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1、内内 容容原理原理 测定参数测定参数临床操作临床操作临床病例临床病例心排监测探讨心排监测探讨第1页/共57页PiCCOPiCCO原理原理第2页/共57页PiCCO Pulse contour cardiac output pulse indicator continue cardiac output 第3页/共57页 PiCCOPiCCO采用成熟的热稀释方法测量单次的采用成熟的热稀释方法测量单次的心输出量（心输出量（COCO），），并通过分析动脉压力波形曲线下面积与并通过分析动脉压力波形曲线下面积与COCO存在的一定关系，来获得连续的心输出量存在的一定关系，来获得连续的心输出量（CCOCCO）
2、a.经肺热稀释技术b.动脉脉搏轮廓分析技术第4页/共57页PiccoPicco技术获得连续技术获得连续COCO的基本原理的基本原理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。第5页/共57页PiCCO plus setupCentral venous catheterInjectate temperature sensor housing PV4046 Arterial thermodilution catheter Injectate temperature sensor cableP
3、C80109 PULSION disposable pressure transducer PV8115PCCIAP AP 140117 92(CVP)5SVRI 2762PCHR 78SVI 42SVV 5%dPmx 1140(GEDI)625 DPT Monitor cablePMK-206Interface cablePC80150 Connection cableto bedside monitorPMK-XXX AUX adaptercable PC81200 第6页/共57页 A.axillaris(A.brachialis)PV2014L08 4F 8 cm A.radialis
4、PV2014L50LGWA 4F 50 cm A.femoralisPV2015L20 5F 20 cmPV2013L07*3F 7 cmPV2014L08*more than 10 kg bodyweight*For application in pediatric patientsApplication sites for thermodilution catheters第7页/共57页TbinjectiontTranspulmonary thermodilution:Cardiac OutputStewart-Hamilton methodTb=Blood temperatureTi =
5、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第8页/共57页Area under pressure curveShape of pressure curvePCCO=cal HR SystoleP(t)SVR+C(p)dPdt()dtAorticcomplianceHeart ratePatient
6、-specific calibration factor(determined by thermodilution)t sP mm HgCalculation of PCCO Model PCCO is displayed as last 12s mean第9页/共57页Methodology of volumetric monitoring(I)ln c(I)injectionAtrecirculationMTtte-1DStc(I)MTt:Mean transit time half of the indicator passed the point of detection DSt:Do
7、wnslope time exponential downslope time of TD curve第10页/共57页ITTV=CO*MTtTDaPTV =CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWCalculation of volumes第11页/共57页PiCCOPiCCO测定的参数测定的参数第12页/共57页Transpulmonary thermodilution para
8、metersCardiac outputCO（心排血量）Intrathoracic blood volumeITBV（胸腔内血容量）Extravascular lung water EVLW（血管外肺水）Cardiac function index CFI（心功能指数）Global ejection fraction GEF(心脏腔室射血分数)经肺热稀释测量的参数经肺热稀释测量的参数第13页/共57页New parametersGEF=GEDV4 x SVGlobal ejection fractionPVPI=PBVEVLWEstimation of pulmonary vascular p
9、ermeability第14页/共57页Pulse contour parametersPulse 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）Stroke 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连续动脉波形
10、测量的参数第15页/共57页正常值范围正常值范围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 10%dP/dtmax 12002000 mmHg/sGEDVI 600750 ml/m2第16页/共57页Decision Tree for volumetric hemodynamic monitoringCI(l/min/m2)ITBVI
11、(ml/m2)TherapyTargetITBVICFIEVLWI(slowly responding)10 V+Cattemporary750-8501010 Cat V-temporary750-850 1010 V+850-100010 V+temporary750-850850850 10 V-temporary750-850 10850EVLWI(ml/kg)V+=volume loading(!=cautiously)V-=volume contractionCat=catecholamines/cardiovascular agents第17页/共57页IndicationsEv
12、ery patient who require a central venous and arterical catheter monitoring.ContraindicationsArterial access restriction due to femoral artery grafting or severe burns in areas where the catheter would normally have been placed.第18页/共57页 The PiCCO method may give incorrect thermodilution measurements
13、 in patients with intracardiac shunts;aortic aneurysm;aortic stenosis;pneumonary;macro lung embolisn and extracorporeal circulation(if blood is either extracted from or infused back into the cardiopulmonary.)第19页/共57页临床操作临床操作第20页/共57页1,按主设定2,收入/转出3,ABP第21页/共57页 按enter收入病人第22页/共57页主设定测量CO 接通第23页/共57页
14、 心输出量测量目录第24页/共57页InjVol选择试验保存第25页/共57页第26页/共57页再采样CVPm2O进行计算第27页/共57页PiCCO临床病例临床病例第28页/共57页病例一病例一l男患男患 5353岁岁 诊断诊断 脓毒症 MODSl处于镇静状态，处于镇静状态，HRHR：9090次分，次分，BPBP：16016070mmHg70mmHg，SaO2SaO2：9090 R R：1515次分次分l气管插管，呼吸机辅助呼吸，气管插管，呼吸机辅助呼吸，SIMVSIMV模式，模式，FIOFIO2 2：6060 PEEPPEEP：8cmH8cmH2 2O O 双肺吸气相呼吸音粗糙，呼气相呼吸
15、音双肺吸气相呼吸音粗糙，呼气相呼吸音弱。弱。l血常规：血常规：WBCWBC：47.0109 NEUT47.0109 NEUT：PLT:25109 PLT:25109 l肝功：肝功：ALT:21U/L AST:14U/L ALBALT:21U/L AST:14U/L ALB：17g17gL Ll肾功：肾功：BUNBUN：L CreaL Crea：399umol399umolL L 第29页/共57页T1第30页/共57页吴国安 T1 T2 BP140/73 196/98 HR8692 CVP58 CI1.662.68 SI19.229.2 SVRI43473933 LCWI2.15.1 LVSW
16、I24.951.6 EVLWI9.16.5 ITBVI453540 GEDVI362432 PVPI 3.7 2.1第31页/共57页病例二病例二女患 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监测第32页/共57页张亚敏 T1 T2 T3 T4 T5 T6 T7 T8 BP71/43 90/48 73/45 79/47 83/50 65/38 69/40 66/33 HR138144127142138147130113 CV
17、P1411109791218 CI3.383.942.743.382.933.513.833.23 SI24.527.421.623.821.323.929.428.6 SVRI9241075131411851526888836719 LCWI2.43.422.72.52.32.72.1 LVSWI17.623.816.119.118.215.620.818.2 EVLWI6.45.37.67.97.27.974.9 ITBVI7658988759638461020962917 GEDVI612718701770677877770733心肺复苏后2小时后850 ml液体扩容后硝普钠多巴酚付肾代
18、入治疗树-OK第33页/共57页第34页/共57页病例三病例三女患 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 米力农第35页/共57页T1T2T3T4T5T6T7 BP85/4593/53mmHg97/55mmHg111/57mmHg94/6299/52mmHg114/52 HR9085bpm85bpm87bpm8366bpm81 CVP99mmHg9mmHg10mmHg912mmHg15 CI0.771.774.314.085.032.964.01 SI9
19、.319.950.746.960.644.849.5 SVRI7718267011141254104814591116 LCWI0.91.644.15.12.73.9 LVSWI10.618.447.547.261.940.347.8 EVLWI13.36.814.414.412.89.621.5 ITBVI72471815631439189715631876 GEDVI57957512511151151712511501CFI1.33.13.43.53.52.32.6停呼吸机多巴胺，多巴酚24小时后多巴胺，多巴酚硝普钠小时持续泵入加用米力农，硝普钠后停多巴胺，多巴酚停米力农第36页/共57页
20、病例四病例四女患 23岁 病毒性脑炎气管插管 呼吸机辅助呼吸 PS 13cmH22O多巴胺 12ug/kg.min 前24小时总入量 6040ml前24小时总出量3750ml第37页/共57页刘晓丽 T1 T2 T3 T4 T5 T5 T6 T7 T8 BP93/49108/5997/56120/76120/72133/78140/79142/81144/79 HR156143106109140114133127132 CVP668562001 CI2.882.763.993.074.212.995.174.73.51 SI18.519.337.628.231.626.338.93726.6
21、SVRI158015641223224016912537154717512304 LCWI2.52.33.73.85.53.976.64.9 LVSWI15.815.835.334.941.334.652.951.936.8 EVLWI6.25.55.565.36.57.38.14.7 ITBVI568591752637713554813837522 GEDVI455473602509570444651670417 CFI 6.35.86.667.37.978.4前24小时入量6040ml，出量3750ml24 小时后入量9010ml出量5430ml48小时后前24小时入量6465出量5660
22、第38页/共57页COCO监测探讨监测探讨第39页/共57页Invasive methodsMinimally invasive methodsNon-invasive methodsThermodilution techniqueFicks cardiac output measurementDoppler ultrasound-Transpulmonary thermodilutionPartial CO2 rebreathingThanspulmonary thermodilutionPulse contour cardiac output estimation without exte
23、rnal caliberation Electrical impedance cardiography第40页/共57页Ficks cardiac output measurement以氧作为指示剂，是一种经典的方法以氧作为指示剂，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 mixed venous blood 第41页/共57页NICO第42页/共57页是利用二氧化碳弥散
24、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)。第43页/共57页优点优点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。第44页/共57页缺点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PETCO2。第45页/共57页Ele
25、ctrical impedance cardiography第46页/共57页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）第47页/共57页第48页/共57页-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 Z
26、0-basal thoracic impedance第49页/共57页操作简单、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第50页/共57页缺点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第51页/共57页020040060080010001200GEDVI(ml/m2)CI(l/min/m2
27、)VolumeInotropicsnormal rangenormal cardiac functionCFI=CI/GEDVICardiac function index(CFI)第52页/共57页EVLWEVLW包括细胞内、组织间、肺泡内包括细胞内、组织间、肺泡内马丽 T9 T8 BP 101/55 101/46 HR90106 CVP109 CI 5.14 6.01 SI 57.1 56.7 SVRI 965 718 LCWI 5 5.2 LVSWI 55.9 48.2 EVLWI 13.4 11.6 ITBVI 1348 1093 GEDVI 1079 874 CFI 4.7 6.8第
28、53页/共57页SVR systemic vascular resistance SVR（MAPCVP）CO CVP经常输入SVRI 1200-2000 dyn*s*cm-5*m2第54页/共57页 SVmaxSVmaxSVminSVminSVmeanSVmeanSVmax SVminSVmax SVminSVV=SVV=SVmeanSVmean SVmax and SVmin are determined over last 30 s windowDetermination of the Stroke Volume Variation(SVV)Only applicable in controlled mechanically ventilated patientsDetermination of the Stroke Volume Variation(SVV)第55页/共57页dPmx=dP/dtmax of arterial pressure curveEstimation of left ventricular pressure velocity increaseIndex of left ventricular contractilityt sP mm Hg第56页/共57页感谢您的观看！第57页/共57页