乐老师新PiCCO

PULSION PiCCO,plus,容量监测仪,PiCCO,.,简便 安全 快速 准确,PICCOplus,监测仪,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,PC81200,1.,什么是,PiCCO,技术,?,PiCCO,技术是经肺热稀释技术和脉搏波型轮廓分析技术的综合， 用于进一步的测量血液动力监测和容量管理，并使大多数病人不再需要放置肺动脉导管：,脉搏轮廓分析技术,中心静脉注射,PULSIOCATH,校正,经肺热稀释技术,注射,t,T,P,t,弹丸注射,肺,PiCCO,导管,如：股动脉,经肺热稀释技术需要在中心静脉注射冷盐水,( 8C),或室温盐水,(, SV,2,SVV,提示心脏对容量治疗的反应好坏,EDV,SV,SVV small,SVV large, EDV,1, EDV,2, SV,1, SV,2,脉压变异,PP,max, PP,min,PPV =,PP,mean,PP,max,PP,mean,PP,min,脉压变异反映了脉压随通气周期变化的情况,PPV,是,.,过去,30,秒的测量结果,只适用于心律规律的完全机械通气病人,正常值范围,ParameterRange,Unit,CI3.0 5.0l/min/m,2,SVI40 60ml/m2,SVRI1200 1800dyn*s*cm-5*m,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,临床,应用,Volume,Drugs,胸腔内血容积（,ITBV,）,和,全心舒张末期容积（,GEDV,）,在反映心脏前负荷方面不但敏感性和特异性优于常规使用的心脏充盈压力,CVP +,PCWP,，而且也优于右心室舒张末期容积,2,3,5,6,8,9,13,14,23,ITBV,和,GEDV,的显著优点是不受机械通气的影响，可以更准确地反映前负荷的情况,2,3,6,7,8,9,13,14, 23,PiCCO,前负荷指标,压力和容量反映前负荷,1,心指数（,CI,）变化与中心静脉压（,CVP,）、肺楔压（,PCWP,）和胸腔内血容积（,ITBI,）变化的关系，病人是急性呼吸衰竭采用机械通气,13,Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992,Pressures as indicators of cardiac preload,Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992,Lichtwarck-Aschoff et al, Intensive Care Med 18: 142-147, 1992,ITBV as indicator of cardiac preload,EVLW,Extravascular Lung Water,Direct quantification in ml,Water content of the lungs,High accuracy and reproducibility,Fast bedside determination,热稀释法测量得到的,血管外肺水（,EVLW,）,已经被双指示剂法和重量法的测量结果验证,12,17,22,24,血管外肺水（,EVLW,）,显示与,ARDS,的严重程度、机械通气天数、住,ICU,时间及死亡率明确相关，在评估肺水肿方面优于胸部,X,线,7,8,16,21,24,25,血管外肺水,Katzenelson et al,Crit Care Med Vol. 29,No 12(Suppl.),心源性,+,非心源性肺水肿,血管外肺水的验证,2,PiCCO EVLW vs.,重量法,EVLW,（狗）,EVLWI*,ST,vs. EVLWI*,TD,in 209 intensive care patients,Sakka et al, Intensive Care Med 26: 180-187, 2000,热稀释单指示剂法测量的,EVLW,Bias = -0.2 ml/kgSD = 1.4 ml/kg,n = 209,r = 0.96,Validation of Extravascular Lung Water* measurement with the COLD System:,Dye dilution (EVLW ) vs. single thermodilution technique (EVLW ),TD,ST,TM,Source ComparisonCorrelation,Baudendistel et al, 1982,X-ray score vs.EVLW,77 %,J Trauma 22: 983,Sibbald et al, 1983,comparison cardiac edema,r = 0,66,Chest 83: 725,comparison non cardiac edema,r = 0,7,Sivak et al, 1983,X-ray score vs EVLW,64 %,Crit Care Med. 11: 498,X-ray score vs.,EVLW,42 %,Laggner et al, 1984,X-ray score vs. EVLW,r = 0,84,Intensive Care Med. 10: 309,Halperin et al, 1985,X-ray score vs.,r = 0,51,Chest 88: 649,EVLW,Haller et al, 1985,X-ray score vs. EVLW,66 %,Fortschr. Rntgenstr. 142: 68,Eisenberg et al, 1987,X-ray score vs. EVLW,76 %,Am Rev Resp Dis 136: 662,Takeda et al, 1995,X-ray score vs. EVLWX-ray insensitive,J,Vet Med Sci 57 (3): 481,Comparison of EVLW and chest X-ray,Source ComparisonCorrelation,Baudendistel et al, 1982,J Trauma 22: 983,X-ray score vs.EVLW*,77 %,Sibbald et al, 1983,Chest 83: 725,comparison cardiac edema,r = 0,66,comparison non cardiac edema,r = 0,7,Sivak et al, 1983,Crit Care Med. 11: 498,X-ray score vs EVLW*,64 %,X-ray score vs.,EVLW*,42 %,Laggner et al, 1984,Intensive Care Med. 10: 309,X-ray score vs. EVLW*,r = 0,84,no / low / high PE, estimated by radiologists,Halperin et al, 1985,Chest 88: 649,X-ray score vs.,EVLW* r = 0,51,Haller et al, 1985,Fortschr. Rntgenstr. 142: 68,X-ray score vs. EVLW*,66 %,Eisenberg et al, 1987,Am Rev Resp Dis 136: 662,X-ray score vs. EVLW*,76 %,Takeda et al, 1995,J,Vet Med Sci 57 (3): 481,X-ray score vs. EVLW*X-ray insensitive,EVLW,和胸部,X,光片的对比,胸部,X,光片常受到胸腔内渗出的影响，并受到床旁拍摄,X,光片技术方面的限制,EVLW,和氧合,2,1,Interstitial space,Alveola,Alveola,Capillary,Erythrocyte,中度和较多的肺水并不一定会造成氧合的降低。,肺水会首先聚积在比较空的间质空隙中（,1,），当肺水进一步增加时才会进入较紧密的间质空隙 （,2,）并影响气体交换功能,24,。,Bck, Lewis, In: Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139,*,在,81,个重症,ICU,病人中,EVLW,与死亡率的关系,Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139,EVLW,与死亡率,1,肺水肿的程度与病人的预后之间有直接的相关性。,死亡率升高直至超过,70%,时都伴随,EVLW,的升高,Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-139,Lung water (EVLW) and mortality,373,位重症,ICU,病人中,EVLWI,与死亡率的关系：其中,193,人感染，,49,人,ARDS,，,48,人头部创伤，,83,人出血性休克。,根据,EVLW,的数值病人分成四组。,Sakka et al , Chest 2002,EVLW,与死亡率,2,ELWI ml/ kg,利用,EVLW,治疗病人,101,位肺水肿病人随时分成肺动脉导管（,PAC,）组与血管外肺水组（,EVLW,），分别 依据,PCWP,和,EVLW,的测量结果进行治疗。,在,EVLW,组的病人在,ICU,的时间和机械通气时间都显著降低。,Mitchell et al, Am Rev Resp Dis 145: 990-998, 1992,22,天,15,天,9,天,7,天,*,*,机械通气天数,住,ICU,天数,n=101,EVLW,组,PAC,组,EVLW,组,PAC,组,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,有肺水肿的病人测量血管内容积和,EVLWI,。,EVLWI,和,CVP,或,PCWP,之间没有相关性。,EVLWI,和,GEDI,之间有明确关联。,Boussat et al, Intensive Care Med, 2002,感染病人的,ELWI,和,GEDI,GEDI ml/m,2,500 1000 1500 2000,ELWI * ml/kg,CVP mmHg,ELWI* , ml/kg,PAOD mmHg,ELWI* ml/kg,有关,SVV,和,PPV,的临床研究,1,Berkenstadt et al, Anesth Analg 92: 984-989, 2001,Sensitivity,1,Specificity,中心静脉压（,CVP,）不能预测增加容量是否会升高每搏量。,- - - CVP,_,SVV,1,0,2,0,4,0,6,0,8,1,0,5,0,0,SVV,和,PPV,是容量反应性的极好预测指标,40,位有急性循环衰竭的感染病人测量,PPV,。在给予,500ml,胶体液后，有较高,PPV,的病人有反应（阈值,13%,），而有较低,PPV,的病人则没有明显心输出量的增加。,因为,PPV,在完全机械通气的病人中可以作为容量治疗的预测指标。,有关,SVV,和,PPV,的临床研究,2,因呼吸引起的动脉脉压变化可以准确预测容量反应性。,Michard et al, Am J Respir Crit Care Med 162, 2000,Cardiac Preload is,Volume,NOT,Pressure,Volume management requiresvolume measurement,Intrathoracic Blood Volume (ITBV),RAEDV,PBV,LAEDV,LVEDV,RVEDV,Thermodilution Screen,Pulse Contour Screen,Normal Range Screen,如何利用,PiCCO,技术来管理病人？,利用,PiCCO,的治疗决策树,+,可以很方便地管理病人的血流动力学状态。,正常值范围和治疗决策树来源于日常临床工作的实践，已经在超过,250,000,个病人上成功运用,（到,2004,年,1,月）,+,不承诺完全合乎您的临床实践,血流动力容量管理决策树,CI (l/min/m,2,),GEDI (ml/m,2,),or,ITBI (ml/m,2,),ELWI* (ml/kg),(slowly responding),3.0,700,850,700,700,850,700,850,ELWI (ml/kg),GEDI (ml/m,2,),or,ITBI (ml/m,2,),CFI (1/min),or,GEF (%),10,10,10,10,10,10,V+,V+!,V+!,V+,Cat,Cat,OK!,V-,700,850,700-800,850-1000,4.5,25,5.5,30,4.5,25,700-800,850-1000,Cat,5.5,30,700,850,700-800,850-1000,700-800,850-1000,10,10,10,10,V-,V,+,=,增加容量,(! =,慎重,),V,-,=,减少容量,Cat =,儿茶酚胺心血管药物,* SVV,只能用于没有心律失常的完全机械通气病人,700,850,10,Optimise to,SVV* (%),10,10,10,测量结果,目标,治疗,1.,2.,不承诺完全合乎您的临床实践,10,10,10,10,CI (l/min/m2),ITBVI (ml/m2),Therapy,Target,ITBVI,CFI,EVLWI (slowly responding),4.5,10,V+!,Cat,temporary,750-850,5.5,10,4.5,3.0,10,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,正常值,ParameterRange,Unit,CI3.0 5.0l/min/m,2,SVI40 60ml/m2,GEDI680 800ml/m,2,ITBI850 1000ml/m,2,ELWI*3.0 7.0ml/kg,PVPI*1.0 3.0,SVV,10%,PPV,10 %,GEF25 35%,CFI4.5 6.51/min,MAP70 90,mmHg,SVRI1700 2400dyn*s*cm-5*m,* not available in the USA (p 63),Berkenstadt,H et al.,Anesth,Analg, 2001,Bindels,A et al.,Crit,Care 4, 2000,Boussat,S et al.,Int,Care Med 2002,Brock,H et,al,.,Eur,J,Anaesth,19 (4), 2002,Della Rocca G,et,al.,Eur,J,Anaesth,19, 2002,Della Rocca G,et,al.,Anesth,Analg,95, 2002,Eisenberg PR et al., Am Rev,Respir,Dis,136 (3), 1987,Gdje O et al., Chest 118, 2000,Gdje O et al.,Eur,J of Cardio-thoracic Surgery 13, 1998,Haperlin,et al., Chest, 1985,Hoeft,A, Yearbook of Intensive Care and Emergency Medicine, 1995,Katzenelson,et al., SCCM 2001, San Diego,Lichtwarck-Aschoff,M et al., Journal of Critical Care 11 (4), 1996,Lichtwarck-Aschoff,M et al., Intensive Care Med 18, 1992,Michard,F et al., Yearbook of Intensive Care Med, 2002,Mitchell JP et al., Am Rev,Respir,Dis,145 (5), 1992,Neumann et al., Intensive Care Med 1999,Reuter DA et al.,Crit,Care Med, 2003,Reuter DA et al., Intensive Care Med, 2002,Reuter DA et,al,.,Brit,J,Anaesth, 2002,Sakka SG et,al,.,Chest,122, 2002,Sakka S et al., Intensive Care Med 2000,Sakka S et al., Journal of Critical Care 14 (2), 1999,Sturm JA, Practical Applications of,Fiberoptics,in Critical Care Monitoring, 1990,Takeda A et al., J Vet Med,Sci,57, 1995,4.,参考文献,创伤小,-,只需放置中心静脉和动脉导管,-,无需肺动脉导管,-,可用于小儿童,初始设置时间短,-,可在几分钟内开始使用,动态、连续测量,-,每次心脏跳动测量心输出量、后负荷和容量反应 性（,beat by beat,）,无需胸部,X,线,-,来确认导管位置,效费比,-,比连续肺动脉导管价格便宜,-,动脉,PiCCO,导管可以放置,10,天,-,减少重症监护时间及花费,参数更明确,-,即使对于没有多少经验的人员而言，,PiCCO,参数 也非常易于判断和理解,血管外肺水,-,床旁定量测量肺水肿,2.,PiCCO,技术的优点,PiCCO ,优点,技术掌握容易，并发症少，可以留置10天,不经过右心，创伤比较小，对每一次心脏跳动进行分析测量,节省医疗资源，有利于病人及早康复,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,全面测量血流动力学参数,对于儿科病人也能良好使用,PiCCO.,.Simple Safe Speedy Specific,