PiCCO监测及临床应用课件.ppt

1、 PiCCOPiCCO的临床应用内内 容容l原理原理 l测定参数测定参数l临床操作临床操作l临床病例临床病例l心排监测探讨心排监测探讨PiCCOPiCCO原理原理PiCCOPiCCOl Pulse contour cardiac output l pulse indicator continue cardiac output l PiCCOPiCCO采用成熟的热稀释方法测量单次采用成熟的热稀释方法测量单次的心输出量（的心输出量（COCO），），l并通过分析动脉压力波形曲线下面积与并通过分析动脉压力波形曲线下面积与COCO存在的一定关系，来获得连续的心输存在的一定关系，来获得连续的心输出量（出量

2、（CCOCCO）a.经肺热稀释技术经肺热稀释技术b.动脉脉搏轮廓分析技术动脉脉搏轮廓分析技术PiccoPicco技术获得连续技术获得连续COCO的基本原理的基本原理lWesseling提出的心搏量同主动脉压力曲线的收缩面积成正比，压力依赖于顺应性及其系统阻力，并作了压力、心率、年龄等影响因素校正后，该方法才得到认可。PiCCO plus setupCentral venous catheterInjectate temperature sensor housing PV4046 Arterial thermodilution catheter Injectate temperature sen

3、sor cablePC80109 PULSION disposable pressure transducer PV8115PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625 DPT Monitor cablePMK-206Interface cablePC80150 Connection cableto bedside monitorPMK-XXX AUX adaptercable PC81200 A.axillaris(A.brachialis)PV2

4、014L08 4F 8 cm A.radialisPV2014L50LGWA 4F 50 cm A.femoralisPV2015L20 5F 20 cmPV2013L07*3F 7 cmPV2014L08*more than 10 kg bodyweight*For application in pediatric patientsApplication sites for thermodilution cathetersTbinjectiontdtTKV)T(TCObiibTDa Transpulmonary thermodilution:Cardiac OutputStewart-Ham

5、ilton methodTb=Blood temperatureTi =Injectate temperatureVi =Injectate volume Tb.dt=Area under the thermodilution curveK=Correction constant,made up of specific weight and specific heat of blood and injectateArea under pressure curveShape of pressure curvePCCO=cal HR SystoleP(t)SVR+C(p)dPdt()dtAorti

6、ccomplianceHeart ratePatient-specific calibration factor(determined by thermodilution)t sP mm HgCalculation of PCCO Model PCCO is displayed as last 12s meanMethodology of volumetric monitoring(I)ln c(I)injectionAtrecirculationMTtte-1DStc(I)MTt:Mean transit time half of the indicator passed the point

7、 of detection DSt:Downslope time exponential downslope time of TD curveITTV=CO*MTtTDaPTV =CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWCalculation of volumesPiCCOPiCCO测定的测定的参数参数Transpulmonary thermodilution parametersC

8、ardiac outputCO（心排血量）心排血量）Intrathoracic blood volumeITBV（胸腔内血容量）胸腔内血容量）Extravascular lung waterEVLW（血管外肺水）血管外肺水）Cardiac function index CFI（心功能指数心功能指数）Global ejection fraction GEF(心脏腔室射血分数心脏腔室射血分数)经肺热稀释测量的参数经肺热稀释测量的参数New parametersGEF=GEDV4 x SVGlobal ejection fractionPVPI=PBVEVLWEstimation of pulmon

9、ary vascular permeabilityPulse contour parametersPulse contour cardiac output PCCO（动脉连续心排动脉连续心排血量）血量）Heart rate HR（心率）心率）Arterial pressure AP（动脉压）动脉压）Stroke volume SV（每搏心排量）每搏心排量）Stroke volume variation SVV（每搏量变异指数）每搏量变异指数）Systemic vascular resistance SVR（体循环阻力）体循环阻力）Index of leftventricular contrac

10、tility dP/dtmax（左室收缩左室收缩力指数）力指数）连续动脉波形测量的参数连续动脉波形测量的参数正常值范围正常值范围ParameterRangeUnitCI3.0 5.0l/min/m2 ITBVI850 1000ml/m2EVLWI 3.0 7.0ml/kgCFI4.5 6.51/minHR60 901/minMAP70 90mmHgSVRI1200 2000dyn*s*cm-5*m2SVI40 60ml/m2SVV 10%dP/dtmax 12002000 mmHg/sGEDVI 600750 ml/m2Decision Tree for volumetric hemodyna

11、mic monitoringCI(l/min/m2)ITBVI(ml/m2)TherapyTargetITBVICFIEVLWI(slowly responding)4.5 10 V+Cattemporary750-8505.5104.53.010 Cat V-temporary750-850 5.5 1010 V+850-100010 V+temporary750-850850850 10 V-temporary750-850 10850EVLWI(ml/kg)V+=volume loading(!=cautiously)V-=volume contractionCat=catecholam

12、ines/cardiovascular agentsIndicationsIndicationslEvery patient who require a central venous and arterical catheter monitoring.ContraindicationslArterial access restriction due to femoral artery grafting or severe burns in areas where the catheter would normally have been placed.lThe PiCCO method may

13、 give incorrect thermodilution measurements in patients with intracardiac shunts;aortic aneurysm;aortic stenosis;pneumonary;macro lung embolisn and extracorporeal circulation(if blood is either extracted from or infused back into the cardiopulmonary.)临床操作临床操作1,按主设定2,收入/转出3,ABPl 1cm=0.393in 1kg=2.2lb

14、l按enterl收入病人l主设定l测量lCO 接通 l心输出量测量l目录lInjVoll选择试验l保存l再采样lCVPm 1mmHg=1.33cmH2Ol进行计算PiCCOPiCCO临床病例临床病例病例一病例一l男患男患 5353岁岁 诊断诊断 脓毒症 MODSl处于镇静状态，处于镇静状态，HRHR：9090次分，次分，BPBP：16016070mmHg70mmHg，SaO2SaO2：9090 R R：1515次分次分l气管插管，呼吸机辅助呼吸，气管插管，呼吸机辅助呼吸，SIMVSIMV模式，模式，FIOFIO2 2：6060 PEEPPEEP：8cmH8cmH2 2O O 双肺吸气相呼吸音粗

15、糙，呼气相呼吸双肺吸气相呼吸音粗糙，呼气相呼吸音弱。音弱。l血常规：血常规：WBCWBC：47.047.0109 NEUT109 NEUT：95.695.6 PLT:25PLT:25109 109 l肝功：肝功：ALT:21U/L AST:14U/L ALBALT:21U/L AST:14U/L ALB：17g17gL Ll肾功：肾功：BUNBUN：36.79mmol36.79mmolL CreaL Crea：399umol399umolL L T1T1吴国安 T1 T2 BP140/73 196/98 HR8692 CVP58 CI1.662.68 SI19.229.2 SVRI434739

16、33 LCWI2.15.1 LVSWI24.951.6 EVLWI9.16.5 ITBVI453540 GEDVI362432 PVPI 3.7 2.1病例二病例二l女患 74岁 食物中毒 感染性休克l入室时意识朦胧，自主呼吸，生命体征：HR140bpm,BP 94/52mmHg,(多巴胺维持）SpO2 98%FiO2 3L/min,RR 31bpml8小时后，心肺复苏后，行PiCCO监测张亚敏 T1 T2 T3 T4 T5 T6 T7 T8 BP71/43 90/48 73/45 79/47 83/50 65/38 69/40 66/33 HR138144127142138147130113

17、 CVP1411109791218 CI3.383.942.743.382.933.513.833.23 SI24.527.421.623.821.323.929.428.6 SVRI9241075131411851526888836719 LCWI2.43.422.72.52.32.72.1 LVSWI17.623.816.119.118.215.620.818.2 EVLWI6.45.37.67.97.27.974.9 ITBVI7658988759638461020962917 GEDVI612718701770677877770733心肺复苏后2小时后850 ml液体扩容后硝普钠0.3

18、ug/kg.min多巴酚18ug/kg.min付肾0.13ug/kg.min代入治疗树-OK病例三病例三l女患 69岁 扩张型心肌病 心衰 心功级l气管插管 呼吸机辅助呼吸 SPONT模式 PS 8cmH2O PEEP 4cmH2O FiO2 50%l多巴胺 25ug/kg.min 多巴酚丁胺25ug/kg.min 米力农0.5ug/kg.minT1T2T3T4T5T6T7 BP85/4593/53mmHg97/55mmHg111/57mmHg94/6299/52mmHg114/52 HR9085bpm85bpm87bpm8366bpm81 CVP99mmHg9mmHg10mmHg912mmH

19、g15 CI0.771.774.314.085.032.964.01 SI9.319.950.746.960.644.849.5 SVRI7718267011141254104814591116 LCWI0.91.644.15.12.73.9 LVSWI10.618.447.547.261.940.347.8 EVLWI13.36.814.414.412.89.621.5 ITBVI72471815631439189715631876 GEDVI57957512511151151712511501CFI1.33.13.43.53.52.32.6停呼吸机多巴胺，多巴酚25ug/kg.min24小

20、时后多巴胺，多巴酚20ug/kg.min硝普钠0.1-0.3ug/kg.min24小时持续泵入加用米力农，硝普钠后停多巴胺，多巴酚停米力农病例四病例四l女患 23岁 病毒性脑炎l气管插管 呼吸机辅助呼吸 PS 13cmH2O PEEP 3.0cmH2Ol多巴胺 12ug/kg.min l前24小时总入量 6040mll前24小时总出量3750ml刘晓丽 T1 T2 T3 T4 T5 T5 T6 T7 T8 BP93/49108/5997/56120/76120/72133/78140/79142/81144/79 HR156143106109140114133127132 CVP6685620

21、01 CI2.882.763.993.074.212.995.174.73.51 SI18.519.337.628.231.626.338.93726.6 SVRI158015641223224016912537154717512304 LCWI2.52.33.73.85.53.976.64.9 LVSWI15.815.835.334.941.334.652.951.936.8 EVLWI6.25.55.565.36.57.38.14.7 ITBVI568591752637713554813837522 GEDVI455473602509570444651670417 CFI 6.35.86.

22、667.37.978.4前24小时入量6040ml，出量3750ml24 小时后入量9010ml出量5430ml48小时后前24小时入量6465出量5660COCO监测探讨监测探讨lInvasive methodslMinimally invasive methodslNon-invasive methodsThermodilution techniqueFicks cardiac output measurementDoppler ultrasound-Transpulmonary thermodilutionPartial CO2 rebreathingThanspulmonary the

23、rmodilutionPulse contour cardiac output estimation without external caliberation Electrical impedance cardiographyFicks cardiac output measurementFicks cardiac output measurementl以氧作为指示剂，是一种经典的方法以氧作为指示剂，是一种经典的方法lV2O2the oxygen content difference between inspired and exhaled gaslCaO2-Oxygen content o

24、f arterial bloodlCvO2-Oxygen content of mixed venous blood CO100)CvO(CaOVOCO222NICONICOl是利用二氧化碳弥散能力强的特点作为指示剂，根据Fick原理来测定心排血量。l基本公式为：QVCO2/(CVCO2-CaCO2)。优点优点lNICO所测心排血量的重点在于CO的有效部分，即积极完成气体交换的血流量，就此点的意义来说NICO大于经典的温度稀释法。lNICO 的数值改变大多发生于温度稀释法测量值变化之前，即NICO对血流动力学改变的反映快于经典的温度稀释法，这对某些关键时刻意义重大。缺点缺点l是任何影响混合静脉

25、血二氧化碳、解剖死腔/潮气量及肺内分流的因素均可影响结果的准确性l尤其要指出刚给完碳酸氢钠后的测量结果也不可靠，NaHCO3可影响PETCO2。Electrical impedance cardiographyl利用心动周期于胸部电阻抗的变化来测定左心室收缩时间间期并计算出每搏量，然后再演算出一系列心功能参数。l基本原理：欧姆定律（电阻电压/电流）l-resistivity of bloodlL-mean distance between the inner electrodeslVET-ventricular ejection timeldZ/dt-the absolute of the m

26、aximum value of the finst derivative during systosle l Z0-basal thoracic impedancel操作简单、费用低、能动态观察心排血量的变化趋势l抗干扰能力差l测量结果略大于温度稀释法测定值缺点缺点l尽管阻抗法以阻抗变化反映CO,可无损伤快速测量CO,但多数人认为阻抗法测定CO影响因素太多,如肥胖、放置胸腔引流管、机械通气、发热、水种、胸膜渗液、心律失常、严重的心瓣膜病、急性心肌梗死和血液动力学不稳l定等因素均会导致监测结果准确性的下降3,因此测量误差较大,临床应用有困难。尤其对危重病人,临床应用一直有争议0200400600

27、800100012002.55.07.510.0GEDVI(ml/m2)CI(l/min/m2)VolumeInotropicsnormal rangenormal cardiac functionCFI=CI/GEDVICardiac function index(CFI)EVLWEVLW包括细胞内、组织间、肺泡内包括细胞内、组织间、肺泡内马丽 T9 T8 BP 101/55 101/46 HR90106 CVP109 CI 5.14 6.01 SI 57.1 56.7 SVRI 965 718 LCWI 5 5.2 LVSWI 55.9 48.2 EVLWI 13.4 11.6 ITBVI

28、 1348 1093 874SVRSVRl systemic vascular resistance lSVR（MAPCVP）CO lCVP经常输入lSVRI 1200-2000 dyn*s*cm-5*m2 SVmax and SVmin are determined over last 30 s windowDetermination of the Stroke Volume Variation(SVV)Only applicable in controlled mechanically ventilated patientsDetermination of the Stroke Volume Variation(SVV)dPmx=dP/dtmax of arterial pressure curveEstimation of left ventricular pressure velocity increaseIndex of left ventricular contractilityt sP mm Hg