PiCCO.VS.PAC.VS.FloTrac

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,*,Company Logo,PiCCO,Tech,VS.,PAC,VS.,FloTrac,内 容,原理背景,1,临床应用指症以及可操作性,2,相关文献报道,3,PiCCO,技术的优势,4,Company Logo,原理背景,PAC,热稀释,Stewart-Hamilton,PiCCO,技术,FloTrac,脉搏轮廓分析,不经肺热稀释,监测：心排量,压力相关参数,导管放置：过右心,风险性：高,影响因素：呼吸周期,动脉顺应性,腹腔内高压,经肺热稀释,监测：心排量,容量相关参数,导管放置：股动脉，腋动脉,风险性：较小,影响因素：不受外界影响,脉搏轮廓分析,经肺热稀释方法所得,CO,校准,无需其他来源,CO,对脉搏轮廓进行校准,导管放置：连接桡动脉导管,受外界影响大，精准度不高,Company Logo,Left heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,arterial thermo-dilution catheter,central venous bolus injection,RA,RV,PA,LA,LV,Aorta,Transpulmonary TD(PiCCO),Pulmonary Artery TD(PAC),这两种方法所得,CO,都是准确的，因为热稀释方法关注的只是,时间以及温度改变！,经肺,VS.,肺动脉热稀释,Company Logo,T,b,=Blood temperature,T,i,=,Injectate,temperature,V,i,=,Injectate,volume,T,b,.,dt=Area under the thermodilution curve,K =Correction constant,made up of specific weight and specific heat of blood and,injectate,心输出量是利用,Stewart-Hamilton,公式对热稀释曲线进行分析所得,T,b,x,dt,(T,b,-T,i,),x,V,i,x,K,T,b,Injection,t,D,=,CO,TD a,热稀释方法所得心输出量的计算,Company Logo,PiCCO,PAC,监测方式,经肺热稀释法和脉搏轮廓分析法,热稀释法,参数,CO(,心排,),有,有,CVP,（压力）,无,有,PAOP,（压力）,无,有,GEDV,（容量）,有,无,ITBV,（容量）,有,无,EVLW,（肺水）,有,无,CFI,有,无,SVV,有,无,AP,有,无,Company Logo,经肺热稀释,The pulse contour analysis is calibrated through the transpulmonary,thermodilution,and is a beat to beat real time analysis of the arterial pressure curve,Injection,脉搏轮廓分析,T=blood temperature,t=time,P=blood pressure,CO,TPD,=SV,TD,HR,PiCCO,和,FloTrac,所得连续心输出量,PiCCO,-,对脉搏轮廓分析进行校准,Company Logo,PiCCO,和,FloTrac,所得连续心输出量,FloTrac,system:,APCO=PR x(,AP,*),AP,=standard deviation of arterial pulse pressure in mmHg is proportional to pulse pressure.,=scaling multivariate parameter proportional to the effects of vascular tone on pulse pressure.,Company Logo,PiCCO,plus,Vigileo,Monitor,参数,缩写,参数,缩写,血流,脉搏轮廓心输出量,PCCO,脉搏轮廓心输出量,CO,心输出,CO,每搏输出量,SV,每搏输出量,SV,前负荷,全心舒张末期容积,GEDV,胸腔内血容积,ITBV,容量反映值,每搏量变异,SVV,每搏量变异,SVV,脉压变异,PPV,收缩力,全心射血分数,GEF,心功能指数,CFI,左心收缩力指数,dPmx,心力输出,CPO,后负荷,全身血管阻力,SVR,全身血管阻力,SVR,肺水肿,血管外肺水,EVLW,肺血管通透性,PVPI,Company Logo,Discussion,3,项技术各自有什么优劣势？,当有临床医生置疑,PiCCO,的准确？,PiCCO,技术制胜点在哪里？,结论,Company Logo,Patient Groups,DACH,Europe,USA(cluster),-,Cardiogenic,Shock,31,900,75,500,22,500,-ARDS,24,100,62,900,33,000,-Cardiac Surgery,117,600,184,520,67,600,PAC rate,5%,5%,5%,PAC indications,8,680,16,146,6,155,News,：,2008,年,6,月,Pulsion,推出,PiCCO,2,Software V2.0,增加了肺动脉压力的监测,临床应用指症以及可操作性,Company Logo,PiCCO,可操作性,监测项目：,CO,，,SVV,，,GEDV,，,EVLW,科室：,ICU,（败血性休克，心源性休克，,ALI,）,麻醉科（移植手术，大的心外科手术）,PAC,可操作性,监测项目：,CO,，,CVP,，,PWAP,科室：,ICU,（,ARDS,）,麻醉科（心脏手术）,FloTrac,可操作性,监测项目：,CO,，,SVV,科室：,ICU,和麻醉科以外没有条件进行有创监测的任何情况。,Surviving,Sepsis,Campaign,Guidelines,SSC,推荐监测,CO,和容量前负荷指标,德国败血症治疗准则,推荐监测,CO,和容量前负荷指标,临床应用指症以及可操作性,Company Logo,ICU,，,OR,病人情况复杂，需要额外压力信息,或者只关注压力（肺高压）,ICU,，,OR,所有血流动力学不稳定,的病人,没有条件做有创监测,病人血动不稳定,常规监护,病人完全稳定,PAC,PiCCO,FloTrac,HR,AP,风险，病人危急度,PiCCO,FloTrac,PAC,在临床应用的梯度图,Company Logo,相关文献,Cardiovascular monitoring tools:use and misuse,，,Bellomo,R,Uchino S,，,Curr,Opin,Crit,Care 9:225 229,2003,，,相比较,PAC,，,PiCCO,对于心血管监测是更好的选择,Haemodynamic,monitoring with pulse-induced contour cardiac output(,PiCCO,)in critical care,，,Ros,Cottis,，,Neil Magee and David J.Higgins,PiCCO,技术所得连续,CO,不受呼吸周期的影响并且,ITBV,等容量参数能更好的反映心脏前负荷,PiCCO,于,Swan-,Ganz,导管监测的比较与思考,，徐向辉，张冬梅，医学与哲学,2007,。,4,第,28,卷,与,Swan-,Ganz,导管监测技术比较，,PiCCO,微创，科学，简便。,The accuracy of the,Vigileo/FloTrac,continuous cardiac output monitor,Vigileo/Flo,Trac,Zimmerman A,Kufner C,Hofbauer S,Steinwendner J,Hitzl W,Fritsch G,Schistek R,Kirnbauer M,Pauser,G.Journal,of Cardiothoracic and Vascular Anesthesia(J,Cardiothorac,Vasc,Anesth,2008,epub,),早期监测心输出量越来越得到推崇，这种监测往往发生在急症科室或者,ICU,以外的任何地方。而通常有创监测（,PiCCO,，漂浮导管）在,ICU,或者手术室外是不便使用的，所以创伤更小便于应用的技术正应运而生,Vigileo,/,FloTrac,监测心排量的准确性很大程度,依赖临床的应用目的。,Company Logo,Discussion,PiCCO,技术的优势以及市场定位,如何面对我们的竞争对手？,不做没有证据的攻击（四院），利用文献强调梯度概念,PiCCO,技术和,PAC,是不是在一个层面上竞争？,时时记得,PiCCO,不仅仅是连续心排量的监测仪，容量参数已经写入欧洲治疗准则代替压力金标准，,PiCCO,是以为床边量化监测肺水的技术,三个技术的概述？,PAC,的压力参数有临床意义，但是风险大，所得参数较局限,FloTrac,应用最为简便，但是绝对值有待商榷,PiCCO,风险性较小，参数较为全面，是均衡性能最佳的产品,Company Logo,Thank You!,