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1、PiCCO连续心排血量测定和容量监测仪,目 录,1.Picco Plus监护仪的外观和组成？2.什么是Picco技术？3.Picco技术有什么优点？4.Picco技术的原理是什么？5.如何使用Picco技术？6.应用Picco技术需要哪些耗材？7.目标销售客户？,1.Picco Plus监护仪的外观和组成,Picco plus主机、温度电缆、压力电缆线、压力转换器、接地线。,Central venous catheter jugular subclavian femoral,PiCCOplus setup,Central venous catheter,Injectate temperatur
2、esensor housing PV4046(included in PV8115),Arterial thermodilution catheter(e.g.PV2015L20),Injectate temperature sensor cable,PULSION disposable pressure transducer,PCCI,AP,13.03 16.28 TB37.0,AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625,Temperature interface cable PC80150,
3、Interface cable forpressure signalPMK-206,AUX-Adaptercable PC81200,PMK XXXConnection cableto bedside monitor,(e.g.PV8115),PC80109,PiCCOplus design Rear panel,PC81200 Adapter cablefor connection of PiCCO plusto bedside vital sign monitor,Potential equalization cable,ON/OFF,serial Interfaceconnection,
4、Mains power connection cable,PMK XXXConnection tobedside monitor,b.动脉脉搏轮廓分析技术（PC）,a.经肺热稀释技术（TPTD）,2.什么是Picco技术,Picco技术由两种技术组成（a+b），用于有效地进行连续的血流动力学监测和容量的治疗。Pulsion公司生产的Picco plus机器将两种技术完美的结合在一起，实现了对于CO的准确和连续的测量。（这是Picco技术的特点之一）,Advanced Thermodilution Curve Analysis,ln Tb,injection,recirculation,MTt,
5、t,e,-1,DSt,Tb,Picco技术的含义之二：通过对热动脉热稀释曲线的进一步分析，得到容量参数和血管外肺水，指导临床容量治疗和呼吸功能的改善。,3.Picco技术有什么优点,Picco能够测量下列参数：热稀释参数：心输出量 CO全心舒张末期容积 GEDV胸腔内血容积 ITBV血管外肺水 EVLW,脉搏轮廓参数：脉搏连续心输出量 PCCO全身血管阻力 SVR每搏量变异 SVV从临床价值区分：1.前负荷参数；2.后负荷参数；3.心肌收缩力参数；4.肺水参数,主要的优点,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,CV,A,B,F,R,No PA-C
6、atheter!,4.Picco技术的基本原理,Picco技术的使用需要插入中心静脉导管，同时使用一条尖端带有热敏电阻的动脉Picco导管。,动脉脉搏波形分析,CV Bolus injection,PULSIOCATH,CALIBRATION,经肺热稀释,Bolus Injection,Lungs,PiCCO Catheter e.g.in femoral artery,经肺热稀释测量需要在中心静脉内注射冷(8C)或者室温(24C)生理盐水,*not available in the USA(p 63),Cardiac output measurement by transpulmonary
7、thermodilution,RA,LA,RV,LV,PBV,EVLW,arterial TD catheter(e.g.PV2015L20),CV bolus injection,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,-,DT,Injection,s,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，描记出经肺热稀释曲线。,Tb,injection,t,Transpulmonary thermodilution:Cardiac Output,Stewart-H
8、amilton method,Tb=血液温度Ti=注射水温度Vi=注射容量 Tb.dt=稀释曲线下面积K=校正常数,（取决于体重，血温和注射水的温度,通过分析热稀释曲线，使用Stewart-Hamilton 方程，计算出CO。,MTt:平均通过时间Mean transit time探测到指示剂通过时间的一半,DSt:下坡时间Downslope time 热稀释曲线的下坡时间指数,通过对热稀释曲线的进一步分析，可以得到很多容量参数。,PTV,RAEDV,LAEDV,LVEDV,RVEDV,PTV=PBV+EVLW,ITBV=PBV+RAEDV+RVEDV+LAEDV+LVEDV,EVLW,EVL
9、W=ITTV-ITBV(?),ITTV,ITTV=CO*MTtTDa,PTV=CO*DStTDa,ITBV=1.25*GEDV,EVLW*=ITTV-ITBV,GEDV=ITTV-PTV,RAEDV,RVEDV,LAEDV,LVEDV,RAEDV,RVEDV,LAEDV,LVEDV,PTV,PTV,Calculation of volumes-Summary,*not available in the USA(p 63),Global Enddiastolic Volume(GEDV)是心脏4个腔室内的血液容量。,PTV,RAEDV,LAEDV,LVEDV,RVEDV,GEDV,GEDV=IT
10、TV-PTV,ITTV,GEDV is calculated by subtraction of PTV from ITTV.,Intrathoracic Blood Volume(ITBV)是心脏4个腔室的容积+肺血管内血液容量(PBV).,ITBV=PBV+GEDV,RAEDV,Therefore it is possible to compute ITBV based on measurement of GEDV:ITBV=1,25 x GEDV,ITBVTD(ml),r=0.96,ITBV=1.25*GEDV 28.4 ml,GEDV vs.ITBV in 57 intensive c
11、are patientsSakka et al,Intensive Care Med 26:180-187,2000,EVLW*,ITBV,ITTV,Extravascular Lung Water(EVLW*)代表的是肺内含有的水量。可以在床旁定量判断肺水肿的程度。,*not available in the USA(p 63),胸腔内血容积（ITBV）和全心舒张末期容积（GEDV）在反映心脏前负荷的敏感性和特异性方面，很多临床研究证实比心脏充盈压力CVP和PCWP有更好的临床价值。ITBV和GEDV的最主要优点是它们不会受到机械通气的影响而产生较大的偏差，因此在这些病人，能够给出更加准确的
12、容量信息。血管外肺水（EVLW）通过经肺热稀释法得到，已经被染料稀释法和重量法证实。血管外肺水（EVLW）在当前的很多报道中发现与ARDS的严重程度、病人机械通气的天数、住ICU的时间以及死亡率等明确相关，其评估肺水肿远远优于胸部X线。,动脉脉搏轮廓分析通过动脉压力波形的形状获得连续的每搏参数,Calibration,Reference CO value from thermodilution,Measured blood pressure(P(t),MAP,CVP),在经过经肺热稀释测量的CO进行系统校正以后，系统根据脉搏波形的曲线下面积，自动计算出每搏量stroke volume(SV)。
13、,心输出量和全身血管阻力由于脉搏轮廓连续测量每搏量和动脉压，可以如下计算得到心输出量(CO)和全身血管阻力(SVR)：CO=每搏量*心率SVR=（平均动脉压-中心静脉压）/CO,SVmax,SVmin,SVmean,SVmax SVmin,SVV=,SVmean,SVV每搏量变异指数用于判定机械通气患者容量负荷的情况,测定每搏量变异指数(SVV),1.首先熟悉仪器与导管的规格型号和操作步骤（详见说明书）2.插入CVC导管，连接温感探头，并与机器连接。3.插入picco动脉导管，连接测压管路。4.观察压力波形，调整仪器，如果要把血压信号传输到床旁监护仪上，请利用Picco后面板上的电缆接口和相应
14、的电缆线。5.准备冷注射液测定心排血量。6.校正脉搏轮廓心排血量，需要完成3次温度稀释心排血量测定。,应用步骤:,5.如何使用Picco技术,6.应用Picco技术需要哪些耗材？,PULSIOCATH动脉热稀释导管 专门实际用于容量、血流动力监测，创伤小 使用Seldinger穿刺技术（导丝穿刺技术）提供用于儿童和成人的型号 可以在病人体内保留10天以上温度感受三通压力传感器中心静脉导管,radial artery,femoral artery,axillary artery(brachial artery),PV2014L08 4F 8 cm,PV2015L20 5F 20 cm,PV201
15、4L50LGWA 4F 50 cm,PV2013L07*3F 7 cm,PV2014L08*more than 10 kg body weight,*for application in paediatric patients,Dilator,Thermodilution-connector,Guidewire,20G,2 Cannulas,18G,Pressure lumen,Example of a PULSIOCATH PV2015L20,PiCCO PULSIOCATH,Content:,Input menu(II),Arterial CatheterConstant(ACC)and
16、the Injectate temperature SensorHousing will be detected automatically,if the PULSIOCATH is connected,24C=room temp.injectate 8 C=cold injectate,Patient,Weight,Height,Catheter type,PV 2015L20,Injectate temp sensor,Injectate temperature,Inj Vol(min.15ml),CVP,Range PCCO,Range AP,Warning PCCO,201000200
17、,75.0 kg,175 cm,ACC:342,PV,24 C,15 ml,10 mmHg,0.10 l/min,60.160 mmHg,0.2.8.6 l/min,INPUT,4046,0 10s 20s,0 10s 20s,0 10s 20s,09.12 15:33 TB37.0,TIME ST CI CFI GEDI ELWI,T 0.31/TI 12,15:05 0 2.92 5.0 489,11:59 0 3.24 5.0 450,15:06 0 3.15 5.0 520,15:29 2.96 480,117,71,AP,97,12,(CVP),(GEDI),SVRI,CI,HR,S
18、VI,SVV,dPmx,PC,2157,2.38,78,38,8%,1530,479,0 10s 20s,Most important data from the thermodilution,Continuous Cardiac Output(PCCO)(mean value of thelast 12 seconds),values from the thermodilution,continuous values,Stroke Volume Variation(SVV),ELWI=Extravascular lung water index,CI=Cardiac index,GEDI=G
19、lobal end diastolic volume index,CFI=CardiacFunction Index,2.96 5.0 480,201000200,0,8,8,MW,8,8,8,5.0,orGEF=GlobalEjection Fraction,ITBI=Intrathoracic blood volume index,or,117,71,09.12 15:33 TB37.0,AP,97,12,(CVP),(GEDI),SVRI,CI,SVI,SVV,dPmx,PC,2157,2.38,78,38,8%,1530,479,HR,.Normal,-Result at 15:30,
20、10,8,6,4,2,0,42,26,18,10,3000,2400,1800,1200,600,0,20,16,12,8,4,0,50,Contractility,CFI,GEF,dPmx,SVV,0 10s 20s,117,71,09.12 15:33 TB37.0,AP,97,12,(CVP),(GEDI),SVRI,CI,SVI,SVV,dPmx,PC,2157,2.38,78,38,8%,1530,479,HR,.Normal,-Result at 15:30,6.0,4.8,2.4,1.2,0.0,80,60,40,20,0.0,160,128,96,64,32,0.0,4000,
21、3200,2400,1600,800,0.0,100,Output,Afterload,CI,SVI,MAP,SVRI,3.6,Patient profile screen(I),1.Output/Afterload,2.Contractility,A bar marks the value of the parameter at the point of time of the last calibration,34,201000200,201000200,The hatched areas display the patient specific normal ranges,正常值,参数范围单位CI3.0 5.0l/min/m2SVI40 60ml/m2 SVRI1200 1800 dyn*s*cm-5*mMAP70 90mmHgGEF25 35%CFI4.5 6.51/minHR60 901/minGEDVI680 800ml/m2ITBVI850 1000ml/m2SVV 10%EVLWI 3.0 7.0ml/kgPVPI1.0 3.0,7.目标销售客户,麻醉科ICU（烧伤、综合、外科）心内科、CCU呼吸内科、RICU小儿科、PICU急诊科、EICU,PCCO值,容量值ITBV,GEDV,ITTV,EVLW,麻醉科,小儿科,烧伤科,ICU,CCU,呼吸内科,
