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1、PiCCO容量容量监护仪在监护仪在ICU中的应用中的应用2PiCCO Technology容量管理Introduction to the PiCCO-TechnologyCOVolumetric preload EVLWContractilityDifferentiated Volume Management-static -dynamic3 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。6Central venous catheter jugular subclavian femoral大
2、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连接连接7Central venous catheter jugular subclavian femoral8PiCCO技术可以监测心输出量技术可以监测心输出量9PiCCO Technology is a combination of transpulmonary
3、thermodilution and pulse contour analysisPrinciples of MeasurementLeft HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology Function10Transpulmonary thermodilutio
4、n methodArterial TD catheter动脉热稀释导管动脉热稀释导管(e.g.PV2014L16)CV bolus injection中心静脉一次注射中心静脉一次注射RAEDV右房舒张末容量右房舒张末容量PBV肺血容量肺血容量EVLWLAEDV左房舒张末容量左房舒张末容量LVEDV左室舒张末容量左室舒张末容量EVLW血管外肺水血管外肺水RVEDV右室舒张末容量右室舒张末容量010203040500,00,20,40,6 C-D DTInjectionsLungsCVCAortaV.cavasup.RAArterial TD catheter11Tb=Blood temperat
5、ureTi =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心输出量是利用 Stewart-Hamilton 公式对热稀释曲线进行分析所得热热稀释释方法所得心输输出量的计计算Tb x dt(Tb-Ti)x Vi x K TbInjectiontD D=COTD a12The area under t
6、he thermodilution curve is inversely proportional to the CO.36,537510Thermodilution curvesNormal CO:5.5l/minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO:1.9l/minHigh CO:19l/minTimeTimeTemperatureTemperatureTemperature13经经肺 vs.肺动动脉热热稀释释Left heartRight HeartPulmonary Circu
7、lationLungsBody CirculationPULSIOCATH arterial thermo-dilution cathetercentral venous bolus injectionRARVPALALVAortaTranspulmonary 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！1415=Cal.xP(mmHg)t(s)171819GEDV评估心脏前负荷容量评估心脏前负荷容量20 Centrol venous pressure(CVP)Pulmonary capillary
8、wedge pressure(PCWP)但是但是這是基於以下的假設“压力压力=容容量量 但這種假設並非完全正確但這種假設並非完全正確 21Kumar et al.,Crit Care Med 2004;32:691-699 21灌注压压 CVP/PCWP反映前负负荷中心静脉压和每搏输出量的关联监测前负荷22Kumar et al.,Crit Care Med 2004;32:691-69922肺动脉嵌压和每搏输出量的关联Measuring Preload监测前负荷灌注压压 CVP/PCWP反映前负负荷23Raper R and Sibbald WJ.Chest 1986 Misled by t
9、he wedge?The Swan-Ganz catheter and left ventricular preload.24GEDV可以作为心脏前负荷的指标Global End-Diastolic Volume evaluated by transpulmonary thermodilutionGEDV25CO x MTt=volume of distribution=1+2+3+4+53Indicator injectionIndicator dilutioncurve1425326CO x MTt=volume of distribution=1+2+3+4+53CO x Dst=lar
10、gest mixing chamber=33Indicator injectionIndicator dilutioncurve1425327CO x MTt=volume of distribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeier et al.J Appl Physiol 1954RALARVLVGEDVNewman et al.Circulation 1951CO x DSt=largest mixing chamber=PBV+EVLWPBVEVLW28-10010203040506070-5051015202530SVIChanges instr
11、oke volumeindex(%)Changes in global end-diastolic volume index(%)r=0.72p 0.00129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30Intrathoracic pressureVenous return to left and right ventricleLeft ventricular preloadLeft ventricular
12、stroke volumeSystolic arterial blood pressureIntrathoracic pressureSqueezing“of the pulmonary bloodLeft ventricular preloadLeft ventricular stoke volumeSystolic arterial blood pressure吸气Reuter et al.,Ansthesist 2003;52:1005-1013容量反映值值的生理学意义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每搏量变异每搏量变异SVV 每搏量变异（每搏量变异（St
13、roke Volume Variation，SVV）反映了每搏量随通气周）反映了每搏量随通气周期变化的情况。期变化的情况。SVV 是是.过去过去30秒的测量结果秒的测量结果 只适用于心律规律的完全机械通气病人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。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。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，对于没有心律失常的完全机械通气病人而言，每搏量变异每搏量变
14、异-SVV33Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery 34心肌收缩状况心肌收缩状况FORCE-FREQUENCY RELATIONDIGITALIS,OTHERINONOTROPIC AGENTSANOXIAHYPERCAPNIAACIDOSISCIRCULATING CATECHOLAMINESSYMPATHETIC NERVEIMPULSESLOSS OFMYOCARDIUMPHARMACOLOGICDEPRESSANTSINTRI
15、NSICDEPRESSIONVENTRICULAR EDVVENTRICULAR STROKE VOLUME35CFI心脏收缩功能指数38t sP mm Hg左心室收缩力指数左心室收缩力指数 dPmx =动脉压力曲线的上升枝动脉压力曲线的上升枝PiCCO心肌收缩力参数39PiCCO心肌收缩力参数dPmx 反映了左心室最大压力增加的速度，反映了左心室最大压力增加的速度，是心肌收缩力的参数是心肌收缩力的参数40全心射血分数（全心射血分数（GEF）（经肺热稀释导管）GEF=GEDV4 x SVRVEF=RVEDVSVLVEF=LVEDVSV右心室射血分数（右心室射血分数（RVEF）（肺动脉热稀释导管
16、）左心室射血分数（左心室射血分数（LVEF）（心脏超声）12&3全心射血分数全心射血分数GEF右心右心左心左心肺肺PBVEVLWEVLWRAEDVRVEDVLVEDV每搏量（每搏量（SV）LAEDV 射血分数：与每搏量和舒张末期容积相关射血分数：与每搏量和舒张末期容积相关41EVLW肺水肿指数肺水肿指数42Extravascular water content of the lungPulmonary circulationLeft HeartRight HeartLungs血管外肺水EVLW在管理前负负荷中的作用EVLW=Extravascular Lung WaterBody 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43RALARVLVGEDVRALARVLVPBVSakka et al.Intensive Care Med 2000ITBV=1.25 x GEDV44CO x MTt=volume of distribution=GEDV+PBV+EVLWRALARVLVPBVEVLWMeier et a
