PiCCO监护仪的临床应用--课件

,单击此处编辑母版标题样式,*,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,PiCCO,监护仪的临床应用,PiCCO监护仪的临床应用,2024/8/13,循环监测的几种方法,阻抗法血流动力学监测,肺动脉内热稀释漂浮导管,(SWAN-GANZ),超声血流监测,PiCCO,技术,(Pulse indicator Continous CO),2023/8/24循环监测的几种方法阻抗法血流动力学监测,2024/8/13,阻抗法血流动力学监测,胸电生物阻抗技术,优点,:,连续、无创、简便、价廉,缺点,:,体表因素、换算,2023/8/24阻抗法血流动力学监测胸电生物阻抗技术,2024/8/13,漂浮导管,2023/8/24漂浮导管,2024/8/13,肺动脉内热稀释漂浮导管,(SWAN-GANZ),经心脏,创伤大,发生心律失常的风险大,以压力代表容量,约,1/2,不准确,2023/8/24肺动脉内热稀释漂浮导管 (SWAN-GA,2024/8/13,超声血流动力学监测,能反应容量,但昂贵、麻烦，不能普及,2023/8/24超声血流动力学监测能反应容量, 但昂贵、麻,2024/8/13,PiCCO,技术,Pulse indicator Continous CO,近年新开发,CO,：热稀释，连续,容量性前负荷：,GEDV,副产品,ITBV,（胸腔内血量）,GEF,（全心射血分数）,EVLW,（血管外肺水）,SVV/PVV,不间断容量反应,PVPI,（肺血管通透性指数）,2023/8/24PiCCO技术Pulse indicat,2024/8/13,基本原理,经肺温度稀释法,-,间断测量,:,测定,CO,容量指标,:,胸腔内血容量,(ITBV),全心舒张末期容量,(GEDV),血管外肺水,(EVLW),动脉脉搏波型曲线下面积分析技术,-,持续测量,:,每次心脏搏动的心输出量,(PCCO),每搏量,(SV),每搏量变化,(SVV),外周血管阻力,(SVR),2023/8/24基本原理经肺温度稀释法-间断测量:测定CO,2024/8/13,经肺热稀释导管测量点,静脉注射指示剂,RAEDV,PBV,EVLW,LAEDV,LVEDV,RVEDV,SWAN-GANS,PiCCO,2023/8/24经肺热稀释导管测量点静脉注射指示剂RAED,2024/8/13,Global Enddiastolic Volume (,GEDV,) is the volume of blood contained in the 4 chambers of the heart.,2023/8/24Global Enddiastolic V,2024/8/13,Intrathoracic Blood Volume (,ITBV,) is the volume of the 4 chambers of the heart + the blood volume in the pulmonary vessels.,2023/8/24Intrathoracic Blood V,2024/8/13,Extravascular Lung Water (,EVLW,)* is the amount of water content in the lungs. It allows bedside quantification of the degree of pulmonary edema.,2023/8/24Extravascular Lung Wa,2024/8/13,PiCCO,监测指标正常值范围,ParameterRangeUnit,CI3.0 5.0l/min/m,2,SVI40 60ml/m2,SVRI1200 1800 dyn*s*cm-5*,MAP70 90mmHg,GEF25 35%,CFI4.5 6.51/min,HR60 901/min,GEDVI680 800ml/m,2,ITBVI850 1000ml/m,2,SVV 10%,EVLWI 3.0 7.0ml/kg,PVPI1.0 3.0,2023/8/24PiCCO监测指标正常值范围Parame,2024/8/13,PiCCO,对容量判断的优势,PiCCO,通过容量指标（,ITBV,、,GEDV,）来反应前负荷,排出机械通气等对容量监测的影响,能更准确的反应容量状况,PiCCO,将血液动力学的容量监测,从由压力监测发展为容量监测是一个革命性的转变,2023/8/24PiCCO对容量判断的优势PiCCO通过容,2024/8/13,0,200,400,600,800,1000,1200,2.5,5.0,7.5,10.0,GEDVI (ml/m,2,),CI (l/min/m,2,),Volume,Inotropics,normal,range,normal cardiac function,CFI= CI / GEDVI,GEDV,是更好的前负荷指标,A,B,C,2023/8/24020040060080010001200,2024/8/13,CI (l/min/m2),ITBVI (ml/m2),Therapy,Target,ITBVI,CFI,EVLWI (slowly responding),4.5,10,V+!,Cat,temporary,750-850,5.5,4.5,3.0,10,Cat,V-,temporary,750-850,5.5,10,10,V+,850-1000,10,V+,temporary,750-850,850,850,10,V-,temporary,750-850,10,850,EVLWI (ml/kg),V+ = volume loading (! = cautiously),V- = volume contraction,Cat = catecholamines/ cardiovascular agents,P,iCCO,诊断治疗树,10,2023/8/24CI (l/min/m2)I,2024/8/13,PiCCO,定量监测肺水,PiCCO,对血管外肺水监测是其他任何循环监测均不能替代的,血管外肺水监测：,床旁、即时、简便,血管外肺水与,ARDS,的严重程度相关,对血管外肺水的评判优于胸片,血管外肺水的监测有利于临床即时肺水管理,2023/8/24PiCCO定量监测肺水PiCCO对血管外肺,2024/8/13,Sakka et al, Intensive Care Med 26: 180-187,2000,Bias = -0.2 ml/kgSD = 1.4 ml/kg,n = 209,r = 0.96,EVLWI,ST,vs. EVLWI,TD,in 209 intensive care patients,EVLW,准确性验证,2023/8/24Sakka et al, Intensiv,2024/8/13,EVLW,与氧和,2023/8/24EVLW与氧和,2024/8/13,Relevance of EVLW - management,After: Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992,22,days,15,days,9,days,7,days,RHC group,RHC,group,EVLW group,EVLW,group,*,*,Ventilation days,ICU days,n=101,：,2023/8/24Relevance of EVLW - m,2024/8/13,临床,应用,Volume,Drugs,2023/8/24临床VolumeDrugs,2024/8/13,2023/8/24,2024/8/13,PiCCO plus,的连接,中心静脉导管,注射水温度测量管,PV4046,动脉热稀释导管（,PiCCO,导管,）,注射水温度测量电缆,PC80109,PULSION,动脉压力传感器,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 1140,(GEDI) 625,DPT Monitor cable,PMK-206,Interface cable,PC80150,连接床旁监护仪,PMK - XXX,AUX adapter,cable,PC81200,2023/8/24PiCCO plus 的连接中心静脉导管注,2024/8/13,适应症,凡心血管功能和循环容量状态测定的病人，均可采用,PiCCO,如：休克、,ARDS,、急性心衰、严重创伤、大手术等,2023/8/24适应症凡心血管功能和循环容量状态测定的病人,2024/8/13,禁忌症,出血性疾病,主动脉瘤、大动脉炎,动脉狭窄，肢体有栓塞史,肺叶切除，肺栓塞，胸内巨大占位性病变,体外循环期间,体温或血压短时间变异过大,严重心律紊乱,严重气胸、心肺压缩性疾病,心腔肿瘤,心内分流,2023/8/24禁忌症出血性疾病体温或血压短时间变异过大,2024/8/13,C,onclusion,Picco,不经过右心，创伤比较小，对每一次心脏跳动进行分析持续测量,全面测量血流动力学参数,直接给出前负荷容量参数，不受压力变化的影响,定量测量肺水肿的情况,能同时更为全面掌握循环、呼吸功能,技术掌握容易，并发症少,2023/8/24ConclusionPicco不经过右心，,2024/8/13,Thanks for your attention,2023/8/24 Thanks for your att,