血流动力学监测-PICCO杜斌

危重病患者的血流动力学监测focusonPiCCO北京协和医院杜斌血流动力学监测增加患者病死率58%60%62%64%66%68%70%RHCNoRHC30天病死率300004000050000RHCNoRHC住院费用(USD)1015RHCNoRHC平均住院日ConnorsAFJr,SperoffT,DawsonNV,ThomasC,HarrelFEJr,WagnerD,DesbjensN,GoldmanL,WuAW,CaliffRM,FulkersonWJJr,VidailletH,BrosteS,BellamyP,LynnJ,KnausWA.Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA1996;276(11):889-897血流动力学监测为何不能改善预后不恰当的适应症PAC的副作用或并发症获得数据的方法不正确仪器定标错误,或传感器位置错误获得的数据不能反映血流动力学状态错误使用数据(对数据的解读错误)作出治疗决定前未考虑其他相关因素CXR,尿量,血清白蛋白采用的治疗措施无效或有害无需血流动力学监测时未及时拔除PACPAC的使用减少:Illinois,USA2000年2001年降低%出院患者数1,636,0461,684,089PAC使用数5,9695,02215.8PAC使用率(/1000)3.652.98年龄0–17岁2195765–74岁1,7391,3752175岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)临床评价vs.血流动力学目的:评价肺动脉导管(PAC)得到的血流动力学指标是否能够改变患者的治疗设计:前瞻性观察患者:103例留置PAC的患者方法:插管前,请医生对一些血流动力学指标的范围,诊断及治疗方案进行预测插管后,复习患者病例,记录插管时及置管8小时内的血流动力学EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553临床评价vs.血流动力学0%20%40%60%PAWPCOSVRRAP预测准确性EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553临床评价vs.血流动力学结果留置PAC后计划治疗方案需要改变58%应用未预计到的治疗方案30%EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553临床评价vs.血流动力学结论单纯根据临床表现难以准确预测血流动力学指标PAC监测数据通常能够改变治疗方案EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学参数改变治疗决定38%80%35%10%0%20%40%60%80%100%最初判断了解PAC资料后作出选择医生的比例与专家意见相同可能有害的意见SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015ICU患者的输液治疗输液治疗的决定因素临床经验中心静脉压或肺动脉楔压BoldtJ,LenzM,KumleB,PapsdorfM.Volumereplacementstrategiesonintensivecareunits:resultsfromapostalsurvey.IntensiveCareMed1998;24:147-151临床判断缺乏准确性:PAWP01015191915100预计PAWP(mmHg)测定PAWP(mmHg)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553NochangeinplannedtherapyaftercatheterizationChangeinplannedtherapyaftercatheterization0临床判断缺乏准确性:CO04.57.0预计CO(L/min)测定CO(L/min)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5534.57.0临床判断缺乏准确性EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553参数判断正确数目/测定数目正确率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855Howgoodareourclinicalskills?CardiacoutputWedgepressureConnors(NEJM‘83)ICUpts44%42%Eisenberg(CCM‘84)ICUpts50%33%Bayliss(BMJ‘83)CCUpts71%62%临床重要的血流动力学参数所有医生(n=417)心内科医生(n=27)CO330(79%)21(75%)PAWP285(68%)27(100%)SvO2220(53%)10(38%)MPAP120(37%)10(38%)SV100(24%)3(13%)RAP20(5%)RVEF20(5%)RVEDV18(4%)SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015心脏手术后患者的血流动力学监测问卷调查(39个问题)血流动力学监测容量替代正性肌力药物/升压药物输血德国的80个ICU主任问卷回收率69%KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroßeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.心脏手术后患者的血流动力学监测血流动力学监测比例(%)基本监测100肺动脉导管(PAC)58.2经食道超声(TEE)38.1PICCO13.0KastrupM,MarkewitzA,SpiesC,CarlM,ErbJ,GroßeJ,SchirmerU.Currentpracticeofhemodynamicmonitoringandvasopressorandinotropictherapyinpost-operativecardiacsurgerypatientsinGermany:resultsfromapostalsurvey.ActaAnaesthesiologicaScandinavica2007;51(3):347-358.英格兰与威尔士ICU的CO监测技术76%53%19%33%8%0%20%40%60%80%100%PACDoppler锂稀释COPICOO其他百分比EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)英格兰与威尔士ICU的CO监测技术CO监测技术2种69%首选经食道多普勒监测CO41%常规监测ScvO220%EsdaileB,RaobaikadyR.SurveyofcardiacoutputmonitoringinintensivecareunitsinEnglandandWales.CriticalCare2005;9(Suppl1):P68(DOI10.1186/cc3131)AreWeUsingPACCorrectly?PAWP测定中的技术问题MorrisAH,ChapmanRH,GardnerRM.Frequencyoftechnicalproblemsencounteredinthemeasurementofpulmonaryarterywedgepressure.CritCareMed1984;12(3):164-170N(%)measurements%oftechnicalproblemsNoproblem1868(69)Technicalproblems843(31)Criterion1(total)(12)(38)Unabletoobtainan“atrialwaveform”1238Criterion2(total)156(6)19WPwaveformintermediatebetweenthephasicPAandatrialwaveforms100(4)12SpontaneousvariationofWP56(2)7Criterion3(total)381(14)45Poordynamicresponse184(7)22Dampedtracing65(2)8Overinflation42(2)5CannotaspiratebloodwiththecatheterinthePA36(1)4Cannotaspiratebloodwiththecatheterinthewedgepo