picco监测的意义及影响因素

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,*,*,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,*,*,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,*,*,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,*,*,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,监测的意义及影响因素,ICU,1,重症患者我们关注什么？,容量,组织器官灌注,心功能,肺部情况,氧供、氧耗,血压、心率,CVP,、,PAWP,皮肤弹性,尿量,心血管彩超,血氧饱和度,PO2,，,PCO2,（,敏感性、特异性差，主观性强，影响因素多，缺乏连续性,）,2,PICCO,监测技术,直观,准确,特异性,连续性,3,PICCO,连接示意图,4,PICCO,的操作方法,在中心静脉内注射冷（,8C,）生理盐水作为指示剂,动脉导管尖端的热敏电阻测量温度下降的变化曲线,使用,Stewart-Hamilton,公式计算得出心输出量（,CO,）,通常使用冰水混合物（,0,）,通常注射,15ml,，休克严重时注射,20ml,5,PICCO,的监测原理,经肺热稀释方法,脉搏轮廓分析法,6,PICCO,的监测原理,s,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,-,D,T,注射,热稀释测量曲线,T,b,=,血流温度,T,i,=,注射指示剂温度,V,i,=,注射指示剂容积, T,b,.,dt =,热稀释曲线下面积,K =,校正系数,Correction constant, made up of specific weight and specific heat of blood and injectate,7,通过,CO,计算出来的容量参数,ITTV,（胸腔温度容积）,=CO,MTt,PTV,（肺温度容积）,=CO,DSt,GEDV,（全心舒张末期容积）,=ITTV-PTV,RAEDV,RVEDV,LAEDV,LVEDV,GEDV,ITTV,PBV,EVLW,PTV,8,通过CO计算出来的容量参数,ITBV,（胸腔内血容积）,=GEDV,（全心舒张末容积）,+,PBV,（肺血管内血液容积）,=,1.25,GEDV,EVLW=ITTV-ITBV,9,PICCO,参数及正常值,心指数,CI 3-5l/min/m,2,每搏量指数,SVI 40-60ml/m2,全身血管阻力,SVRI 1200-1800,平均动脉压,MAP 70-90mmHg,全心射血分数,GEF 25-35%,舒张末期容积指数,GEDI 680-800ml/m2,胸腔血容积指数,ITBI 850-1000ml/m2,每搏量变异,SVV 10%,血管外肺水指数,EVLWI 3-7ml/kg,肺血管通透指数,PVPI 1-3,10,3,次,热稀释校准,经肺热稀释,曲线,injection,t,T,动脉脉搏轮廓分析,P,t,两种技术,经热稀释方法得到的非连续性参数,心输出量,CO,全心舒张末期容积,GEDV,胸腔内血容量,ITBV,血管外肺水,EVLW,*,肺血管通透性指数,PVPI,*,心功能指数,CFI,全心射血分数,GEF,动脉轮廓分析法得到的连续性参数,连续心输出量,PCCO,动脉压,AP,心率,HR,每搏量,SV,每搏量变异,SVV,脉压变异,PPV,系统血管阻力,SVR,左心室收缩力指数,dPm,a,x,*,血液动力学,和,容量,进行监护管理,两部分参数,PiCCO,PiCCO,(,P,ulse,i,ndicate,C,ontour,C,ardiac,O,utput),脉搏轮廓动脉压波形分析法,11,中心静脉导管,注射液温度探头容纳管,PV4046,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,压力线,206PMK,动脉热稀释导管,PULSION,一次性压力传感器,PV8115,（包括,PV4046,）,温度测量电缆,PC80150,注射液温度电缆,PC80109,导管连接,12,PICCO2,连接图,13,ScvO2 ,中心静脉氧饱和度,通过标准中心静脉导管放置,SvO2 (,混合静脉氧饱和度,),目前只能通过高创伤性的右心导管获得,ScvO2,和,SvO2,之间有良好的相关性,正常值范围,:ScvO270-80%,SvO265-75%,14,氧供和氧耗,DO,2,I ,氧供,(Index),通过,CI,，血红蛋白，动脉血氧饱和度来计算,VO,2,I,氧耗,(Index),通过,CI,，血红蛋白，动脉以及,混合静脉氧饱和度,来计算,正常值范围,:DO,2,400 - 650 ml/min/m,2,VO,2,125 - 175 ml/min/m,2,S(c)vO,2,CO, Hb,Oxygen intake,Oxygen transport,Oxygen delivery,Oxygen consumption,VO,2,I = CI,x,Hb,x,1,34,x,(SaO,2, S(c)vO,2,),DO,2,I = CI,x,Hb,x,1,34,x,SaO,2,SaO,2,Consumption,Delivery,15,经肺热稀释,在中心静脉内注射冷（,8C,）生理盐水作为指示剂,动脉导管尖端的热敏电阻测量温度下降的变化曲线,使用,Stewart-Hamilton,公式计算得出心输出量（,CO,）,PiCCO,测得的,CO,与肺动脉导管测得的,CO,相关良好,s,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,-,D,T,注射,热稀释测量曲线,T,b,=,血流温度,T,i,=,注射指示剂温度,V,i,=,注射指示剂容积, T,b,.,dt =,热稀释曲线下面积,K =,校正系数,Correction constant, made up of specific weight and specific heat of blood and injectate,16,热稀释曲线下的面积与心输出量成反比,36,5,37,5,10,热稀释曲线,Normal CO: 5.5l/min,36,5,37,36,5,37,Time,low CO: 1.9l/min,High CO: 19l/min,Time,Time,Temperature,Temperature,Temperature,17,MTt: Mean Transit time,平均通过时间,the mean time required for the indicator to reach the detection point,DSt: Down Slope time,斜面下时间,the exponential downslope time of the thermodilution curve,Recirculation,t,e,-1,Tb,From the characteristics of the thermodilution curve it is possible to determine certain time parameters,根据热稀释曲线可以算出时间参数,对热稀释曲线做进一步分析,Introduction to the PiCCO-Technology Thermodilution,Injection,In Tb,MTt,DSt,T,b,= blood temperature; lnTb = logarithmic blood temperature; t = time,18,Pulmonary Thermal Volume,PTV,肺内热容积,= Dst x CO,By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated,计算,ITTV,与,PTV,Introduction to the PiCCO-Technology Thermodilution,Recirculation,t,e,-1,Tb,Injection,In Tb,Intrathoracic Thermal Volume,ITTV,胸腔内热容积,= MTt x CO,MTt,DSt,19,Pulmonary Thermal Volume (PTV),Intrathoracic Thermal Volume (ITTV),Calculation of ITTV and PTV,Einfhrung in die PiCCO-Technologie Thermodilution,ITTV = MTt x CO,PTV = Dst x CO,RA,RV,LA,LV,PBV,EVLW,EVLW,20,GEDV is the difference between intrathoracic and pulmonary thermal volumes,Global End-diastolic Volume (GEDV),Volumetric preload parameters GEDV,RA,RV,LA,LV,PBV,EVLW,EVLW,ITTV,GEDV,PTV,Introduction to the PiCCO Technology Thermodilution,21,Volumetric preload parameters ITBV,Intrathoracic Blood Volume (ITBV),GEDV,ITBV,PBV,RA,RV,LA,LV,PBV,EVLW,EVLW,Introduction to the PiCCO Technology Thermodilution,ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels (PBV),22,ITTV, ITBV,= EVLW,The Extravascular Lung Water is the difference between the intrathoracic thermal volume and the intrathoracic blood volume. It represents the amount of water in the lungs outside the blood vessels.,Calculation of Extravascular Lung Water (EVLW),Introduction to the PiCCO Technology Extravascular Lung Water,23,容量测量小结,ITTV = CO * MTt,TDa,PTV = CO * DSt,TDa,ITBV,= 1.25 * GEDV,EVLW = ITTV -,ITBV,GEDV,=,ITTV - PTV,RAEDV,RVEDV,LAEDV,LVEDV,RAEDV,RVEDV,LAEDV,LVEDV,PBV,RAEDV,RVEDV,LAEDV,LVEDV,PTV,PTV,EVLW,EVLW,24,Transpulmonary Thermodilution,The pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve,动脉脉搏波形校准,Introduction to the PiCCO-Technology Pulse contour analysis,Injection,Pulse Contour Analysis,T = blood temperature,t = time,P = blood pressure,CO,TPD,= SV,TD,HR,25,脉搏轮廓分析,Cal =,校准系数来自经肺热稀释方法,Surface,= Cal.,x,S,troke,v,olume,26,动脉脉搏轮廓分析,压力曲线下面积,压力曲线型状,PCCO = cal HR ,Systole,P(t),SVR,+,C(p) ,dP,dt,(,),dt,动脉顺应性参数,心,率,与病人有关的校正因子,t s,P mm Hg,27,t s,P mm Hg,左心室收缩力指数,dPmx,=,动脉压力曲线的上升枝,PiCCO,心肌收缩力参数,收缩力参数,dPmx,指的是左心室压力曲线上的最大值。,28,SV,max, SV,min,SVV =,SV,mean,SV,max,SV,min,SV,mean,The Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle, measured over the previous 30 second period.,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Stroke Volume Variation,SVV,提示心脏对容量治疗的反应好坏,每博量变异是每博量在一个呼吸周期中的变异，它所测量的是之前,30,秒的值。,29,PP,max, PP,min,PPV =,PP,mean,The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle, measured over the previous 30 second period.,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Pulse Pressure Variation,PP,max,PP,mean,PP,min,脉压变异是在一个呼吸周期里面脉搏压力的变异，它测得的是之前,30,秒的值。,30,GEF,是,4,倍的,SV,除以全心舒张末期容量,它反应的是全心功能参数,GEF = Global Ejection Fraction,Contractility parameters from the thermodilution measurement,Introduction to the PiCCO-Technology Contractility parameters,4 x SV,GEF =,GEDV,LA,LV,RA,RV,31,CFI,是,CI,除以全心舒张末期容量指数,它与,GEF,相似，是反映全心功能的参数,CFI = Cardiac Function Index,CI,CFI =,GEDVI,Introduction to the PiCCO-Technology Contractility parameters,Contractility parameters from the thermodilution measurement,32,作为一个后负荷指数，它是心血管状况更深层的决定性因素。,这是一个非常重要的参数，它可以提示容量控制和儿茶酚胺的治疗。,(MAP CVP) x 80,SVR =,CO,Afterload parameter,后负荷,SVR = Systemic Vascular Resistance,全身血管阻力,MAP = Mean Arterial Pressure,CVP = Central Venous Pressure,CO = Cardiac Output,80 = Factor for correction of units,Introduction to the PiCCO Technology Afterload parameter,33,Differentiating Lung Oedema,PVPI = Pulmonary Vascular Permeability Index,肺血管通透性指数,肺血管通透性可以鉴别肺水肿的类型（静水压型,vs,渗透型）,EVLW,PVPI =,PBV,PBV,EVLW,Introduction to PiCCO Technology Pulmonary Permeability,34,PBV,肺血容量,静水压肺水肿,渗透性肺水肿,PVPI =,PBV,EVLW,正常,升高,升高,PVPI =,PBV,EVLW,升高,升高,正常,PVPI =,PBV,EVLW,正常,正常,正常,PBV,EVLW*,PBV,EVLW*,PBV,EVLW*,正常肺,EVLW,血管外肺水,用肺血管通透性指数（,PVPI,）判断肺水肿的种类,35,相关要素,指示剂 量、温度、注射速度,血温、心率、血压,热稀释波形,脉搏波形轮廓,患者身高、体重,36,全心舒张末期血容量（,GEDV,）,巨大主动脉瘤会造成数值偏高,当血管内容量严重不足时，数值偏大,血管外肺水（,EVLW,）,巨大肺栓塞的时候，数据偏大,肺切除病人，数据偏低,经肺热稀释法所得参数,左向右,分流,时，无法进行测量,体外循环期间影响容量参数的监测,脉搏轮廓分析所得参数,当病人使用,IABP,时皆不可测得,严重,心率,不齐时皆不可测得,哪些情况会造成,PiCCO,参数准确性偏差？,37,冷注射液,8,；（成人,10-15ml,；儿童,3-5ml,；单次不能超过,20ml,）。,注射速度应快速、均匀，以,5,秒为佳；三次测量时间控制在,15min,内。,打入冷盐水时，手不要触及温度容纳仓及中心静脉导管。,冷盐水注入通道严禁使用血管活性药物。,温度容纳仓与中心静脉导管间不能加延长管。,注意事项,经肺热稀释法由中心静脉导管打入冷盐水（,CVC,至少两腔）：,校正,：,一般每,8,小时通过热稀释法对脉搏轮廓分析法进行校正。,明显改变药物或容量状态，以及,SVRI,有明显变化时（,20%,）也建议重新校正。,建议每,24h,对,ScvO,2,进行一次真实校正。,38,注意事项,其他,：,每,1,小时用肝素生理盐水手动冲洗动脉压力监测通道，保持畅通，加压袋压力维持在,300mmHg,（肝素配比,24u/ml,） 。,注意对穿刺侧支护理。,建议,PiCCO,导管最多放置,10,天。,中心静脉导管长度必须与,Cevox,光纤匹配，放置光纤通道接生理盐水袋持续冲管，防止栓塞。,动脉穿刺点：成人（股动脉、肱动脉、腋动脉），儿童（股动脉） 。,输入病人信息时，体重输入实际体重。,39,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),40,Thank you!,41,PICCO的监测原理,42,