>100%時(shí),胸片才會(huì)發(fā)生改變BongardFS,Surgery1984胸片對(duì)EVLW的改變并不敏感HelperinBD,Chest1984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Rubenfeldetal,Chest1999血管外肺水的測(cè)定當(dāng)EVLW增加>100%時(shí),胸片才會(huì)發(fā)生容量測(cè)量小結(jié)ITTV=COxMTtTDaPTV=COxDStTDaITBV

=1.25xGEDVEVLW=ITTV–ITBVGEDV

=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW容量測(cè)量小結(jié)ITTV=COxMTtTDaPTV=EVLW:PiCCOvs.重力法測(cè)定Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139EVLW:PiCCOvs.重力法測(cè)定Sturm,In血管外肺水的臨床驗(yàn)證Sakkaetal,IntensiveCareMed26:180-187,2000Bias = -0.2ml/kg

SD = 1.4ml/kgn=209r=0.96EVLWISTvs.EVLWITDin209intensivecarepatients血管外肺水的臨床驗(yàn)證Sakkaetal,Intensi減少血管外肺水:臨床試驗(yàn)Mitchelletal,AmRevRespDis145:990-998,1992減少血管外肺水:臨床試驗(yàn)Mitchelletal,A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)已證實(shí)血管外肺水(EVLW)與ARDS的嚴(yán)重程度,病人機(jī)械通氣的天數(shù),住ICU的時(shí)間及死亡率明確相關(guān),其評(píng)估肺水腫遠(yuǎn)遠(yuǎn)優(yōu)于胸部X線肺血管通透性指數(shù)(PVPI)一定程度上反映了肺水腫形成的原因PVPI=EVLW/PBV血管外肺水血管外肺水(EVLW)通過(guò)經(jīng)肺熱稀釋法得到,已被隱匿性肺水腫的檢測(cè)指標(biāo)EVLW增加臨床癥狀100–200%胸片100–200%氧合(機(jī)械通氣時(shí))300%EVLW(PiCCO)10–15%隱匿性肺水腫的檢測(cè)指標(biāo)EVLW增加臨床癥狀100–200原發(fā)性與繼發(fā)性ARDS/ALI的鑒別患者人群(n=10)原發(fā)性ARDS/ALI(n=4):肺炎,誤吸繼發(fā)性ARDS/ALI(n=6):全身性感染評(píng)價(jià)指標(biāo)ITBVIEVLWIPVPI(EVLW/ITBV)MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673)原發(fā)性與繼發(fā)性ARDS/ALI的鑒別患者人群(n=10)原發(fā)性與繼發(fā)性ARDS/ALI的鑒別MorisawaK,TairaY,TakahashiH,MatsuiK,OuchiM,FujinawaN,NodaK.DothedataobtainedbythePiCCOsystemenableonetodifferentiatebetweendirectALI/ARDSandindirectALI/ARDS?CriticalCare2006,10(Suppl1):P326(doi:10.1186/cc4673)直接ARDS/ALI間接ARDS/ALIP值ITBVI984

331.71279

312.10.0001EVLWI13.2

4.716.8

6.50.014PVPI0.59

0.270.44

0.220.006原發(fā)性與繼發(fā)性ARDS/ALI的鑒別MorisawaK,SIRS及ARDS:肺血管通透性與肺水腫PVPISIRS組(n=31)2.371.0ARDS組(n=13)3.21.10非ARDS組(n=18)1.70.44非SIRS組(n=10)1.20.21TagamiT,KushimotoS,AtsumiT,MatsudaK,MiyazakiY,OyamaR,KoidoY,KawaiM,YokotaH,YamamotoY.InvestigationofthepulmonaryvascularpermeabilityindexandextravascularlungwaterinpatientswithSIRSandARDSunderthePiCCOsystem.CriticalCare2006;10(Suppl1):P352(doi:10.1186/cc4699)SIRS及ARDS:肺血管通透性與肺水腫PVPISIRS組血管外肺水的測(cè)定胸片,氧合障礙及PAWP與EVLW之間的相關(guān)性很差床旁測(cè)定EVLW為危重病患者的診斷,隨訪及治療評(píng)估提供了新的方法血管外肺水的測(cè)定胸片,氧合障礙及PAWP與EVLW之間的相PiCCO技術(shù)問(wèn)題PiCCO技術(shù)問(wèn)題熱稀釋法測(cè)定心輸出量目的:確定熱稀釋法一次測(cè)定心輸出量是否準(zhǔn)確方法:回顧分析18名神經(jīng)外科ICU患者共417次測(cè)定,1465次操作ANOVA分析WolfS,PlevD,SchürerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524)熱稀釋法測(cè)定心輸出量目的:確定熱稀釋法一次測(cè)定心輸出量是否熱稀釋法測(cè)定心輸出量差值中位數(shù)兩次測(cè)定95%可重復(fù)系數(shù)相當(dāng)于正常值百分比CI(L/min)0.30.7248%ITBVI(ml/m2)80270180%EVLWI(ml/kg)13.587%WolfS,PlevD,SchürerL,LumentaC.Therepeatabilityoftranspulmonarythermodilutionmeasurements.CriticalCare2004;8(Suppl1):P57(DOI10.1186/cc2524)熱稀釋法測(cè)定心輸出量差值中位數(shù)兩次測(cè)定95%可重復(fù)系數(shù)相當(dāng)于熱稀釋法測(cè)定心輸出量目的:確定熱稀釋法測(cè)定心輸出量時(shí)2次測(cè)定與3次測(cè)定的準(zhǔn)確性方法:回顧分析2年期間PiCCO監(jiān)測(cè)的所有數(shù)據(jù)共25名感染性休克患者共249次心輸出量測(cè)定比較前2次(M1)與3次測(cè)定心輸出量(M2)的平均值A(chǔ)layaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293熱稀釋法測(cè)定心輸出量目的:確定熱稀釋法測(cè)定心輸出量時(shí)2次測(cè)熱稀釋法測(cè)定心輸出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293CI(L/min/m2)M13.281.07M25.741.0743%熱稀釋法測(cè)定心輸出量AlayaS,Abdellatif熱稀釋法測(cè)定心輸出量結(jié) 論采用PiCCO進(jìn)行監(jiān)測(cè)時(shí),2次熱稀釋法顯然不足以可靠地測(cè)定心輸出量AlayaS,AbdellatifS,NasriR,KsouriH,BenLakhalS.PiCCOmonitoring–aretwoinjectionsenough?CriticalCare2007;11(Suppl2):P293熱稀釋法測(cè)定心輸出量結(jié) 論AlayaS,Abdellat中心靜脈插管部位的影響SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786頸內(nèi)靜脈vs.股靜脈中心靜脈插管部位的影響SchmidtS,Westhoff中心靜脈插管部位的影響人口統(tǒng)計(jì)學(xué)資料MSD范圍性別男8,女3年齡,歲58.717.521–74身高,cm174.97.9165–185體重,kg75.510.265–90體表面積,m21.900.151.73–2.14SAPSII51.310.136–61SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786中心靜脈插管部位的影響人口統(tǒng)計(jì)學(xué)資料MSD范圍性別男8中心靜脈插管部位的影響心肺指標(biāo)MSD范圍HR,bpm88.517.966–124MAP,mmHg84.711.370–103COavg,L/min7.662.952.9–12.2GEDIavg,ml/m2947.2314.8577–1789EVLWIavg,ml/kg15.012.84–51SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786中心靜脈插管部位的影響心肺指標(biāo)MSD范圍HR,bpm中心靜脈插管部位的影響差異95%范圍COfemvs.COjug,L/min+0.16-1.13,1.45EVLWIfemvs.EVLWIjug,ml/kg+0.23-1.77,2.23GEDVIfemvs.GEDVIjug,ml/m2+140.7-2.58,284.02SchmidtS,WesthoffTH,HofmannC,SchaeferJ-H,ZidekW,ComptonF,vanderGietM.Effectofthevenouscathetersiteontranspulmonarythermodilutionmeasurementvariables.CritCareMed2007;35:783-786中心靜脈插管部位的影響差異95%范圍COfemvs.CO中心靜脈插管部位的影響頸內(nèi)靜脈,sec股靜脈,secPMTt43.418.946.618.30.0068DSt23.315.224.113.50.35AUC6.52.56.62.60.27SchmidtS,We