PiCCO在ICU中的应用.ppt

PiCCO容量监护仪在ICU中的应用,2,PiCCO Technology,容量管理,Introduction to the PiCCO-Technology,CO,Volumetric preload,EVLW,Contractility,Differentiated Volume Management,static - dynamic,3,正确的监测才能进行正确的治疗,4,什么是PiCCO？,5,PiCCO是一种技术，是一种简便、微创、高效费比的，对重症病人主要血流动力学参数进行监测的工具。,6,Central venous catheter jugular subclavian femoral,大多数血流动力学不稳定的患者都会置 中心静脉导管 (vasoactive agents administration) 动脉导管 (monitoring of blood pressure, blood samples),Thermodilution arterial catheter femoral axillary long radial,连接,7,Central venous catheter jugular subclavian femoral,8,PiCCO技术可以监测心输出量,9,PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysis,Principles of Measurement,Left Heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATH arterial thermodilution catheter,central venous bolus injection,Introduction to the PiCCO-Technology Function,10,Transpulmonary thermodilution method,Arterial TD catheter 动脉热稀释导管 (e.g. PV2014L16),CV bolus injection 中心静脉一次注射,RAEDV 右房舒张末容量,PBV 肺血容量,EVLW,LAEDV 左房舒张末容量,LVEDV 左室舒张末容量,EVLW 血管外肺水,RVEDV 右室舒张末容量,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,-,D,T,Injection,s,Lungs,CVC,Aorta,V. cavasup.,RA,Arterial TD catheter,11,Tb = Blood temperature Ti = Injectate temperature Vi = Injectate volume Tb . 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,热稀释方法所得心输出量的计算,12,The area under the thermodilution curve is inversely proportional to the CO.,36,5,37,5,10,Thermodilution curves,Normal CO: 5.5l/min,Introduction to the PiCCO-Technology Thermodilution,36,5,37,36,5,37,Time,low CO: 1.9l/min,High CO: 19l/min,Time,Time,Temperature,Temperature,Temperature,13,经肺 vs. 肺动脉热稀释,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！,14,Transpulmonary thermodilution CO measurement (vs PA thermodilution),Author Bias (L/min) SD r Godje Chest 1998 0.16 0.35 0.96 Sakka ICM 1999 0.68 0.62 0.97 Goedje CCM 1999 0.29 0.60 0.93 Bindels CC 2000 0.49 0.78 0.95 Goedje Chest 2000 0.35 0.72 0.98 Della Rocca BJA 2002 0.15 0.87 0.93 Sander CC 20050.000.70 0.95 Ostergaard AAS 2006 0.46 0.55,15,Pulse contour analysis 脉搏轮廓分析,Cal = calibration factor obtained from transpulmonary thermodilution (cold bolus injection) 校准系数来自经肺热稀释方法,Surface = Cal. x Stroke volume,P (mmHg),t (s),17,Validation of continuous cardiac output measurement by the pulse contour analysis (PiCCO system) PiCCO所得连续心排量数值准确性论证,Roedig G et al. Br J Anaesth 1999; 82: 525-530 Goedje O et al. Ann Thorac Surg 1999; 68: 1532-1536 Buhre W et al. J Cardiothorac Vasc Anesth 1999; 13: 437-440 Goedje O et al. Crit Care Med 1999; 27: 2407-2412 Zollner C et al. J Cardiothorac Vasc Anesth 2000;14: 125-129 Goedje O et al. Med Sci Monit 2001; 7: 1344-1350 Felbinger TW et al. J Clin Anaesth 2002; 14: 296-301 Goedje O et al. Crit Care Med 2002; 30:52-58 Rauch H et al. Acta Anaesthesiol Scand 2002; 46: 426-429 Felbinger et al. J Clin Anaesth 2005; 17: 241-248 Ostergaard et al. Acta Anaesthesiol Scand 2006; 50: 1044-1049,18,PiCCO不仅是 心排量监测仪,19,PiCCO technology,GEDV评估心脏前负荷容量,20,目前医学界判斷心脏前負荷的标准,Centrol venous pressure (CVP) Pulmonary capillary wedge pressure (PCWP) 但是 這是基於以下的假設 “ 压力 = 容量 但這種假設並非完全正確,PULSION Medical Systems,21,Kumar et al., Crit Care Med 2004;32: 691-699,21,灌注压 CVP / PCWP反映前负荷,中心静脉压和每搏输出量的关联,监测前负荷,22,Kumar et al., Crit Care Med 2004;32: 691-699,22,肺动脉嵌压和每搏输出量的关联,Measuring Preload,监测前负荷,灌注压 CVP / PCWP反映前负荷,23,Raper R and Sibbald WJ. Chest 1986 Misled by the wedge ? The Swan-Ganz catheter and left ventricular preload.,24,GEDV可以作为心脏前负荷的指标,Global End-Diastolic Volume evaluated by transpulmonary thermodilution,GEDV,25,CO x MTt = volume of distribution = 1 + 2 + 3 + 4 + 5,3,Indicator injection,Indicator dilution curve,26,CO x MTt = volume of distribution = 1 + 2 + 3 + 4 + 5,3,CO x Dst = largest mixing chamber = 3,Indicator injection,Indicator dilution curve,27,CO x MTt = volume of distribution = GEDV + PBV + EVLW,EVLW,Meier et al. J Appl Physiol 1954,28,Changes in stroke volume index (%),Changes in global end-diastolic volume index (%),r = 0.72 p < 0.001,Transpulmonary thermodilution as a guide to fluid therapy in septic patients with acute circulatory failure. Michard et al. SCCM 2002,29,治疗指南Surviving Sepsis Campaign Guidelines 2008: 灌注压在评估扩容治疗中已经被证实有局限性 . 使用血流量或者容量参数指导容量管理或许更有优势 这些技术已经能够在ICU内实现 ,PiCCO技术,30,Intrathoracic pressure Venous return to left and right ventricle Left ventricular preload Left ventricular stroke volume Systolic arterial blood pressure,Intrathoracic pressure Squeezing “ of the pulmonary blood Left ventricular preload Left ventricular stoke volume Systolic arterial blood pressure,PPmax,PPmin,PPmax,PPmin,吸气,Reuter et al., Ansthesist 2003;52: 1005-1013,容量反映值的生理学意义,呼气,吸气,呼气,吸气早期,吸气晚期,呼吸周期中血压的波动,监测前负荷,31,SVmax,SVmin,SVmean,每搏量变异SVV,每搏量变异（Stroke Volume Variation，SVV）反映了每搏量随通气周期变化的情况。,SVV 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,32,SVV 反映了心脏对因机械通气导致的前负荷周期性变化的敏感性。1,15,18,19,20 SVV 可用于预测扩容治疗对每搏量的提高程度。1,15,18,19,20,对于没有心律失常的完全机械通气病人而言，,每搏量变异 - SVV,33,0 0.5 1,1- specificity,sensitivity,SVV,CVP,0,0.6,0.4,1,0.8,0.2,Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery Berkenstadt H. Margalit N, Hadani M, Friedman Z, Segal E, Vila Y, Perel A . Anesth Analg 2001;92:984-9,sensitivity = 79 % specificity = 93 %,34,心肌收缩状况,FORCE - FREQUENCY RELATION,DIGITALIS, OTHER INONOTROPIC AGENTS,ANOXIA HYPERCAPNIA ACIDOSIS,CIRCULATING CATECHOLAMINES,SYMPATHETIC NERVE IMPULSES,LOSS OF MYOCARDIUM,PHARMACOLOGIC DEPRESSANTS,INTRINSIC DEPRESSION,VENTRICULAR EDV,VENTRICULAR STROKE VOLUME,From Braunwald E et al. Mechanisms of contraction of the normal and failing heart 2nd ed. Boston, Little, Brown, 1976,35,CFI心脏收缩功能指数,TEE FAC,PiCCO CFI,r = 0.80,38,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,39,PiCCO心肌收缩力参数,dPmx 反映了左心室最大压力增加的速度， 是心肌收缩力的参数,40,全心射血分数（GEF） （经肺热稀释导管）,GEF =,GEDV,4 x SV,右心室射血分数（RVEF） （肺动脉热稀释导管）,左心室射血分数（LVEF） （心脏超声）,1,2,&,3,全心射血分数GEF,右心,左心,肺,PBV,EVLW,EVLW,RAEDV,RVEDV,LVEDV,每搏量（SV）,LAEDV,射血分数：与每搏量和舒张末期容积相关,41,EVLW肺水肿指数,42,Extravascular water content of the lung,Pulmonary circulation,Left Heart,Right Heart,Lungs,血管外肺水EVLW在管理前负荷中的作用,EVLW = Extravascular Lung Water,Body circulation,监测前负荷,分辨以及量化肺水肿 仅有的一个在床边获得肺水量化值的方法 对容量过度补充有预警功能,43,44,45,CO x MTtcold = cold indicator volume of distribution,EVLW,CO x MTtICG = ICG volume of distribution,RA,LA,RV,LV,PBV,46,47,EVLW measured with the PiCCO system compared with gravimetrics in dogs with cardiogenic and non-cardiogenic pulmonary edema,Katzenelson et al. SCCM 2002,EVLWPiCCO,EVLWGrav.,48,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 edemar = 0,66 comparison non cardiac edemar = 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: 68X-ray score vs. EVLW*66 % Eisenberg et al, 1987, Am Rev Resp Dis 136: 662X-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,49,监测ELWI能够发现肺水10-15%的增加 X-ray只有在肺水100-300%增长时才能甄别,50,373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,51,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,In critically ill patients for identifying patients with pulmonary edema 针对危重病人，甄别病人是否有肺水肿,In case of doubtful diagnosis based on conventional criteria 尤其当传统的标准产生不确定诊断时,How to use EVLW measurements ? 如何应用EVLW指标？,In critically ill patients for identifying patients with pulmonary edema 针对危重病人，甄别病人是否有肺水肿,In patients with pulmonary edema for diagnosing hydrostatic vs. increased permeability pulmonary edema 针对已经确诊肺水肿的病人， 诊断肺水肿的类型（静水压型，高渗透型）,How to use EVLW measurements ? 如何应用EVLW指标？,54,PiCCO肺相关指标,肺血管通透性指数（Pulmonary Vascular Permeability Index，PVPI）= 血管外肺水（EVLW）与肺血容积（PBV），反映了肺水肿的类型,Pulmonarv Blood Volume,静水压 肺水肿,通透性 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,Extra Vascular Lung Water,In critically ill patients for identifying patients with pulmonary edema 针对危重病人，甄别病人是否有肺水肿,In patients with pulmonary edema for diagnosing hydrostatic vs increased permeability pulmonary edema 针对已经确诊肺水肿的病人， 诊断肺水肿的类型（静水压型，高渗透型）,In ALI/ARDS patients for identifying patients with high degree of pulmonary edema 针对ALI/ARDS的病人群， 从中甄别严重肺水肿的病人,How to use EVLW measurements ? 如何应用EVLW指标？,SVV/PPV GEDV CO EVLW,扩容,继续扩容,停止补液,SVV 和 PPV 预测容量反映,GEDV 监测扩容后实际的有效增加前负荷的量,EVLW 判断肺部对扩容的承受度，避免肺水肿,CO 评估扩容后实际效果,PiCCO技术的价值,指导扩容或者容量限制 尤其是针对ALI/ARDS病人以及循环休克,50,2.3,650 (n= 650-800),9 (n < 10),24,MAP mmHg,CI l/min/m2,GEDVi ml/m2,EVLW ml/kg,PPV %,治疗方案 ? A- 不进行治疗 B- 扩容 C- 正性肌力药物 D- 血管加压药,Patient with septic shock and bilateral pneumonia 感染性休克，双侧肺炎病人,50,2.3,650,9,24,MAP,CI,GEDVi,EVLW,PPV %,扩容,继续扩容,治疗方案 ? A- 不进行治疗 B- 扩容 C- 正性肌力药物 D- 血管加压药,Patient with septic shock and bilateral pneumonia 感染性休克，双侧肺炎病人,50,2.3,650,9,24,MAP,CI,GEDVi,EVLW,PPV %,扩容,继续扩容,16,停止补液 考虑药物治疗,治疗方案 ? A- 不进行治疗 B- 扩容 C- 正性肌力药物 D- 血管加压药,Patient with septic shock and bilateral pneumonia 感染性休克，双侧肺炎病人,60,CO = 12-15 L/min SVR = 400-500 ITBVI = 1200 ml/m2 (800-1000) EVLW = 19-23 ml/kg (4-7),Low !,High !,High !,High !,你会选择扩容治疗吗？,A patient with head injury, severe ARDS and septic shock,积极的利尿 + 去甲肾上腺素!,X,61,谢 谢 ！,