picco监测的意义及影响因素

PICCO监测的意义及影响因素泉州市正骨医院ICU重症患者我们关注什么？•容量•组织器官灌注•心功能•肺部情况•氧供、氧耗•血压、心率•CVP、PAWP•皮肤弹性•尿量•心血管彩超•血氧饱和度•氧分压、二氧化碳分压（敏感性、特异性差，主观性强，影响因素多，缺乏连续性）PICCO监测技术•直观•准确•特异性•连续性3次热稀释校准经肺热稀释曲线injectiontT动脉脉搏轮廓分析Pt＝两种技术经热稀释方法得到的非连续性参数•心输出量CO•全心舒张末期容积GEDV•胸腔内血容量ITBV•血管外肺水EVLW*•肺血管通透性指数PVPI*•心功能指数CFI•全心射血分数GEF动脉轮廓分析法得到的连续性参数•连续心输出量PCCO•动脉压AP•心率HR•每搏量SV•每搏量变异SVV•脉压变异PPV•系统血管阻力SVR•左心室收缩力指数dPmax*血液动力学和容量进行监护管理＋两部分参数PiCCOPiCCO(PulseindicateContourCardiacOutput)脉搏轮廓动脉压波形分析法中心静脉导管注射液温度探头容纳管PV4046PCCIAP13.0316.28TB37.0AP14011792(CVP)5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140(GEDI)625压力线206PMK动脉热稀释导管PULSION一次性压力传感器PV8115（包括PV4046）温度测量电缆PC80150注射液温度电缆PC80109导管连接PICCO2连接图•ScvO2–中心静脉氧饱和度•通过标准中心静脉导管放置•SvO2(混合静脉氧饱和度)目前只能通过高创伤性的右心导管获得•ScvO2和SvO2之间有良好的相关性•正常值范围:ScvO270-80%SvO265-75%氧供和氧耗DO2I–氧供(Index)•通过CI，血红蛋白，动脉血氧饱和度来计算VO2I–氧耗(Index)•通过CI，血红蛋白，动脉以及混合静脉氧饱和度来计算正常值范围:DO2400-650ml/min/m2VO2125-175ml/min/m2S(c)vO2CO,HbOxygenintakeOxygentransportOxygendeliveryOxygenconsumptionVO2I=CIxHbx1,34x(SaO2–S(c)vO2)DO2I=CIxHbx1,34xSaO2SaO2ConsumptionDelivery经肺热稀释•在中心静脉内注射冷（8ºC）生理盐水作为指示剂•动脉导管尖端的热敏电阻测量温度下降的变化曲线•使用Stewart-Hamilton公式计算得出心输出量（CO）••PiCCO测得的CO与肺动脉导管测得的CO相关良好[s]010203040500,00,20,40,6[°C]-DT注射热稀释测量曲线D-dtTKV)T(TCObiibTDaTb=血流温度Ti=注射指示剂温度Vi=注射指示剂容积∫∆Tb.dt=热稀释曲线下面积K=校正系数Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectate热稀释曲线下的面积与心输出量成反比36,537510热稀释曲线NormalCO:5.5l/min36,53736,537TimelowCO:1.9l/minHighCO:19l/minTimeTimeTemperatureTemperatureTemperatureMTt:MeanTransittime平均通过时间themeantimerequiredfortheindicatortoreachthedetectionpointDSt:DownSlopetime斜面下时间theexponentialdownslopetimeofthethermodilutioncurveRecirculationte-1TbFromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters根据热稀释曲线可以算出时间参数对热稀释曲线做进一步分析IntroductiontothePiCCO-Technology–ThermodilutionInjectionInTbMTtDStTb=bloodtemperature;lnTb=logarithmicbloodtemperature;t=timePulmonaryThermalVolumePTV肺内热容积=DstxCOByusingthetimeparametersfromthethermodilutioncurveandtheCOITTVandPTVcanbecalculated计算ITTV与PTVIntroductiontothePiCCO-Technology–ThermodilutionRecirculationte-1TbInjectionInTbIntrathoracicThermalVolumeITTV胸腔内热容积=MTtxCOMTtDStPulmonaryThermalVolume(PTV)IntrathoracicThermalVolume(ITTV)CalculationofITTVandPTVEinführungindiePiCCO-Technologie–ThermodilutionITTV=MTtxCOPTV=DstxCORARVLALVPBVEVLWEVLWGEDVisthedifferencebetweenintrathoracicandpulmonarythermalvolumesGlobalEnd-diastolicVolume(GEDV)Volumetricpreloadparameters–GEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroductiontothePiCCO–Technology–ThermodilutionVolumetricpreloadparameters–ITBVIntrathoracicBloodVolume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroductiontothePiCCO–Technology–ThermodilutionITBVisthetotaloftheGlobalEnd-DiastolicVolumeandthebloodvolumeinthepulmonaryvessels(PBV)ITTV–ITBV=EVLWTheExtravascularLungWateristhedifferencebetweentheintrathoracicthermalvolumeandtheintrathoracicbloodvolume.Itrepresentstheamountofwaterinthelungsoutsidethebloodvessels.CalculationofExtravascularLungWater(EVLW)IntroductiontothePiCCO–Technology–ExtravascularLungWater容量测量小结ITTV=CO*MTtTDaPTV=CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWTranspulmonaryThermodilutionThepulsecontouranalysisiscalibratedthroughthetranspulmonarythermodilutionandisabeattobeatrealtimeanalysisofthearterialpressurecurve动脉脉搏波形校准IntroductiontothePiCCO-Technology–PulsecontouranalysisInjectionPulseContourAnalysisT=bloodtemperaturet=timeP=bloodpressureCOTPD=SVTDHR脉搏轮廓分析Cal=校准系数来自经肺热稀释方法Surface=Cal.xStrokevolume动脉脉搏轮廓分析压力曲线下面积压力曲线型状PCCO=cal•HR•SystoleP(t)SVR+C(p)•dPdt()dt动脉顺应性参数心率与病人有关的校正因子t[s]P[mmHg]t[s]P[mmHg]左心室收缩力指数dPmx=动脉压力曲线的上升枝PiCCO心肌收缩力参数收缩力参数dPmx指的是左心室压力曲线上的最大值。SVmax–SVminSVV=SVmeanSVmaxSVminSVmeanTheStrokeVolumeVariationisthevariationinstrokevolumeovertheventilatorycycle,measuredovertheprevious30secondperiod.IntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–StrokeVolumeVariationSVV提示心脏对容量治疗的反应好坏每博量变异是每博量在一个呼吸周期中的变异，它所测量的是之前30秒的值。PPmax–PPminPPV=PPmeanThepulsepressurevariationisthevariationinpulsepressureovertheventilatorycycle,measuredovertheprevious30secondperiod.IntroductiontothePiCCO-Technology–PulseContourAnalysisDynamicparametersofvolumeresponsiveness–PulsePressureVariationPPmaxPPmeanPPmin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。•GEF是4倍的SV除以全心舒张末期容量•它反应的是全心功能参数GEF=GlobalEjectionFractionContractilityparametersfromthethermodilutionmeasurementIntroductiontothePiCCO-Technology–Contractilityparameters4xSVGEF=GEDVLALVRARV•CFI是CI除以全心舒张末期容量指数•它与GEF相似，是反映全心功能的参数CFI=CardiacFunctionIndexCICFI=GEDVIIntroductiontothePiCCO-Technology–ContractilityparametersContractilityparametersfromthethermodilutionmeasurement•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。•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)x80SVR=COAfterloadparameter后负荷SVR=SystemicVascularResistance全身血管阻力MAP=MeanArterialPressureCVP=CentralVenousPressureCO=CardiacOutput80=FactorforcorrectionofunitsIntroductiontothePiCCO–Technology–AfterloadparameterDifferentiatingLungOedemaPVPI=PulmonaryVascula