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1、血流动力学监测,Theory and Practice,血流动力学,Swan和Ganz发明通过血流引导的气囊漂浮导管（漂浮导管 或 Swan-Ganz 导管 或 肺动脉导管）继中心静脉压（CVP）之后临床监测的一大新进展,Dr.William Ganz(1919-2009.11.10),Swan-Ganz 导管,通过热稀释法获得心排 假设 PCWP(肺毛细血管嵌压)LAP（左房压）LVEDP(左室舒张末压)LVEDV(左室舒张末容量)相 当于前负荷来通过压力指标来反映容量状态,经食管超声技术（TEE）,原理物体（红细胞）移动的速度和已知频率超声波的反射频率成正比 HemoSonicTM100的
2、超声多普勒探头 通过测定红细胞移动的速度来推算降主动脉的血流量,TEE,优势：准确性高 降主动脉的血流量是CO的70%劣势：误差多，对操作者经验要求高，需严格培训，费用高,7,监测生命体征,Monitoring,Respiration Rate,Temperature,8,一些重要的指标,Monitoring,Blood Pressure(NiBP),no correlation with CO no correlation with oxygen delivery,ECG,Respiration Rate,Temperature,PiCCO Technology,液体管理所需要的指标,Int
3、roduction to the PiCCO-Technology,CO,前负荷,EVLW,收缩力指数,个性化的容量管理,static-dynamic,PiCCO 技术监测,功能原理热稀释技术脉搏轮廓分析技术收缩力指数前、后负荷参数血管外肺水肺部通透性指数,血流动力学监测,PiCCO 技术 依据经肺热稀释技术以及脉搏轮廓分析技术,原理,Left Heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATH arterial thermodilution ca
4、theter,central venous bolus injection,Introduction to the PiCCO-Technology Function,Bolus injection,concentration changes over time(Thermodilution curve),中心静脉处注入冰盐水，依次经过胸腔内各腔室,股动脉导管内有热敏电阻，会记录温度的变化,Introduction to the PiCCO-Technology Function,Left heart,Right heart,Lungs,原理,胸腔内各腔室,Introduction to th
5、e PiCCO-Technology Function,肺内热容积(PTV),胸腔内热容积(ITTV),Total of mixing chambers,最大混合腔室,血流动力学监测,Introduction to PiCCO Technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,Tb x dt,(Tb-Ti)x Vi x K,Tb,Injection,t,D,=,COTD a,Tb=Blood temperatureTi=Injectate temperatureVi=Injectate volume Tb.dt=Area under the
6、thermodilution curveK=Correction constant,made up of specific weight and specific heat of blood and injectate,CO的计算是通过对热稀释曲线分析，使用 Stewart-Hamilton 方程式,心排的计算,Introduction to the PiCCO-Technology Thermodilution,热稀释曲线下面积反比例反映CO,36,5,37,5,10,热稀释曲线,Normal CO:5.5l/min,Introduction to the PiCCO-Technology
7、Thermodilution,36,5,37,36,5,37,Time,low CO:1.9l/min,High CO:19l/min,Time,Time,Temperature,Temperature,Temperature,经肺热稀释 vs.肺动脉导管,Left heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH arterial thermo-dilution catheter,central venous bolus injection,RA,RV,PA,LA,LV,Aorta,Transp
8、ulmonary TD(PiCCO),Pulmonary Artery TD(PAC),In both procedures only part of the injected indicator passes the thermistor.Nonetheless the determination of CO is correct,as it is not the amount of the detected indicator but the difference in temperature over time that is relevant!,Introduction to the
9、PiCCO Technology Thermodilution,Comparison with the Fick Method,0,97,0,68 0,62,37/449,Sakka SG et al.,Intensive Care Med 25,1999,-/-,0,19 0,21,9/27,McLuckie A.et a.,Acta Paediatr 85,1996,0,96,0,16 0,31,30/150,Gdje O et al.,Chest 113(4),1998,0.98,0,32 0,29,23/218,Holm C et al.,Burns 27,2001,0,93,0,13
10、 0,52,60/180,Della Rocca G et al.,Eur J Anaest 14,2002,0,95,-0,04 0,41,17/102,Friedman Z et al.,Eur J Anaest,2002,0,95,0,49 0,45,45/283,Bindels AJGH et al.,Crit Care 4,2000,0,98,0,03 0,17,18/54,Pauli C.et al.,Intensive Care Med 28,2002,24/120,n(Pts/Measurements),0,99,0,03 0,24,Tibby S.et al.,Intensi
11、ve Care Med 23,1997,r,bias SD(l/min),Comparison with Pulmonary Artery Thermodilution,经肺热稀释技术的有效性,Introduction to the PiCCO Technology Thermodilution,MTt:Mean Transit time the mean time required for the indicator to reach the detection point,DSt:Down Slope time the exponential downslope time of the t
12、hermodilution curve,Recirculation,t,e-1,Tb,From the characteristics of the thermodilution curve it is possible to determine certain time parameters,对热稀释曲线做进一步分析,Introduction to the PiCCO-Technology Thermodilution,Injection,In Tb,MTt,DSt,Tb=blood temperature;lnTb=logarithmic blood temperature;t=time,
13、Pulmonary Thermal VolumePTV=Dst x CO,By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated,计算 ITTV 与 PTV,Introduction to the PiCCO-Technology Thermodilution,Recirculation,t,e-1,Tb,Injection,In Tb,Intrathoracic Thermal VolumeITTV=MTt x CO,MTt,DSt,Pulmona
14、ry Thermal Volume(PTV),Intrathoracic Thermal Volume(ITTV),Calculation of ITTV and PTV,Einfhrung in die PiCCO-Technologie Thermodilution,ITTV=MTt x CO,PTV=Dst x CO,GEDV is the difference between intrathoracic and pulmonary thermal volumes,Global End-diastolic Volume(GEDV),Volumetric preload parameter
15、s GEDV,ITTV,GEDV,PTV,Introduction to the PiCCO Technology Thermodilution,Volumetric preload parameters ITBV,Intrathoracic Blood Volume(ITBV),GEDV,ITBV,PBV,Introduction to the PiCCO Technology Thermodilution,ITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary ve
16、ssels(PBV),ITBVTD(ml),ITBV=1.25*GEDV 28.4 ml,GEDV vs.ITBV in 57 Intensive Care Patients,Intrathoracic Blood Volume(ITBV),Introduction to the PiCCO-Technology Thermodilution,ITBV is calculated from the GEDV by the PiCCO Technology,GEDV(ml),Sakka et al,Intensive Care Med 26:180-187,2000,Summary and Ke
17、y Points-Thermodilution,PiCCO 技术是一种微创的方法，用以监测容量状态和心血管功能 根据经肺热稀释技术可以计算出各种容积参数.CO 由热稀释曲线形状描记.心脏前负荷相关的容积参数可以通过对热稀释曲线进一步分析获得。,Introduction to the PiCCO-Technology,Haemodynamic Monitoring,Introduction to PiCCO Technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,Transpulmonary Thermodilution,The pulse cont
18、our analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve,Calibration of the Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,Injection,Pulse Contour Analysis,T=blood temperature t=ti
19、meP=blood pressure,COTPD,=SVTD,HR,PCCO=cal HR,P(t),SVR,+C(p),dP,dt,(,),dt,Cardiac Output,Heart rate,Systole,Introduction to the PiCCO-Technology Pulse contour analysis,Parameters of Pulse Contour Analysis,n(Pts/Measurements),0,94,0,03 0,63,12/36,Buhre W et al.,J Cardiothorac Vasc Anesth 13(4),1999,1
20、9/76,24/517,62/186,20/360,25/380,22/96,-/-,-0,40 1,3,Mielck et al.,J Cardiothorac Vasc Anesth 17(2),2003,0,88,0,31 1,25,Zllner C et al.,J Cardiothorac Vasc Anesth 14(2),2000,0,88,-0,2 1,15,Gdje O et al.,Crit Care Med 30(1),2002,0,94,-0,02 0,74,Della Rocca G et al.,Br J Anaesth 88(3),2002,0,93,-0,14
21、0,33,Felbinger TW et al.,J Clin Anesth 46,2002,-/-,0,14 0,58,Rauch H et al.,Acta Anaesth Scand 46,2002,r,bias SD(l/min),Comparison with pulmonary artery thermodilution,Validation of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse contour analysis,SVmax SVmin,SVV=,SVmean,The Stroke
22、Volume Variation is the variation in stroke volume over the ventilatory cycle,measured over the previous 30 second period.,Parameters of Pulse Contour Analysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Stroke Volume Variation,The increase
23、 of preload volume is equal:EDV1=EDV2 SV1 SV2,SVV 提示心脏对容量治疗的反应好坏,EDV,SV,SVV small,SVV large,EDV1,EDV2,SV1,SV2,PPmax PPmin,PPV=,PPmean,The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle,measured over the previous 30 second period.,Parameters of Pulse Contour An
24、alysis,Introduction to the PiCCO-Technology Pulse Contour Analysis,Dynamic parameters of volume responsiveness Pulse Pressure Variation,PPmax,PPmean,PPmin,Summary pulse contour analysis-CO and volume responsiveness,PiCCO脉搏轮廓分析技术是由经肺热稀释技术计算进一步获得PiCCO 技术分析动脉压力曲线每次的搏动，可以提供实时的参数 CO之外，反映容积相关的血流动力学参数SVV(s
25、troke volume variation)和PPV(pulse pressure variation)可以持续获得,Introduction to the PiCCO-Technology Pulse contour analysis,Haemodynamic Monitoring,Introduction to PiCCO Technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,Contractility is a measure for the performance of the heart muscle,Contractility pa
26、rameters of PiCCO technology:dPmx(maximum rate of the increase in pressure)GEF(Global Ejection Fraction)CFI(Cardiac Function Index),Contractility,Introduction to the PiCCO-Technology Contractility parameters,kg,Contractility parameter from the pulse contour analysis,Introduction to the PiCCO-Technol
27、ogy Contractility parameters,dPmx=maximum velocity of pressure increase,The contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.,Contractility parameter from the pulse contour analysis,Introduction to the PiCCO-Technology Contractility parameters,femora
28、l dP/max mmHg/s,LV dP/dtmax mmHg/s,dPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients,de Hert et al.,JCardioThor&VascAnes 2006,n=220y=-120+(0,8*x)r=0,82p 0,001,0,500,1000,1500,0,1000,1500,2000,2000,500,dPmx=maximu
29、m velocity of pressure increase,is calculated as 4 times the stroke volume divided by the global end-diastolic volume reflects both left and right ventricular contractility,GEF=Global Ejection Fraction,Contractility parameters from the thermodilution measurement,Introduction to the PiCCO-Technology
30、Contractility parameters,4 x SV,GEF=,GEDV,LA,LV,RA,RV,Combes et al,Intensive Care Med 30,2004,GEF=Global Ejection Fraction,Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1 specifity,22,
31、20,19,18,16,12,8,D FAC,%,D GEF,%,5,10,-5,-20,-10,10,20,15,-15,-10,r=076,p0,0001n=47,Introduction to the PiCCO-Technology Contractility parameters,Contractility parameters from the thermodilution measurement,is the CI divided by global end-diastolic volume index is-similar to the GEF a parameter of b
32、oth left and right ventricular contractility,CFI=Cardiac Function Index,CI,CFI=,GEDVI,Introduction to the PiCCO-Technology Contractility parameters,Contractility parameters from the thermodilution measurement,Combes et al,Intensive Care Med 30,2004,sensitivity,0,0,4,0,6,0,8,0,1,0,2,0,2,0,4,0,6,0,8,1
33、 specificity,6,5,4,3,5,3,2,D FAC,%,D GEF,%,5,10,-5,-20,-10,10,20,15,-15,-10,r=079,p0,0001n=47,CFI=Cardiac Function Index,Introduction to the PiCCO-Technology Contractility parameters,CFI was compared to the gold standard TEE measured contractility in patients without right heart failure,Contractilit
34、y parameters from the thermodilution measurement,Haemodynamic Monitoring,Introduction to PiCCO technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性,is calculated as the difference between MAP and CVP divided by CO as an afterload parameter it represents a further determinant of the cardiovascular situat
35、ion is an important parameter for controlling volume and catecholamine therapies,(MAP CVP)x 80,SVR=,CO,Afterload parameter,SVR=Systemic Vascular Resistance,MAP=Mean Arterial PressureCVP=Central Venous PressureCO=Cardiac Output80=Factor for correction of units,Introduction to the PiCCO Technology Aft
36、erload parameter,收缩力指数 dPmx 由脉搏轮廓分析技术获得，用于评估左室心肌功能，给出了心功能重要的信息，可以指导治疗 收缩力指数 GEF 和 CFI 是评估全心功能的重要参数，支持心衰的早期诊断 外周血管阻力 SVR 由血压和心排获得，是一个进一步评估心血管功能的指数，对于容量的控制和血管活性药物的应用提供了重要信息。,Summary and Key Points,Introduction to the PiCCO Technology Contractility and Afterload,Haemodynamic Monitoring,Introduction to
37、PiCCO technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,To Dry or Not to Dry,ITTV ITBV=EVLW,The Extravascular Lung Water is the difference between the intrathoracic thermal volume and the intrathoracic blood volume.It represents the amount of water in the lungs outside the blood vessels.,Calculatio
38、n of Extravascular Lung Water(EVLW),Introduction to the PiCCO Technology Extravascular Lung Water,容量测量小结,ITTV=CO*MTtTDa,PTV=CO*DStTDa,ITBV=1.25*GEDV,EVLW=ITTV-ITBV,GEDV=ITTV-PTV,Katzenelson et al,Crit Care Med 32(7),2004,Sakka et al,Intensive Care Med 26:180-187,2000,Gravimetry,Dye dilution,EVLW fro
39、m the PiCCO technology has been shown to have a good correlation with the measurement of extravascular lung water via the gravimetry and dye dilution reference methods,Validation of Extravascular Lung Water,n=209r=0.96,ELWI by gravimetry,ELWI by PiCCO,R=0,97P 0,001,Y=1.03x+2.49,0,10,20,30,20,30,40,1
40、0,ELWITD(ml/kg),0,5,10,20,15,25,25,5,0,10,0,20,15,ELWIST(ml/kg),Introduction to the PiCCO Technology Extravascular Lung Water,Boeck J,J Surg Res 1990;254-265,High extravascular lung water is not reliably identified by blood gas analysis,EVLW as a quantifier of lung edema,PaO2/FiO2,10,20,550,30,150,2
41、50,0,450,ELWI(ml/kg),0,50,350,Introduction to the PiCCO Technology Extravascular Lung Water,ELWI=7 ml/kg,ELWI=8 ml/kg,ELWI=14 ml/kg,ELWI=19 ml/kg,Extravascular lung water index(ELWI)normal range:3 7 ml/kg,Pulmonary oedema,Normal range,EVLW as a quantifier of lung oedema,Introduction to the PiCCO Tec
42、hnology Extravascular Lung Water,40,Halperin et al,1985,Chest 88:649,Chest x ray does not reliably quantify pulmonary oedema and is difficult to judge,particularly in critically ill patients,r=0.1p 0.05,0,20,80,15,-10,-15,10,60,D radiographic score,-80,-60,-40,-20,D ELWI,EVLW as a quantifier of lung
43、 oedema,Introduction to the PiCCO Technology Extravascular Lung Water,ELWI(ml/kg),21 n=54,14-21 n=100,7-14 n=174,7 n=45,Mortality(%),Sturm J in:Lewis,Pfeiffer(eds):Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin-Heidelberg-NewYork 1990,pp 129-139,Relevance of
44、 EVLW Assessment,The amount of extravascular lung water is a predictor for mortality in the intensive care patient,Sakka et al,Chest 2002,Introduction to the PiCCO Technology Extravascular Lung Water,Intensive Care days,Mitchell et al,Am Rev Resp Dis 145:990-998,1992,Relevance of EVLW Assessment,Vol
45、ume management guided by EVLW can significantly reduce time on ventilation and ICU length of stay in critically ill patients,when compared to PCWP oriented therapy,Ventilation Days,PAC Group,n=101,*p 0,05,PAC Group,EVLW Group,EVLW Group,22 days,15 days,9 days,7 days,*p 0,05,Introduction to the PiCCO
46、 Technology Extravascular Lung Water,Haemodynamic Monitoring,Introduction to PiCCO Technology,功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数,Differentiating Lung Oedema,PVPI=Pulmonary Vascular Permeability Index,is the ratio of Extravascular Lung Water to Pulmonary Blood Volume is a measure of the permeabi
47、lity of the lung vessels and as such can classify the type of lung oedema(hydrostatic vs.permeability caused),EVLW,PVPI=,PBV,PBV,EVLW,Introduction to PiCCO Technology Pulmonary Permeability,permeability,PVPI normal(1-3),PVPI raised(3),Classification of Lung Oedema with the PVPI,Difference between th
48、e PVPI with hydrostatic and permeability lung oedema:,Lung oedema,hydrostatic,PBV,EVLW,PBV,EVLW,PBV,EVLW,PBV,EVLW,Introduction to PiCCO Technology Pulmonary Permeability,16 patients with congestive heart failure and acquired pneumonia.In both groups EVLW was 16 ml/kg.,Validation of the PVPI,PVPI can
49、 differentiate between a pneumonia caused and a cardiac failure caused lung oedema.,Benedikz et al ESICM 2003,Abstract 60,Cardiac insufficiency,PVPI,Pneumonia,4,3,2,Introduction to PiCCO Technology Pulmonary Permeability,EVLWI answers the question:,Clinical Relevance of the Pulmonary Vascular Permea
50、bility Index,PVPI answers the question:,and can therefore give valuable aid for therapy guidance!,肺水有多少?,它是怎么来的?,Introduction to PiCCO Technology Pulmonary Permeability,Summary and Key Points,EVLW 用于评估肺间质的含水量，是唯一用于评估床旁肺水肿程度的参数.血气分析和胸片用于评估肺水肿，不能提供有价值的信息EVLW 可用于评估ICU病人死亡率 肺血管通透性指数PVPI用于鉴别静水压型肺水肿或是通透性肺
