ICU血流动力学监测和PICCO技术课件

,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,*,*,*,ICU血流动力学监测和PICCO技术,ICU血流动力学监测和PICCO技术,1,ICU患者的输液治疗的决定因素,临床经验,中心静脉压(CVP),肺动脉楔压(PAWP),Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151,ICU患者的输液治疗的决定因素Boldt J,Lenz M,2,ICU患者的输液治疗的决定因素,临床经验,中心静脉压(CVP),肺动脉楔压(PAWP),Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151,ICU患者的输液治疗的决定因素Boldt J,Lenz M,3,临床评价 vs.血流动力学,目的:评价肺动脉导管(PAC)得到的血流动力学指标是否能够改变患者的治疗,设计:前瞻性观察,患者:103例留置PAC的患者,方法:,插管前,请医生对一些血流动力学指标的范围,诊断及治疗方案进行预测,插管后,复习患者病例,记录插管时及置管8小时内的血流动力学,Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,临床评价 vs.血流动力学目的:评价肺动脉导管(PAC),4,临床评价 vs.血流动力学,Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,临床评价 vs.血流动力学Eisenberg PR,Ja,5,临床判断缺乏准确性:PAWP,0,10,15,19,19,15,10,0,预计PAWP(mmHg),测定PAWP(mmHg),Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,No change in planned therapy after catheterization,Change in planned therapy after catheterization,临床判断缺乏准确性:PAWP01015191915100预,6,0,临床判断缺乏准确性:CO,0,4.5,7.0,预计CO(L/min),测定CO(L/min),Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,4.5,7.0,0临床判断缺乏准确性:CO04.57.0预计CO(L/m,7,临床判断缺乏准确性,Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,参数,判断正确数目/测定数目,正确率(%),PAWP,31/102,30,CO,49/97,51,SVR,39/88,44,RAP,54/98,55,临床判断缺乏准确性Eisenberg PL,Jaffe A,8,临床判断血流动力学的准确性,Clinical Setting,Accurate Assessment,%,Unanticipated Changes in Therapy Based on PAC,%,Connors,et al,62 noncardiac medical intensive care patients,48,48,Eisenberg,et al,103 critically ill patients,50,30,Tuchschmidt and Sharma,35 noncardiac medical intensive care patients,42,65,Steingrub,et al,154 combined medical/surgical intensive care patients,51,47,Connors,et al,Cardiac and noncardiac medical intensive care,66,47,临床判断血流动力学的准确性Clinical SettingA,9,ICU患者的输液治疗的决定因素,临床经验,中心静脉压(CVP),肺动脉楔压(PAWP),Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151,ICU患者的输液治疗的决定因素Boldt J,Lenz M,10,压力有时不能代表前负荷,左室,舒张末容积（LVEDV，真实的左室前负荷）,肺动脉阻塞压（PAOP）,压力有时不能代表前负荷左室舒张末容积（LVEDV，真实的左室,11,CVP/PAWP不能预测扩容反应,Lichtwarck-Aschoff et al,Intensive Care Med,1992;,18:142-147,CVP/PAWP不能预测扩容反应 Lichtwarck-As,12,何去何从,何去何从,13,PICCO技术,PICCO技术,14,Central venous catheter,Injectate temperature,sensor housing,PV4046,Arterial thermodilution catheter,Injectate temperature sensor cable,PC80109,PULSION disposable pressure transducer 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,Connection cable,to bedside monitor,PMK-XXX,AUX adapter,cable,PC81200,Central venous catheterInjecta,15,PiCCO的技术原理,PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:,a.,经肺热稀释技术,b.,动脉脉搏轮廓分析技术,PiCCO的技术原理PiCCO技术由下列两种技术组成,用于,16,PiCCO容量参数,全心舒张末期容积GEDV,胸腔内血容积ITBV,血管外肺水EVLW,通过对热稀释曲线的分析,可以得到这些容量参数,ln c(I),注射,At,再循环,MTt,t,e,-1,DSt,c(I),PiCCO容量参数全心舒张末期容积GEDVln c(I,17,全心舒张末期容积(GEDV),全心舒张末期容积(GEDV)是心脏4个腔室内的血容量,全心舒张末期容积(GEDV)全心舒张末期容积(GEDV)是心,18,胸腔内血容积(ITBV),胸腔内血容积(ITBV)是心脏4个腔室的容积+肺血管内的血液容量,胸腔内血容积(ITBV)胸腔内血容积(ITBV)是心脏4个腔,19,血管外肺水(EVLW),血管外肺水(EVLW)是肺内含有的水量,可以在床旁定量判断肺水肿的程度,血管外肺水(EVLW)血管外肺水(EVLW)是肺内含有的水量,20,ITBV能够更好地反映前负荷,Lichtwarck-Aschoff et al,Intensive Care Med,1992;,18:142-147,ITBV能够更好地反映前负荷 Lichtwarck-Asch,21,前负荷指标与,SV/CI的相关性,所有患者,单一患者,相关系数,r,SVIart,CIart,CIart(最低值 最高值),CVP,-0.09,0.00,-0.01 0.33,PAWP,-0.02,-0.01,-0.36 0.03,RAEDVI,0.28,-0.11,-0.02 0.37,RVEDVI,0.03,-0.02,0.02 0.03,ITBVI,0.76,0.83,0.67 0.91,GEDVI,0.82,0.87,0.70 0.93,Goedje et al,Eur J Cardiothorac Surg 1998;13(5):533-539;discussion 539-540,前负荷指标与SV/CI的相关性所有患者单一患者相关系,22,PiCCO前负荷指标,在反映心脏前负荷的敏感性和特异性方面,已经证实胸腔内血容积(ITBV)和全心舒张末期容积(GEDV)不但优于CVP及PAWP,也优于右室舒张末期容量(RVEDV),胸腔内血容积(ITBV)和全心舒张末期容积(GEDV)最主要的优点是不受机械通气的影响而产生错误,因此能够在任何情况下提供前负荷情况的正确信息,PiCCO前负荷指标在反映心脏前负荷的敏感性和特异性方面,23,血管外肺水,血管外肺水(EVLW)通过经肺热稀释法得到,已被染料稀释法和重量法证实,已证实血管外肺水(EVLW)与ARDS的严重程度,病人机械通气的天数,住ICU的时间及死亡率明确相关,其评估肺水肿远远优于胸部X线,血管外肺水血管外肺水(EVLW)通过经肺热稀释法得到,已被,24,PiCCO优点,更小的创伤和侵入性,安装操作简便,动态、连续测量,效费比更高,参数更加明确,床旁测定血管外肺水,PiCCO优点更小的创伤和侵入性,25,正常值范围,ParameterRange,Unit,心指数（,CI）,3.0 5.0l/min/m,2,每搏量指数（,SVI）,40 60ml/m2,全身血管阻力（,SVRI）,1200 1800dyn*s*cm-5*m,平均动脉压（,MAP）70 90mmHg,全心射血分数（,GEF）25 35%,心功能指数（,CFI）,4.5