血流动力学监测PICCO杜斌.pptx

血流动力学监测增加患者病死率Connors AF Jr,Speroff T,Dawson NV,Thomas C,Harrel FE Jr,Wagner D,Desbjens N,Goldman L,Wu AW,Califf RM,Fulkerson WJ Jr,Vidaillet H,Broste S,Bellamy P,Lynn J,Knaus WA.The effectiveness of right heart catheterization in the initial care of critically ill patients.SUPPORT Investigators.JAMA 1996;276(11):889-897 第1页/共110页血流动力学监测为何不能改善预后不恰当的适应症PAC的副作用或并发症获得数据的方法不正确仪器定标错误,或传感器位置错误获得的数据不能反映血流动力学状态错误使用数据(对数据的解读错误)作出治疗决定前未考虑其他相关因素CXR,尿量,血清白蛋白采用的治疗措施无效或有害无需血流动力学监测时未及时拔除PAC第2页/共110页PAC的使用减少:Illinois,USA2000年年2001年年降低降低%出院患者数1,636,0461,684,089PAC使用数5,9695,02215.8PAC使用率(/1000)3.652.98年龄0 17岁2195765 74岁1,7391,37521 75岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterization has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132)第3页/共110页临床评价 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第5页/共110页临床评价 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第6页/共110页临床评价 vs.血流动力学结果留置PAC后计划治疗方案需要改变58%应用未预计到的治疗方案30%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第7页/共110页临床评价 vs.血流动力学结论单纯根据临床表现难以准确预测血流动力学指标PAC监测数据通常能够改变治疗方案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第8页/共110页血流动力学参数改变治疗决定Squara P,Bennett D,Perret C.Pulmonary artery catheter:does the problem lie in the users?Pulmonary artery catheter:does the problem lie in the users?Chest 2002;121:2009-2015第12页/共110页ICU患者的输液治疗输液治疗的决定因素临床经验中心静脉压或肺动脉楔压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第13页/共110页临床判断缺乏准确性:PAWP01015191915100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):549-553No change in planned therapy after catheterizationChange in planned therapy after catheterization第14页/共110页0临床判断缺乏准确性:CO04.57.0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):549-5534.57.0第15页/共110页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):549-553参数参数判断正确数目判断正确数目/测定数目测定数目正确率正确率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855第16页/共110页How good are our clinical skills?Cardiac outputWedge pressureConnors(NEJM 83)ICU pts44%42%Eisenberg(CCM 84)ICU pts50%33%Bayliss(BMJ 83)CCU pts71%62%第17页/共110页临床重要的血流动力学参数所有医生所有医生(n=417)心内科医生心内科医生(n=27)CO330(79%)21(75%)PAWP285(68%)27(100%)SvO2220(53%)10(38%)MPAP120(37%)10(38%)SV100(24%)3(13%)RAP20(5%)RVEF20(5%)RVEDV18(4%)Squara P,Bennett D,Perret C.Pulmonary artery catheter:does the problem lie in the users?Pulmonary artery catheter:does the problem lie in the users?Chest 2002;121:2009-2015第21页/共110页心脏手术后患者的血流动力学监测问卷调查(39个问题)血流动力学监测容量替代正性肌力药物/升压药物输血德国的80个ICU主任问卷回收率69%Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.第22页/共110页心脏手术后患者的血流动力学监测血流动力学监测血流动力学监测比例比例(%)基本监测100肺动脉导管(PAC)58.2经食道超声(TEE)38.1PICCO13.0Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.第23页/共110页英格兰与威尔士ICU的CO监测技术Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)第24页/共110页英格兰与威尔士ICU的CO监测技术CO监测技术 2种69%首选经食道多普勒监测CO41%常规监测ScvO220%Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)第25页/共110页Are We Using PAC Correctly?第26页/共110页PAWP测定中的技术问题Morris AH,Chapman RH,Gardner RM.Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure.Crit Care Med 1984;12(3):164-170N(%)measurements%of technical problemsNo problem1868(69)Technical problems843(31)Criterion 1(total)(12)(38)Unable to obtain an“atrial waveform”1238Criterion 2(total)156(6)19WP waveform intermediate between the phasic PA and atrial waveforms100(4)12Spontaneous variation of WP56(2)7Criterion 3(total)381(14)45Poor dynamic response184(7)22Damped tracing65(2)8Overinflation42(2)5Cannot aspirate blood with the catheter in the PA36(1)4Cannot aspirate blood with the catheter in the wedge position54(2)6第27页/共110页PAWP测定中的技术问题Morris AH,Chapman RH,Gardner RM.Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure.Crit Care Med 1984;12(3):164-170WPTechnical ProblemCorrected byInitialConfirmed228OverinflationDeflated balloon812Venous bloodAdvance 2 cm308Venous bloodWithdrawn156Venous bloodNothing812Poor dynamic responseWithdrawn 4 cm248Poor dynamic responseDeflated and inflated balloon2313Poor dynamic responseWithdrawn128Poor dynamic responseFlushed3618Partial WPPatient coughed214Partial WPRepositioned720Partial WPNothing1420?RepositionedWP initial WP confirmed=11 6 mmHgRange(-13,+22)第28页/共110页ICU医生缺乏PAC的相关知识目的:评价欧洲国家ICU医生对PAC相关知识的了解程度设计:调查问卷背景:86个欧洲大学及非大学医院ICU对象:从两个欧洲危重病医学会目录中选取134个ICU.其中86个ICU的535名医生参加问卷调查干预:在每个ICU中,所有医生均被要求同时完成一项调查问卷,包括31个多选题,涉及床旁留置PAC的所有方面Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220第31页/共110页ICU医生缺乏PAC的相关知识Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220PAC相关知识调查问卷的内容分类1压力或心输出量测定的技术问题2相关指标的计算3血流动力学指标的解读4留置导管5导管相关并发症的识别,预防及治疗6应用PAC指导治疗7其他第32页/共110页ICU医生缺乏PAC的相关知识In-TrainingPostgraduate Training CompletedPrimary Medical SpecialtyAnesthesiology69.9 13.777.0 12.6Internal Medicine67.9 14.378.3 11.5Others62.4 16.369.8 15.2Opinion of Respondents on Their Knowledge of PACsInadequate57.6 15.355.0 17.3Minimal65.7 14.371.9 14.1Adequate73.2 13.179.2 10.7Superfluous-83.3 0Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220第33页/共110页Is There an Easy Alternative to This Dilemma?第37页/共110页Central venous catheterInjectate temperature sensor housing PV4046 Arterial thermodilution catheter Injectate temperature sensor cablePC80109 PULSION disposable pressure transducer PV8115PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625 DPT Monitor cablePMK-206Interface cablePC80150 Connection cableto bedside monitorPMK-XXX AUX adaptercable PC81200 第38页/共110页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第39页/共110页心输出量的测定:经肺热稀释技术中心静脉内注射指示剂后,动脉导管尖端的热敏电阻测量温度下降的变化曲线通过分析热稀释曲线,使用Stewart-Hamilton公式计算得出心输出量(CO)Tb注射t第40页/共110页心输出量的测定:经肺热稀释技术经肺热稀释测量只需要在中心静脉内注射冷(8C)或室温(24C)生理盐水中心静脉注射右心左心肺PiCCO导管如插在股动脉内第41页/共110页热稀释法测定CO:PiCCO vs.PACPCCO动脉热稀释测量位置静脉注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常规热稀释测量位置s010203040500,00,20,40,6C-D DT注射注射热稀释测量曲线Tb=血流温度Ti =注射指示剂温度Vi =注射指示剂容积 Tb.dt=热稀释曲线下面积K=校正系数第42页/共110页动脉脉搏轮廓分析动脉脉搏轮廓分析通过动脉压力波型的形状获得连续的每搏参数通过经肺热稀释法的初始校正后,该公式可以在每次心脏搏动时计算出每搏量(SV)t sP mm HgSV第43页/共110页连续心输出量测定:PiCCO压力曲线下面积压力曲线型状PCCO=cal HR SystoleP(t)SVR+C(p)dPdt()dt动脉顺应性参数心率与病人有关的校正因子 t sP mm HgPCCO is displayed as last 12s mean第44页/共110页心输出量的测定:PiCCO vs.热稀释AuthorPt/ObsCOTDa COTDpaBias SDrVon Spiegel,et al.Anaesthesist 1996;45(11)21/48-4.7 1.5%.97McLuckie,et al.Acta Paediatr 1996;859/?0.19 0.21 L/min/m2Goedje,et al.Chest 1998;113(4)30/1500.16 0.31 L/min/m2.96Goedje,et al.Thorac Cardiovasc Surg 1998;4630/8100.26 0.71 L/min.96Zoolner,et al.Anaesthesist 1998;47(11)18/1600.03 1.04 L/min.91Goedje,et al.Crit Care Med 1999;27(11)24/216-0.29 0.66 L/min.93Sakka,et al.Intensive Care Med 1999;2537/4490.68 0.62 L/min.97Sakka,et al.J Cardiothorac Vasc Anesth 2000;14(2)12/510.73 0.38 L/min.96Zoolner,et al.J Cardiothorac Vasc Anesth 2000;14(2)19/760.21 0.73 L/min.96Bindels,et al.Crit Care 2000;445/2830.49 0.45 L/min/m2.95第45页/共110页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第46页/共110页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MTtte-1DStc(I)第47页/共110页全心舒张末期容积(GEDV)全心舒张末期容积(GEDV)是心脏4个腔室内的血容量第48页/共110页胸腔内血容积(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第49页/共110页血管外肺水(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第50页/共110页容量的测量原理ln c(I)注射At再循环的影响MTtte-1DStc(I)MTt:Mean transit time平均传输时间平均传输时间 half of the indicator passed the point of detection DSt:Downslope time下降时间下降时间 exponential downslope time of TD curve第51页/共110页容量的测量原理Vall=V1+V2+V3+V4 =MTt x FlowMeier et al.J Appl Physiol.1954V3=最大腔的容积 =DSt x FlowNewman et al.Circulation.1951指示剂由注射点到检测点的平均传输时间MTt由两点间的总容积决定下降时间DSt由其中最大的腔室决定(比其它腔至少大 20%成立!)flowV3V4V2V1注射检测第52页/共110页胸腔内的容积组成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV=肺内热容积肺内热容积,在一系列混合腔室中具有最大的热容积在一系列混合腔室中具有最大的热容积(DSt 容积容积)ITTV=胸腔内总热容积胸腔内总热容积,从注射点到测量的热容积之和从注射点到测量的热容积之和(MTt 容积容积)GEDV=全心舒张末期容积全心舒张末期容积=ITTV PTV第53页/共110页容量的测量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔总热容积(ITTV)ITTV=CO x MTtTDa肺内总热容积(PTV)PTV =CO x DStTDa全心舒张末期容积GEDV=ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPTVPTV第54页/共110页ITBV的测量原理Sakka et al,Intensive Care Med 2000;26:180-187ITBV=1.25*GEDV 28.4 mlr=0.96ITBVTD(ml)GEDVST(ml)GEDV vs.ITBV in 57 intensive care patients第55页/共110页ITBV准确性的临床验证Sakka et al,Intensive Care Med 26:180-187,2000n=209r=0.97Bias=-7.6 ml/m2SD=57.4 ml/m2ITBVIST vs.ITBVITD in 209 intensive care patients第56页/共110页容量测量小结ITTV=CO x MTtTDaPTV =CO x DStTDaITBV=1.25 x GEDVGEDV=ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTV第57页/共110页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ITBV和GEDV不但优于CVP及PAWP,也优于RVEDVITBV和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经由GEDV和SV计算得到的全心射血分数(GEF),在一定程度上反映了心肌收缩功能GEF=4 x SV/GEDV第58页/共110页容量负荷反应组与无反应组的CVP第59页/共110页扩容治疗前的肺动脉楔压PAOP(mmHg)有反应者有反应者无反应者无反应者Calvin et al8 17 2Schneider et al10 110 1Reuse et al10 410 3Diebel et al14 77 2 Diebel et al16 615 5Wagner and Leatherman10 314 4 Tavernier et al10 412 3Tousignant et al12 316 3 Michard et al10 311 2 p 100%时,胸片才会发生改变Bongard FS,Surgery 1984胸片对EVLW的改变并不敏感Helperin BD,Chest 1984确定患者是否符合ARDS影像学表现时,医生之间存在非常明显的差异Rubenfeldet al,Chest 1999第74页/共110页容量测量小结ITTV=CO x MTtTDaPTV =CO x DStTDaITBV=1.25 x GEDVEVLW=ITTV ITBVGEDV=ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLW第75页/共110页EVLW:PiCCO vs.重力法测定Sturm,In:Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin-Heidelberg-NewYork 1990,pp 129-139第76页/共110页血管外肺水的临床验证Sakka et al,Intensive Care Med 26:180-187,2000Bias=-0.2 ml/kgSD=1.4 ml/kgn=209r=0.96EVLWIST vs.EVLWITD in 209 intensive care patients第77页/共110页减少血管外肺水:临床试验Mitchell et al,Am Rev Resp Dis 145:990-998,1992第78页/共110页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线肺血管通透性指数(PVPI)一定程度上反映了肺水肿形成的原因PVPI=EVLW/PBV第79页/共110页隐匿性肺水肿的检测指标指标EVLW增加增加临床症状100 200%胸片100 200%氧合(机械通气时)300%EVLW(PiCCO)10 15%第80页/共110页原发性与继发性ARDS/ALI的鉴别患者人群(n=10)原发性ARDS/ALI(n=4):肺炎,误吸继发性ARDS/ALI(n=6):全身性感染评价指标ITBVIEVLWIPVPI(EVLW/ITBV)Morisawa K,Taira Y,Takahashi H,Matsui K,Ouchi M,Fujinawa N,Noda K.Do the data obtained by the PiCCO system enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS?Critical Care 2006,10(Suppl 1):P326(doi:10.1186/cc4673)第81页/共110页原发性与继发性ARDS/ALI的鉴别Morisawa K,Taira Y,Takahashi H,Matsui K,Ouchi M,Fujinawa N,Noda K.Do the data obtained by the PiCCO system enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS?Critical Care 2006,10(Suppl 1):P326(doi:10.1186/cc4673)直接直接ARDS/ALI间接间接ARDS/ALIP值值ITBVI984 331.71279 312.10.0001EVLWI13.2 4.716.8 6.50.014PVPI0.59 0.270.44 0.220.006第82页/共110页SIRS及ARDS:肺血管通透性与肺水肿PVPISIRS组(n=31)2.37 1.0ARDS组(n=13)3.2 1.10非ARDS组(n=18)1.7 0.44非SIRS组(n=10)1.2 0.21Tagami T,Kushimoto S,Atsumi T,Matsuda K,Miyazaki Y,Oyama R,Koido Y,Kawai M,Yokota H,Yamamoto Y.Investigation of the pulmonary vascular permeability index and extravascular lung water in patients with SIRS and ARDS under the PiCCO system.Critical Care 2006;10(Suppl 1):P352(doi:10.1186/cc4699)第83页/共110页血管外肺水的测定胸片,氧合障碍及PAWP与EVLW之间的相关性很差床旁测定EVLW为危重病患者的诊断,随访及治疗评估提供了新的方法第84页/共110页PiCCO技术问题第85页/共110页热稀释法测定心输出量目的:确定热稀释法一次测定心输出量是否准确方法:回顾分析18名神经外科ICU患者共417次测定,1465次操作ANOVA分析Wolf S,Plev D,Schrer L,Lumenta C.The repeatability of transpulmonary thermodilution measurements.Critical Care 2004;8(Suppl 1):P57(DOI 10.1186/cc2524)第86页/共110页热稀释法测定心输出量差值中位数差值中位数两次测定两次测定95%可重复系数可重复系数相当于正常相当于正常值百分比值百分比CI(L/min)0.30.7248%ITBVI(ml/m2)80270180%EVLWI(ml/kg)13.587%Wolf S,Plev D,Schrer L,Lumenta C.The repeatability of transpulmonary thermodilution measurements.Critical Care 2004;8(Suppl 1):P57(DOI 10.1186/cc2524)第87页/共110页热稀释法测定心输出量目的:确定热稀释法测定心输出量时2次测定与3次测定的准确性方法:回顾分析2年期间PiCCO监测的所有数据共25名感染性休克患者共249次心输出量测定比较前2次(M1)与3次测定心输出量(M2)的平均值Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two injections enough?Critical Care 2007;11(Suppl 2):P293第88页/共110页热稀释法测定心输出量Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two injections enough?Critical Care 2007;11(Suppl 2):P293CI(L/min/m2)M13.28 1.07M25.74 1.0743%第89页/共110页热稀释法测定心输出量结论采用PiCCO进行监测时,2次热稀释法显然不足以可靠地测定心输出量Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two injections enough?Critical Care 2007;11(Suppl 2):P293第90页/共110页中心静脉插管部位的影响Schmidt S,Westhoff TH,Hofmann C,Schaefer J-H,Zidek W,Compton F,van der Giet M.Effect of the venous catheter site on transpulmonary thermodilution measurement variables.Crit Care Med 2007;35:783-786颈内静脉vs.股静脉第91页/共110页中心静脉插管部位的影响人口统计学资料人口统计学资料M SD范围范围性别男8,女3年龄,岁58.7 17.521 74身高,cm174.9 7.9165 185体重,kg75.5 10.265 90体表面积,m21.90 0.151.73 2.14SAPS II51.3 10.136 61Schmidt S,Westhoff TH,Hofmann C,Schaefer J-H,Zidek W,Compton F,van der Giet M.Effect of the venous catheter site on transpulmonary thermodilution measurement variables.Crit Care Med 2007;35:783-786第92页/共110页中心静脉插管部位的影响心肺指标心肺指标M SD范围范围HR,bpm88.5 17.966 124MAP