血流动力学监测 最新picco的临床应用.ppt

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1、血血流动力学监测流动力学监测血流动力学 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的超声多普勒探头 通过测定红细胞移

2、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监监测生命体征测生命体征MonitoringRespiration RateTemperature8一一些重要的指标些重要的指标MonitoringBlood Pressure(NiBP)no correlation with CO no correlation with oxygen deliveryECGRespiration RateTemperaturePiCCO Technology液液体管理所需要的指标体管理所需要的指标Introduction

3、 to the PiCCO-TechnologyCO前负荷 EVLW收缩力指数个性化的容量管理-static -dynamicPiCCO 技术监测1.功能原理2.热稀释技术3.脉搏轮廓分析技术4.收缩力指数5.前、后负荷参数6.血管外肺水7.肺部通透性指数血流动动力学监测监测PiCCO 技术术 依据经肺热稀释技术以及脉搏轮廓分析技术原原理理Left HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution catheter

4、central venous bolus injectionIntroduction to the PiCCO-Technology FunctionBolus injectionconcentration 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 FunctionLeft heartRight heartLungsRARVLALVPBVEVLWEVLW原原理理胸胸腔内各腔室腔内各腔室Introduc

5、tion to the PiCCO-Technology Function肺内热热容积积(PTV)胸胸腔内热容积腔内热容积(ITTV)Total of mixing chambers RARVLALVPBVEVLWEVLW最大混合腔室血流动动力学监测监测Introduction to PiCCO Technology1.功能原理2.热稀释技术3.脉搏轮廓分析技术4.收缩力指数5.后负荷参数6.血管外肺水7.肺部通透性指数Tb x dt(Tb-Ti)x Vi x K TbInjectiontD D=COTD aTb=Blood temperatureTi =Injectate temperatu

6、reVi =Injectate volume Tb.dt=Area under the thermodilution curveK =Correction constant,made up of specific weight and specific heat of blood and injectateCO的计算是通过对热稀释曲线分析，使用 Stewart-Hamilton 方程式 心排的计计算Introduction to the PiCCO-Technology Thermodilution热稀释曲线下面积反比例反映CO 36,537510热热稀释释曲线线Normal CO:5.5l/

7、minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO:1.9l/minHigh CO:19l/minTimeTimeTemperatureTemperatureTemperature经经肺热热稀释释 vs.肺动动脉导导管Left heartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATH arterial thermo-dilution cathetercentral venous bolus injectionRAR

8、VPALALVAortaTranspulmonary 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!Intro

9、duction to the PiCCO Technology ThermodilutionComparison with the Fick Method0,970,68 0,6237/449Sakka SG et al.,Intensive Care Med 25,1999-/-0,19 0,219/27McLuckie A.et a.,Acta Paediatr 85,19960,960,16 0,3130/150Gdje O et al.,Chest 113(4),19980.980,32 0,2923/218Holm C et al.,Burns 27,20010,930,13 0,5

10、260/180Della Rocca G et al.,Eur J Anaest 14,20020,95-0,04 0,4117/102Friedman Z et al.,Eur J Anaest,20020,950,49 0,4545/283Bindels AJGH et al.,Crit Care 4,20000,980,03 0,1718/54Pauli C.et al.,Intensive Care Med 28,200224/120n(Pts/Measurements)0,990,03 0,24Tibby S.et al.,Intensive Care Med 23,1997r bi

11、as SD(l/min)Comparison with Pulmonary Artery Thermodilution经经肺热热稀释释技术术的有效性Introduction to the PiCCO Technology ThermodilutionMTt:Mean Transit time the mean time required for the indicator to reach the detection pointDSt:Down Slope time the exponential downslope time of the thermodilution curveRecirc

12、ulationte-1TbFrom the characteristics of the thermodilution curve it is possible to determine certain time parameters 对对热热稀释释曲线线做进进一步分析 Introduction to the PiCCO-Technology ThermodilutionInjectionIn TbMTtDStTb=blood temperature;lnTb=logarithmic blood temperature;t=timePulmonary Thermal VolumePTV=Dst

13、 x COBy using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated 计计算 ITTV 与 PTVIntroduction to the PiCCO-Technology ThermodilutionRecirculationte-1TbInjectionIn TbIntrathoracic Thermal VolumeITTV=MTt x COMTtDStPulmonary Thermal Volume(PTV)Intrathoracic Therma

14、l Volume(ITTV)Calculation of ITTV and PTVEinfhrung in die PiCCO-Technologie ThermodilutionITTV=MTt x COPTV=Dst x CO RARVLALVPBVEVLWEVLWGEDV is the difference between intrathoracic and pulmonary thermal volumesGlobal End-diastolic Volume(GEDV)Volumetric preload parameters GEDVRARVLALVPBVEVLWEVLWITTVG

15、EDVPTVIntroduction to the PiCCO Technology ThermodilutionVolumetric preload parameters ITBVIntrathoracic Blood Volume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroduction to the PiCCO Technology ThermodilutionITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vesse

16、ls(PBV)ITBVTD(ml)ITBV=1.25*GEDV 28.4 mlGEDV vs.ITBV in 57 Intensive Care PatientsIntroduction to the PiCCO-Technology ThermodilutionITBV is calculated from the GEDV by the PiCCO Technology 01000200030000100020003000GEDV(ml)Sakka et al,Intensive Care Med 26:180-187,2000Summary and Key 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 MonitoringIntroduction to PiCCO Technology1.功能