PiCCO监测及临床应用.

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•Pulsecontourcardiacoutput•pulseindicatorcontinuecardiacoutput•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）a.经肺热稀释技术b.动脉脉搏轮廓分析技术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。PiCCOplussetupCentralvenouscatheterInjectatetemperaturesensorhousingPV4046ArterialthermodilutioncatheterInjectatetemperaturesensorcablePC80109PULSIONdisposablepressuretransducerPV8115PCCIAP13.0316.28TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625DPTMonitorcablePMK-206InterfacecablePC80150ConnectioncabletobedsidemonitorPMK-XXXAUXadaptercablePC81200A.axillaris(A.brachialis)PV2014L084F8cmA.radialisPV2014L50LGWA4F50cmA.femoralisPV2015L205F20cmPV2013L07*3F7cmPV2014L08*morethan10kgbodyweight*ForapplicationinpediatricpatientsApplicationsitesforthermodilutioncathetersTbinjectiontdtTKV)T(TCObiibTDaTranspulmonarythermodilution:CardiacOutputStewart-HamiltonmethodTb=BloodtemperatureTi=InjectatetemperatureVi=Injectatevolume∫∆Tb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectateAreaunderpressurecurveShapeofpressurecurvePCCO=cal•HR•SystoleP(t)SVR+C(p)•dPdt()dtAorticcomplianceHeartratePatient-specificcalibrationfactor(determinedbythermodilution)t[s]P[mmHg]CalculationofPCCOModelPCCOisdisplayedaslast12smeanMethodologyofvolumetricmonitoring(I)lnc(I)injectionAtrecirculationMTtte-1DStc(I)MTt:Meantransittime≈halfoftheindicatorpassedthepointofdetectionDSt:Downslopetime≈exponentialdownslopetimeofTDcurveITTV=CO*MTtTDaPTV=CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWCalculationofvolumesPiCCO测定的参数TranspulmonarythermodilutionparametersCardiacoutputCO（心排血量）IntrathoracicbloodvolumeITBV（胸腔内血容量）ExtravascularlungwaterEVLW（血管外肺水）CardiacfunctionindexCFI（心功能指数）GlobalejectionfractionGEF(心脏腔室射血分数)经肺热稀释测量的参数NewparametersGEF=GEDV4xSVGlobalejectionfractionPVPI=PBVEVLWEstimationofpulmonaryvascularpermeabilityPulsecontourparametersPulsecontourcardiacoutputPCCO（动脉连续心排血量）HeartrateHR（心率）ArterialpressureAP（动脉压）StrokevolumeSV（每搏心排量）StrokevolumevariationSVV（每搏量变异指数）SystemicvascularresistanceSVR（体循环阻力）IndexofleftventricularcontractilitydP/dtmax（左室收缩力指数）连续动脉波形测量的参数正常值范围ParameterRangeUnitCI3.0–5.0l/min/m2ITBVI850–1000ml/m2EVLWI3.0–7.0ml/kgCFI4.5–6.51/minHR60–901/minMAP70–90mmHgSVRI1200–2000dyn*s*cm-5*m2SVI40–60ml/m2SVV10%dP/dtmax1200—2000mmHg/sGEDVI600—750ml/m2DecisionTreeforvolumetrichemodynamicmonitoringCI(l/min/m2)ITBVI(ml/m2)TherapyTargetITBVICFIEVLWI(slowlyresponding)10V+850-10004.510V+Cattemporary750-8505.51010Cat4.53.03.010CatV-temporary750-8505.51010V+850-10001010V+temporary750-8501085085085010OK!10V-temporary750-85010850EVLWI(ml/kg)V+=volumeloading(!=cautiously)V-=volumecontractionCat=catecholamines/cardiovascularagentsIndications•Everypatientwhorequireacentralvenousandartericalcathetermonitoring.Contraindications•Arterialaccessrestrictionduetofemoralarterygraftingorsevereburnsinareaswherethecatheterwouldnormallyhavebeenplaced.•ThePiCCOmethodmaygiveincorrectthermodilutionmeasurementsinpatientswithintracardiacshunts;aorticaneurysm;aorticstenosis;pneumonary;macrolungembolisnandextracorporealcirculation(ifbloodiseitherextractedfromorinfusedbackintothecardiopulmonary.)临床操作1,按主设定2,收入/转出3,ABP•1cm=0.393in1kg=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•CVPm1mmHg=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：160／70mmHg，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糙，呼气相呼吸音弱。血常规：WBC：47.0×109NEUT％：95.6％PLT:25×109肝功：ALT:21U/LAST:14U/LALB：17g／L肾功：BUN：36.79mmol／LCrea：399umol／LT1吴国安T1T2BP140/73196/98HR8692CVP58CI1.662.68SI19.229.2SVRI43473933LCWI2.15.1LVSWI24.951.6EVLWI9.16.5ITBVI453540GEDVI362432PVPI3.72.1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,BP94/52mmHg,(多巴胺维持）SpO298%FiO23L/min,RR31bpm•8小时后，心肺复苏后，行PiCCO监测张亚敏T1T2T3T4T5T6T7T8BP71/4390/4873/4579/4783/5065/3869/4066/33HR138144127142138147130113CVP1411109791218CI3.383.942.743.382.933.513.833.23SI24.527.421.623.821.323.929.428.6SVRI9241075131411851526888836719LCWI2.43.422.72.52.32.72.1LVSWI17.623.816.119.118.215.620.818.2EVLWI6.45.37.67.97.27.974.9ITBVI7658988759638461020962917GEDVI612718701770677877770733心肺复苏后2小时后850ml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--OK病例三•女患69岁扩张型心肌病心衰心功Ⅲ级•气管插管呼吸机辅助呼吸SPONT模式PS8cmH2OPEEP4cmH2OFiO250%•多巴胺25ug/kg.min多巴酚丁胺25ug/kg.min米力农0.5ug/kg.minT1T2T3T4T5T6T7BP85/4593/53mmHg97/55mmHg111/57mmHg94/6299/52mmHg114/52HR9085bpm85bpm87bpm8366bpm81CVP99mmHg9mmHg10mmHg912mmHg15CI0.771.774.314.085.032.964.01SI9.319.950.746.960.644.849.5SVRI7718267011141254104814591116LCWI0.91.644.15.12.73.9LVSWI10.618.447.547.261.940.347.8EVLWI13.36.814.414.412.89.621.5ITBVI72471815631439189715631876GEDVI57957512511151151712511501CFI1.33.13.43.53.52.32.6停呼吸机多巴胺，多巴酚25ug/kg.min24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