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1、,PiCCO,的临床应用,内 容,原理 测定参数临床操作临床病例心排监测探讨,PiCCO原理,PiCCO,Pulse contour cardiac output pulse indicator continue cardiac output,PiCCO采用成熟的热稀释方法测量单次的心输出量（CO），并通过分析动脉压力波形曲线下面积与CO存在的一定关系，来获得连续的心输出量（CCO）,Picco技术获得连续CO的基本原理,Wesseling提出的心搏量同主动脉压力曲线的收缩面积成正比，压力依赖于顺应性及其系统阻力，并作了压力、心率、年龄等影响因素校正后，该方法才得到认可。,PiCCO plus
2、 setup,Central venous catheter,Injectate temperature sensor housing PV4046,Arterial thermodilution catheter,Injectate temperature sensor cablePC80109,PULSION disposable pressure transducer PV8115,PCCI,AP,13.03 16.28 TB37.0,AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625,DPT M
3、onitor cablePMK-206,Interface cablePC80150,Connection cableto bedside monitorPMK-XXX,AUX adaptercable PC81200,*For application in pediatric patients,Application sites for thermodilution catheters,Tb,injection,t,Transpulmonary thermodilution:Cardiac Output,Stewart-Hamilton method,Tb=Blood temperature
4、Ti=Injectate temperatureVi=Injectate volume Tb.dt=Area under the thermodilution curveK=Correction constant,made up of specific weight and specific heat of blood and injectate,Area under pressure curve,Shape of pressure curve,Aorticcompliance,Heart rate,Patient-specific calibration factor(determined
5、by thermodilution),t s,P mm Hg,Calculation of PCCO Model,PCCO is displayed as last 12s mean,Methodology of volumetric monitoring(I),MTt:Mean transit time half of the indicator passed the point of detection,DSt:Downslope time exponential downslope time of TD curve,ITTV=CO*MTtTDa,PTV=CO*DStTDa,ITBV=1.
6、25*GEDV,EVLW=ITTV-ITBV,GEDV=ITTV-PTV,RAEDV,RVEDV,LAEDV,LVEDV,RAEDV,RVEDV,LAEDV,LVEDV,PTV,PTV,Calculation of volumes,PiCCO测定的参数,Transpulmonary thermodilution parameters,Cardiac outputCO（心排血量）Intrathoracic blood volumeITBV（胸腔内血容量）Extravascular lung waterEVLW（血管外肺水）Cardiac function index CFI（心功能指数）Glob
7、al ejection fraction GEF(心脏腔室射血分数),经肺热稀释测量的参数,New parameters,GEF=,GEDV,4 x SV,Global ejection fraction,PVPI=,PBV,EVLW,Estimation of pulmonary vascular permeability,Pulse contour parameters,Pulse contour cardiac output PCCO（动脉连续心排血量）Heart rate HR（心率）Arterial pressure AP（动脉压）Stroke volume SV（每搏心排量）Str
8、oke volume variation SVV（每搏量变异指数）Systemic vascular resistance SVR（体循环阻力）Index of leftventricular contractility dP/dtmax（左室收缩力指数）,连续动脉波形测量的参数,正常值范围,ParameterRangeUnitCI3.0 5.0l/min/m2 ITBVI850 1000ml/m2EVLWI 3.0 7.0ml/kgCFI4.5 6.51/minHR60 901/minMAP70 90mmHgSVRI1200 2000dyn*s*cm-5*m2SVI40 60ml/m2SVV
9、 10%dP/dtmax 12002000 mmHg/sGEDVI 600750 ml/m2,Decision Tree for volumetric hemodynamic monitoring,CI(l/min/m2),ITBVI(ml/m2),TherapyTargetITBVICFIEVLWI(slowly responding),4.5,10 V+Cattemporary750-8505.510,4.5,3.0,3.0,10 Cat V-temporary750-850 5.5 10,10 V+850-100010,10 V+temporary750-85010,850,850,85
10、0,10 OK!,10 V-temporary750-850 10,850,EVLWI(ml/kg),V+=volume loading(!=cautiously),V-=volume contraction,Cat=catecholamines/cardiovascular agents,Indications,Every patient who require a central venous and arterical catheter monitoring.ContraindicationsArterial access restriction due to femoral arter
11、y grafting or severe burns in areas where the catheter would normally have been placed.,The PiCCO method may give incorrect thermodilution measurements in patients with intracardiac shunts;aortic aneurysm;aortic stenosis;pneumonary;macro lung embolisn and extracorporeal circulation(if blood is eithe
12、r extracted from or infused back into the cardiopulmonary.),临床操作,1,按主设定2,收入/转出3,ABP,1cm=0.393in 1kg=2.2lb按enter收入病人,主设定测量CO 接通,心输出量测量目录,InjVol选择试验保存,再采样CVPm 1mmHg=1.33cmH2O进行计算,PiCCO临床病例,病例一,男患 53岁 诊断 脓毒症 MODS处于镇静状态，HR：90次分，BP：16070mmHg，SaO2：90 R：15次分气管插管，呼吸机辅助呼吸，SIMV模式，FIO2：60 PEEP：8cmH2O 双肺吸气相呼吸音粗
13、糙，呼气相呼吸音弱。血常规：WBC：47.0109 NEUT：95.6 PLT:25109 肝功：ALT:21U/L AST:14U/L ALB：17gL肾功：BUN：36.79mmolL Crea：399umolL,T1,病例二,女患 74岁 食物中毒 感染性休克入室时意识朦胧，自主呼吸，生命体征：HR140bpm,BP 94/52mmHg,(多巴胺维持）SpO2 98%FiO2 3L/min,RR 31bpm8小时后，心肺复苏后，行PiCCO监测,心肺复苏后,2小时后850 ml液体扩容后硝普钠0.3ug/kg.min多巴酚18ug/kg.min付肾0.13ug/kg.min,代入治疗树-
14、OK,病例三,女患 69岁 扩张型心肌病 心衰 心功级气管插管 呼吸机辅助呼吸 SPONT模式 PS 8cmH2O PEEP 4cmH2O FiO2 50%多巴胺 25ug/kg.min 多巴酚丁胺25ug/kg.min 米力农0.5ug/kg.min,停呼吸机,多巴胺，多巴酚25ug/kg.min,24小时后多巴胺，多巴酚20ug/kg.min硝普钠0.1-0.3ug/kg.min24小时持续泵入,加用米力农，硝普钠后,停多巴胺，多巴酚,停米力农,病例四,女患 23岁 病毒性脑炎气管插管 呼吸机辅助呼吸 PS 13cmH2O PEEP 3.0cmH2O多巴胺 12ug/kg.min 前24小
15、时总入量 6040ml前24小时总出量3750ml,前24小时入量6040ml，出量3750ml,24 小时后入量9010ml出量5430ml,48小时后前24小时入量6465出量5660,CO监测探讨,Invasive methodsMinimally invasive methodsNon-invasive methods,Thermodilution techniqueFicks cardiac output measurement,Doppler ultrasound-Transpulmonary thermodilutionPartial CO2 rebreathingThanspu
16、lmonary thermodilutionPulse contour cardiac output estimation without external caliberation,Electrical impedance cardiography,Ficks cardiac output measurement,以氧作为指示剂，是一种经典的方法V2O2the oxygen content difference between inspired and exhaled gasCaO2-Oxygen content of arterial bloodCvO2-Oxygen content of
17、 mixed venous blood,NICO,是利用二氧化碳弥散能力强的特点作为指示剂，根据Fick原理来测定心排血量。基本公式为：QVCO2/(CVCO2-CaCO2)。,优点,NICO所测心排血量的重点在于CO的有效部分，即积极完成气体交换的血流量，就此点的意义来说NICO大于经典的温度稀释法。NICO 的数值改变大多发生于温度稀释法测量值变化之前，即NICO对血流动力学改变的反映快于经典的温度稀释法，这对某些关键时刻意义重大。,缺点,是任何影响混合静脉血二氧化碳、解剖死腔/潮气量及肺内分流的因素均可影响结果的准确性尤其要指出刚给完碳酸氢钠后的测量结果也不可靠，NaHCO3可影响PET
18、CO2。,Electrical impedance cardiography,利用心动周期于胸部电阻抗的变化来测定左心室收缩时间间期并计算出每搏量，然后再演算出一系列心功能参数。基本原理：欧姆定律（电阻电压/电流）,-resistivity of bloodL-mean distance between the inner electrodesVET-ventricular ejection timedZ/dt-the absolute of the maximum value of the finst derivative during systosle Z0-basal thoracic
19、impedance,操作简单、费用低、能动态观察心排血量的变化趋势抗干扰能力差测量结果略大于温度稀释法测定值,缺点,尽管阻抗法以阻抗变化反映CO,可无损伤快速测量CO,但多数人认为阻抗法测定CO影响因素太多,如肥胖、放置胸腔引流管、机械通气、发热、水种、胸膜渗液、心律失常、严重的心瓣膜病、急性心肌梗死和血液动力学不稳定等因素均会导致监测结果准确性的下降3,因此测量误差较大,临床应用有困难。尤其对危重病人,临床应用一直有争议,0,200,400,600,800,1000,1200,2.5,5.0,7.5,10.0,GEDVI(ml/m2),CI(l/min/m2),Volume,Inotropi
20、cs,normal range,normal cardiac function,CFI=CI/GEDVI,Cardiac function index(CFI),EVLW包括细胞内、组织间、肺泡内,SVR,systemic vascular resistance SVR（MAPCVP）CO CVP经常输入SVRI 1200-2000 dyn*s*cm-5*m2,SVmax,SVmin,SVmean,SVmax SVmin,SVV=,SVmean,SVmax and SVmin are determined over last 30 s window,Determination of the Stroke Volume Variation(SVV),Only applicable in controlled mechanically ventilated patients,Determination of the Stroke Volume Variation(SVV),dPmx=,dP/dtmax of arterial pressure curve,Estimation of left ventricular pressure velocity increase,Index of left ventricular contractility,t s,P mm Hg,
