爱爱医资源cv未p与血流动力学监测ppt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,*,*,2024/9/28,1,CVP,测定与血流动力学监测,2024/9/28,2,cvp,Cvp,是临床反应有心功能和有效循环血容量负荷的简便而实用的指标,常用的静脉穿刺部位有锁骨下、颈内、贵要、大隐、股静脉将导管置入上腔静脉或右心房。,2024/9/28,3,适应证,严重创伤、失血、脱水、血容量不足、休克,急性心功能衰竭者,术前心功能不全，术中及术后需要进行心功能及血容量监测者,需要大量输液、输血或需要,TPN,者,心血管及其他大而复杂的手术,2024/9/28,4,危重病患者的中心静脉插管,静脉通路,输液,输注血管活性药物,血流动力学监测,2024/9/28,5,中心静脉压的临床意义,CVP,正常值,2 6 mmHg,CVP 6 mmHg,容量过多,心功能不良,CVP 200 ml/h,时,成人导管,: CVP,升高,4 mmHg,儿童导管,: CVP,升高,8 mmHg,Ho AMH, Dion PW, Karmakar MK, Jenkins CR. Accuracy of central venous pressure monitoring during simultaneous continuous infusion through the same catheter. Anaesthesia 2005; 60: 1027-1030,2024/9/28,26,下腔静脉压与中心静脉压,股静脉插管测定,CVP (ACVP) vs.,上腔静脉插管测定,CVP (TCVP),平均差异,: 0.45 mm Hg (SD 0.89: 95% Cl 0.30-0.60),随,PEEP,及,MAP,增加, ACVP,与,TCVP,差值呈现轻度增加趋势,统计学差异显著,临床意义并不明确,Joynt GM, Gomersall CD, Buckley TA, Oh TE, Young RJ, Freebairn RC. Comparison of intrathoracic and intra-abdominal measurements of central venous pressure. Lancet 1996; 347(9009): 1155-7.,2024/9/28,27,下腔静脉压与中心静脉压,目的,:,研究机械通气的危重病患者髂总静脉压,(CIVP),与上腔静脉压,(SVCP),的相关性,设计,:,随机盲法比较,背景,:,大学教学医院综合性,ICU,患者,: 20,名机械通气危重病患者,结果,:,平均差异,0.1,1.06 mmHg (95%CI -0.10 to 0.25),平均气道压,腹腔内压和,PEEP,无显著影响,Ho K, Joynt GM, Tan P. A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Critical Care Medicine 1998; 26(3): 461-464.,2024/9/28,28,下腔静脉压与中心静脉压,结论,在机械通气患者,经股静脉留置,15 20 cm,的中心静脉插管所测定的静脉压力与,SVCP(,上腔静脉压,),无显著差异,Ho K, Joynt GM, Tan P. A comparison of central venous pressure and common iliac venous pressure in critically ill mechanically ventilated patients. Critical Care Medicine 1998; 26(3): 461-464.,2024/9/28,29,内容,1,2,3,4,中心静脉压的标准测定方法,经中心静脉插管测定中心静脉压,经外周静脉测定中心静脉压,经,PICC,测定中心静脉压,2024/9/28,30,内容,1,2,3,4,中心静脉压的标准测定方法,经,PICC,测定中心静脉压,经中心静脉插管测定中心静脉压,经外周静脉测定中心静脉压,2024/9/28,31,经外周静脉测定中心静脉压,不同部位的影响,上肢静脉,下肢静脉,不同体温的影响,2024/9/28,32,外周静脉部位与静脉压力的准确性,PVP,（外周静脉压）测定不能准确反映每位患者,CVP,的绝对数值,动态测定,PVP,有助于确定危重病患者容量状态及指导输液治疗,PVP,与,CVP,方向相同,Charalambous C, Barker TA, Zipitis CS, Siddique I, Swindell R, Jackson R, Benson J. Comparison of peripheral and central venous pressures in critically Ill patients. Anaesth Intensive Care. 2003; 31(1): 34-9.,2024/9/28,33,体温对外周静脉压力准确性的影响,外周静脉压力与中心静脉压力相关,体温改变可以影响血管张力,低体温,外周血管收缩,收缩血管中的,循环血量占心,输出量的,10%,无循环改变,Sahin A, Salman MA, Salman AE, Aypar U. Effect of Body Temperature on Peripheral Venous Pressure Measurements and Its Agreement with Central Venous Pressure in Neurosurgical Patients. J Neurosurg Anesthesiol 2005; 17: 91-96,2024/9/28,34,血流动力学的概念,血流动力学,(Hemodynamics ),研究血液在心血管系统中流动的一系列物理学问题，即流量、阻力、压力之间的关系。,BP=CO*SVR,意义：,了解病情发展,氧代谢动力学,指导临床治疗,(,容量及血管活性药物管理）,2024/9/28,35,循环监测的方法,无创监测,一般监测,:HR,BP,周围皮肤,尿量,阻抗法血流动力学监测,超声血流动力学监测,有创监测,肺动脉内热稀释漂浮导管,(SWAN-GANZ),PiCCO,技术,(Pulse indicator Continous CO),氧动力学,组织氧合状况监测,2024/9/28,36,无创监测部分,2024/9/28,37,常用监测,BP,、,EKG,、,HR,、,T,、,SpO2,体征,:,周围皮肤,、肺底细罗音颈静脉扩张、外周水肿,SpO2,取决于呼吸与循环,2024/9/28,38,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,2024/9/28,39,超声血流动力学监测,能反应容量,但昂贵、麻烦，不能普及,2024/9/28,40,有创监测部分,2024/9/28,41,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）,2024/9/28,42,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,AP 140,117 92,(CVP) 5,SVRI 2762,PC,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,PC81200,2024/9/28,43,2024/9/28,44,测量原理,Volume,Drugs,2024/9/28,45,PiCCO,监测指标（,1,）,热稀释法,（间断测定）,心输出量,(CO),及指数,(CI),胸腔内血容量,(ITBV),及指数,(ITBI),全心舒张末期容量,(GEDV),及指数,(GEDI),心功能指数,(CFI),全心射血分数,(GEF),血管外肺水,(EVLW),及指数,(ELWI ),肺血管通透性指数,(PVPI),2024/9/28,46,PiCCO,监测指标（,2,）,动脉脉搏波型曲线下面积分析技术,（,可连续监测）,每次心脏搏动的心输出量,(PCCO),及指数,(PCCI),动脉压,(AP),心率,(HR),每搏量,(SV),及指数,(SVI),每搏量变化,(SVV),外周血管阻力,(SVR),及指数,(SVRI,),2024/9/28,47,基本原理（,1,）,心输出量测定,心输出量的测定,基本原理,:,经肺温度稀释法,。,与肺动脉导管温度稀释曲线相比，经肺温度稀释曲线更长、更平坦。,PiCCO,利用经肺温度稀释法测得的,COTDa,与同时利用肺动脉导管测得的,COTDpa,相关良好。,2024/9/28,48,经肺热稀释法与传统右心热稀释法,经肺热稀释导管测量点,静脉注射指示剂,RAEDV,PBV,ETV,LAEDV,LVEDV,ETV,RVEDV,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,D,T,Injection,s,传统热稀释导管测量点,SWAN-GANS,2024/9/28,49,Global Enddiastolic Volume (,GEDV,) is the volume of blood contained in the 4 chambers of the heart.,2024/9/28,50,Intrathoracic Blood Volume,(,ITBV,) is the volume of the 4 chambers of the heart + the blood volume in the pulmonary vessels.,2024/9/28,51,Extravascular Lung Water (,EVLW,)* is the amount of water content in the lungs. It allows bedside quantification of the degree of pulmonary edema.,2024/9/28,52,基本原理（,2,）,容量指标及血管外肺水,RAEDV,PBV,EVLW,LAEDV,LVEDV,EVLW,RVEDV,PTV,GEDV,ITTV,GEDV =,ITTV,-,PTV,2024/9/28,53,基本原理（,2,）,容量指标及血管外肺水,RAEDV,PBV,EVLW,LAEDV,LVEDV,EVLW,RVEDV,ITBV,ITBV = 1.25 * GEDV,EVLW = ITTV - ITBV,2024/9/28,54,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,2024/9/28,55,基本原理（,3,）,结合热稀释将脉搏波图形面积变成持续,CO,2024/9/28,56,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,主动脉顺应性,心率,校正系数,(,通过热稀释法校正,),t s,P mm Hg,基本原理（,3,）,结合热稀释将脉搏波图形面积变成持续,CO,PCCO is displayed as last 12s mean,2024/9/28,57,PiCCO,监测指标临床意义,GEDV，ITBV,容量性前负荷优于,PAWP，CVP,压力性前负荷。,压力性前负荷,易受多种因素影响,(,如血管充盈度、血容量、心肌收缩力、心血管顺应性、胸内压、通气状态、测定技术误差）。,血管外肺水,(EVLW),有利于,ARDS,的,EVLW,管理,。,每搏量变异,(SVV),：,不间断容量反应，有利于机械通气患者的液体管理,。,2024/9/28,58,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,：,2024/9/28,59,SVmax,SVmin,SVmean,SVmax SVmin,SVV =,SVmean,SVmax,和,SVmin,是过去 30 秒中的最大和最小值,每搏量变异,(SVV),只在受控机械通气病人有意义,2024/9/28,60,The increase of preload volume is equal: EDV,1,= EDV,2, SV,1, 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,2,2024/9/28,61,PiCCO,监测指标,正常值范围,ParameterRange,Unit,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 3.0,2024/9/28,62,CI (l/min/m2),ITBVI (ml/m2),Therapy,Target,ITBVI,CFI,EVLWI (slowly responding),10,V+!,Cat,temporary,750-850,10,10,Cat,V-,temporary,750-850,10,10,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,