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1、PiCCO TechnologyParameters for guiding volume therapyIntroduction to the PiCCO-TechnologyCO心排量Volumetric preload容量负荷 EVLW肺水Contractility收缩力Differentiated Volume Management-static -dynamic -第1页/共49页PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysisPiCCO技术是经肺
2、热稀释法和脉搏轮廓分析法的结合Principles of MeasurementLeft HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology Function第2页/共49页Bolus injectionconcentration changes over time(T
3、hermodilution curve)After central venous injection the cold bolus sequentially passes through the various intrathoracic compartments 中心静脉弹丸注射后，冰盐水会通过胸腔内的各个腔室。The temperature change over time is registered by a sensor at the tip of the arterial catheter 动脉导管尖端的感受器探测到注射液温度的改变。Introduction to the PiCCO
4、-Technology FunctionLeft heartRight heartLungsRARVLALVPBVEVLWEVLWPrinciples of Measurement第3页/共49页Intrathoracic Compartments(mixing chambers)Introduction to the PiCCO-Technology FunctionPulmonary Thermal Volume(PTV)肺内热稀释容积Intrathoracic Thermal Volume(ITTV)胸腔内热容积胸腔内热容积Total of mixing chambers 所有的混合腔室
5、 RARVLALVPBVEVLWEVLWLargest single mixing chamber最大的单一混合腔室第4页/共49页Haemodynamic MonitoringE.Introduction to PiCCO Technology1.Principles of function 2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability第5页/共49页Tb x d
6、t(Tb-Ti)x Vi x K TbInjectiontD D=COTD aTb=Blood temperatureTi =Injectate temperatureVi =Injectate volume Tb.dt=Area under the thermodilution curveK =Correction constant,made up of specific weight and specific heat of blood and injectateThe CO is calculated by analysis of the thermodilution curve usi
7、ng the modified Stewart-Hamilton algorithm 心排量是通过分析热稀释曲线得来的，应用Stewart-Hamilton定律。Calculation of the Cardiac OutputIntroduction to the PiCCO-Technology Thermodilution第6页/共49页The area under the thermodilution curve is inversely proportional to the CO.热稀释曲线下的面积是与CO呈反比的。36,537510Thermodilution curvesNor
8、mal CO:5.5l/minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO:1.9l/minHigh CO:19l/minTimeTimeTemperatureTemperatureTemperature第7页/共49页Transpulmonary vs.Pulmonary Artery ThermodilutionLeft heartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATH arterial thermo-
9、dilution cathetercentral venous bolus injectionRARVPALALVAortaTranspulmonary TD(PiCCO)Pulmonary Artery TD(PAC)In both procedures only part of the injected indicator passes the thermistor.在这两种方式中只有一部分注射液会通过热敏感受器。Nonetheless the determination of CO is correct,as it is not the amount of the detected in
10、dicator but the difference in temperature over time that is relevant!但是CO正确与否的决定性因素，并不是指示剂的量，而是随着时间变化导致的温度变化，这两者相关的。Introduction to the PiCCO Technology Thermodilution第8页/共49页Comparison 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.,
11、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 0,5260/180Della 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 0,17
12、18/54Pauli C.et al.,Intensive Care Med 28,200224/120n(Pts/Measurements)0,990,03 0,24Tibby S.et al.,Intensive Care Med 23,1997r bias SD(l/min)Comparison with Pulmonary Artery ThermodilutionValidation of the Transpulmonary ThermodilutionIntroduction to the PiCCO Technology Thermodilution第9页/共49页MTt:Me
13、an Transit time the mean time required for the indicator to reach the detection pointDSt:Down Slope time the exponential downslope time of the thermodilution curveRecirculationte-1TbFrom the characteristics of the thermodilution curve it is possible to determine certain time parameters 从热稀释曲线的特点来看，它
14、是可以决定某些时间参数的。Extended analysis of the thermodilution curve Introduction to the PiCCO-Technology ThermodilutionInjectionIn TbMTtDStTb=blood temperature;lnTb=logarithmic blood temperature;t=time第10页/共49页Pulmonary Thermal VolumePTV=Dst x COBy using the time parameters from the thermodilution curve and
15、the CO ITTV and PTV can be calculated 通过热稀释曲线的时间参数，可以计算出ITTV和PTV.Calculation of ITTV and PTVIntroduction to the PiCCO-Technology ThermodilutionRecirculationte-1TbInjectionIn TbIntrathoracic Thermal VolumeITTV=MTt x COMTtDSt第11页/共49页Pulmonary Thermal Volume(PTV)Intrathoracic Thermal Volume(ITTV)Calcu
16、lation of ITTV and PTVEinfhrung in die PiCCO-Technologie ThermodilutionITTV=MTt x COPTV=Dst x CO RARVLALVPBVEVLWEVLW第12页/共49页GEDV is the difference between intrathoracic and pulmonary thermal volumes.GEDV就是胸腔内热容积和肺内热容积的差值。Global End-diastolic Volume(GEDV)Volumetric preload parameters GEDVRARVLALVPBV
17、EVLWEVLWITTVGEDVPTVIntroduction to the PiCCO Technology Thermodilution第13页/共49页Volumetric 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
18、in the pulmonary vessels(PBV)第14页/共49页ITBVTD(ml)ITBV=1.25*GEDV 28.4 mlGEDV vs.ITBV in 57 Intensive Care PatientsI Intrantrat thoracic horacic B Blood lood V Volume(olume(ITBVITBV)Volumetric preload parameters ITBVIntroduction to the PiCCO-Technology ThermodilutionITBV is calculated from the GEDV by
19、the PiCCO Technology 01000200030000100020003000GEDV(ml)Sakka et al,Intensive Care Med 26:180-187,2000第15页/共49页Summary and Key Points-ThermodilutionPiCCO Technology is a less invasive method for monitoring the volume status and cardiovascular function.PiCCO技术是一种监测容量状态和心肌功能的微创技术。Transpulmonary thermod
20、ilution allows calculation of various volumetric parameters.经肺热稀释法可以计算各种容量参数。The CO is calculated from the shape of the thermodilution curve.CO是通过热稀释曲线的面积计算而得的。The volumetric parameters of cardiac preload can be calculated through advanced analysis of the thermodilution curve.心脏前负荷的容量参数是通过进一步分析热稀释曲线
21、获得的。For the thermodilution measurement only a fraction of the total injected indicator needs to pass the detection site,as it is only the change in temperature over time that is relevant.对于热稀释测量来讲，只需要一部分的指示剂通过监测点，同样只需要在相关的时间里面温度有所改变即可。Introduction to the PiCCO-Technology 第16页/共49页Haemodynamic Monito
22、ringE.Introduction to PiCCO Technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability第17页/共49页Transpulmonary ThermodilutionThe pulse contour analysis is calibrated through the transpulm
23、onary thermodilution and is a beat to beat real time analysis of the arterial pressure curve.脉搏轮廓分析法是通过经肺热稀释法计算，同时也是实时分析动脉压力曲线得出的。Calibration of the Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse contour analysisInjectionPulse Contour AnalysisT=blood temperature t=timeP=blood press
24、ure CO COTPDTPD=SV=SVTDTDHRHR第18页/共49页PCCO=cal HR P(t)SVR+C(p)dPdt()dtCardiac OutputPatient-specific calibration factor(determined by thermodilution)Heart rateArea under the pressure curveShape of the pressure curveAortic complianceSystoleIntroduction to the PiCCO-Technology Pulse contour analysisPa
25、rameters of Pulse Contour Analysis第19页/共49页 n(Pts/Measurements)0,940,03 0,6312/36Buhre W et al.,J Cardiothorac Vasc Anesth 13(4),199919/7624/51762/18620/36025/38022/96-/-0,40 1,3Mielck et al.,J Cardiothorac Vasc Anesth 17(2),20030,880,31 1,25Zllner C et al.,J Cardiothorac Vasc Anesth 14(2),20000,88-
26、0,2 1,15Gdje O et al.,Crit Care Med 30(1),20020,94-0,02 0,74Della Rocca G et al.,Br J Anaesth 88(3),20020,93-0,14 0,33Felbinger TW et al.,J Clin Anesth 46,2002-/-0,14 0,58Rauch H et al.,Acta Anaesth Scand 46,2002r bias SD(l/min)Comparison with pulmonary artery thermodilutionValidation of Pulse Conto
27、ur AnalysisIntroduction to the PiCCO-Technology Pulse contour analysis第20页/共49页SVSVmaxmax SV SVminminSVV=SVV=SVSVmeanmeanSVSVmaxmaxSVSVminminSVSVmeanmeanThe Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle,measured over the previous 30 second period.每博量变异是每博量在一个呼吸
28、周期中的变异，它所测量的是之前30秒的值。Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Stroke Volume Variation第21页/共49页PPPPmaxmax PP PPminminPPV=PPV=PPPPmeanmeanThe pulse pressure variation is the variation in pulse pressure ov
29、er the ventilatory cycle,measured over the previous 30 second period.脉压变异是在一个呼吸周期里面脉搏压力的变异，它测得的是之前30秒的值。Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Pulse Pressure VariationPPPPmaxmaxPPPPmeanmeanPPPPminmin第
30、22页/共49页Summary pulse contour analysis-CO and volume responsivenessThe PiCCO technology pulse contour analysis is calibrated by transpulmonary thermodilution PiCCO技术脉搏轮廓分析基于热稀释法来计算的PiCCO technology analyses the arterial pressure curve beat by beat thereby providing real time parameters.PiCCO技术分析实时动脉
31、压力曲线，因此它提供了实时的监测数据。Besides cardiac output,the dynamic parameters of volume responsiveness SVV(stroke volume variation)and PPV(pulse pressure variation)are determined continuously.除了心输出量，SVV和PPV都是连续性的参数。Introduction to the PiCCO-Technology Pulse contour analysis第23页/共49页Haemodynamic MonitoringE.Intro
32、duction to PiCCO Technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability第24页/共49页Contractility is a measure for the performance of the heart muscle 收缩力指数是评估心肌功能的参数Contractility parame
33、ters of PiCCO technology:PiCCO技术监测心肌收缩力的参数:-dPmx(maximum rate of the increase in pressure)-GEF(Global Ejection Fraction)-CFI(Cardiac Function Index)Contractility Introduction to the PiCCO-Technology Contractility parameterskg第25页/共49页Contractility parameter from the pulse contour analysisIntroductio
34、n to the PiCCO-Technology Contractility parametersdPmx=maximum velocity of pressure increaseThe contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.收缩力参数dPmx指的是左心室压力曲线上的最大值。第26页/共49页Contractility parameter from the pulse contour analysisIntroduction to
35、the PiCCO-Technology Contractility parametersfemoral dP/max mmHg/sLV dP/dtmax mmHg/sdPmx was shown to correlate well with direct measurement of velocity of left ventricular pressure increase in 70 cardiac surgery patients dPmx的值与左心室压力的测量值在70个心脏手术的病例中，呈现很好的正相关。de Hert et al.,JCardioThor&VascAnes 2006
36、 n=220y=-120+(0,8*x)r=0,82p 0,00105001000150001000150020002000500dPmx=maximum velocity of pressure increase第27页/共49页is calculated as 4 times the stroke volume divided by the global end-diastolic volume GEF是4倍的SV除以全心舒张末期容量 reflects both left and right ventricular contractility它反应的是全心功能参数GEF=Global Ej
37、ection FractionContractility parameters from the thermodilution measurementIntroduction to the PiCCO-Technology Contractility parameters4 x SVGEF=GEDVLALVRARV第28页/共49页Combes et al,Intensive Care Med 30,2004GEF=Global Ejection Fraction Comparison of the GEF with the gold standard TEE measured contrac
38、tility in patients without right heart failure.GEF和金标准TEE同时在右心功能正常的病例中的对比。sensitivity00,40,60,8010,20,20,40,60,81 specifity2220191816128D FAC,%D GEF,%510-5-20-10102015-15-10r=076,p0,0001n=47Introduction to the PiCCO-Technology Contractility parametersContractility parameters from the thermodilution
39、measurement第29页/共49页is the CI divided by global end-diastolic volume indexCFI是CI除以全心舒张末期容量指数 is-similar to the GEF a parameter of both left and right ventricular contractility它与GEF相似，是反映全心功能的参数CFI=Cardiac Function IndexCICFI=GEDVIIntroduction to the PiCCO-Technology Contractility parametersContracti
40、lity parameters from the thermodilution measurement第30页/共49页Combes et al,Intensive Care Med 30,2004sensitivity00,40,60,8010,20,20,40,60,81 specificity6543,532D FAC,%D GEF,%510-5-20-10102015-15-10r=079,p0,0001n=47CFI=Cardiac Function IndexIntroduction to the PiCCO-Technology Contractility parametersC
41、FI was compared to the gold standard TEE measured contractility in patients without right heart failure.CFI与金标准的TEE在右心功能正常病人中的对比Contractility parameters from the thermodilution measurement第31页/共49页Haemodynamic MonitoringE.Introduction to PiCCO technology1.Functions2.Thermodilution3.Pulse contour ana
42、lysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability第32页/共49页is calculated as the difference between MAP and CVP divided by CO as an afterload parameter it represents a further determinant of the cardiovascular situation 作为一个后负荷指数，它是心血管状况更深层的决定性因素。i
43、s an important parameter for controlling volume and catecholamine therapies这是一个非常重要的参数，它可以提示容量控制和儿茶酚胺的治疗。(MAP CVP)x 80SVR=COAfterload parameterSVR=Systemic Vascular ResistanceMAP=Mean Arterial PressureCVP=Central Venous PressureCO=Cardiac Output80=Factor for correction of unitsIntroduction to the Pi
44、CCO Technology Afterload parameter第33页/共49页The parameter dPmx from the pulse contour analysis as a measure of the left ventricular myocardial contractility gives important information regarding cardiac function and therapy guidance.脉搏轮廓分析得出的参数dPmx能提示左心室心肌收缩力的重要信息，这关乎心肌的功能和治疗方向。The contractility para
45、meters GEF and CFI are important parameters for assessing the global systolic function and supporting the early diagnosis of myocardial insufficiency.心功能指数GEF和CFI是非常重要的参数，可以用来评估整体收缩期的心肌功能以及对于心肌损伤的早期诊断。The Systemic Vascular Resistance SVR calculated from blood pressure and cardiac output is a further
46、 parameter of the cardiovascular situation,and gives additional information for controlling volume and catecholamine therapies.SVR是基于血压和心输出量来分析的，这是评估心血管功能重要的参数，能提示容量管理和儿茶酚胺类药物的治疗。Summary and Key PointsIntroduction to the PiCCO Technology Contractility and Afterload第34页/共49页Haemodynamic MonitoringE.I
47、ntroduction to PiCCO technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability第35页/共49页ITTV ITBV=EVLWThe Extravascular Lung Water is the difference between the intrathoracic thermal vol
48、ume and the intrathoracic blood volume.It represents the amount of water in the lungs outside the blood vessels.EVLW是胸腔内热容积和胸腔内血容积的差值。它反应肺血管外的水有多少。Calculation of Extravascular Lung Water(EVLW)Introduction to the PiCCO Technology Extravascular Lung Water第36页/共49页Katzenelson et al,Crit Care Med 32(7),
49、2004 Sakka et al,Intensive Care Med 26:180-187,2000GravimetryDye dilutionEVLW from 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.PiCCO技术测得的EVLW与通过重力实验与染料稀释法测得的血管外肺水有很好的相关性Validatio
50、n of Extravascular Lung Watern=209r=0.96ELWI by gravimetryELWI by PiCCOR=0,97P 0.050208015-10-151060D D radiographic score-80-60-40-20D D ELWIEVLW as a quantifier of lung oedemaIntroduction to the PiCCO Technology Extravascular Lung Water第40页/共49页ELWI(ml/kg)21 n=5414-21 n=1007-14 n=174 2090100Sakka