1、危重病患者的血流动力学监测危重病患者的血流动力学监测focus on PiCCO北京协和医院杜斌血流动力学监测增加患者病死率血流动力学监测增加患者病死率Connors AF Jr,Speroff T,Dawson NV,Thomas C,Harrel FE Jr,Wagner D,Desbjens N,Goldman L,Wu AW,Califf RM,Fulkerson WJ Jr,Vidaillet H,Broste S,Bellamy P,Lynn J,Knaus WA.The effectiveness of right heart catheterization in the ini
2、tial care of critically ill patients.SUPPORT Investigators.JAMA 1996;276(11):889-897 血流动力学监测为何不能改善预后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n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nCXR,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的使用减少的使用减少:Illinois,USA2000年年2001年年降低降低%出院患者数1,
3、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1,7391,37521 75岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterization has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132)PAC的使用减少的使用减少:Illinois,USA200
4、0年年2001年年降低降低%医院大医院87369620其他医院5,0924,32615地区Chicago39.4Rockford40St.Louis33.6中部15Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterization has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132)临床评价临床评价 vs.血流动力学血流动力学目的: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
5、法:n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n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Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553临床评价临床评价 vs.血流动力学血流动力学0%20%40%60%PAWPCOSVRRAP预测
6、准确性预测准确性Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553临床评价临床评价 vs.血流动力学血流动力学结果留置PAC后n计划治疗方案需要改变58%u应用未预计到的治疗方案30%Eisenberg PR,Jaffe AS,Schuster DP.Clinical ev
7、aluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553临床评价临床评价 vs.血流动力学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Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterizat
8、ion in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553血流动力学数据的解释血流动力学数据的解释临床场景(n=44)心脏外科术后16ARDS 9全身性感染 9心源性休克 5其他情况 5Squara P,Fourquet E,Jacquet L,Broccard A,Uhlig T,Rhodes A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterizatio
9、n data:results of the European HEMODYN resident study.Intensive Care Med 2003;29:735-741血流动力学数据的解释血流动力学数据的解释不同意见数目不同意见数目Kappa计算机辅助诊治前住院医生与计算机5.7 2.20.64 0.14*计算机辅助诊治后住院医生与计算机1.9 2.00.88 0.12住院医生与主治医生1.2 1.70.92 0.10主治医生与计算机0.9 1.20.95 0.07*p 0.05Squara P,Fourquet E,Jacquet L,Broccard A,Uhlig T,Rhode
10、s A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterization data:results of the European HEMODYN resident study.Intensive Care Med 2003;29:735-741血流动力学数据的解释血流动力学数据的解释计算机辅助前计算机辅助前计算机辅助后计算机辅助后RCRCRSSC酸碱失衡0.830.930.950.98机械通气0.780.950.960.98代谢0.520.860.900.96充盈状态0.560.840
11、.910.93泵功能0.530.840.900.90循环0.720.910.940.96RC:住院医生与计算机;RS:住院医生与主治医生;SC:主治医生与计算机Squara P,Fourquet E,Jacquet L,Broccard A,Uhlig T,Rhodes A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterization data:results of the European HEMODYN resident study.Intensive Care Med 2003
12、;29:735-741血流动力学参数改变治疗决定血流动力学参数改变治疗决定Squara P,Bennett D,Perret C.Chest 2002;121:2009-2015ICU患者的输液治疗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Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151临床判断缺乏准确性临床判断缺乏准确性:
13、PAWP01015191915100预计预计PAWP(mmHg)测定测定PAWP(mmHg)Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553No change in planned therapy after catheterizationChange in planne
14、d therapy after catheterization0临床判断缺乏准确性临床判断缺乏准确性:CO04.57.0预计预计CO(L/min)测定测定CO(L/min)Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-5534.57.0临床判断缺乏准确性临床判断缺乏准确性Ei
15、senberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553参数参数判断正确数目判断正确数目/测定数目测定数目正确率正确率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855How good are our clinical skills?Cardia
16、c outputWedge pressureConnors(NEJM 83)ICU pts44%42%Eisenberg(CCM 84)ICU pts50%33%Bayliss(BMJ 83)CCU pts71%62%临床判断缺乏准确性临床判断缺乏准确性Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patientsEisenberg PR,et al.Crit Care Med 1984;12:349Assessin
17、g hemodynamic status in critically ill patients:Do physicians use clinical information optimally?Connors AF,et al.J Crit Care 1987;2:174Therapeutic impact of PAC in the ICUSteingrub,et al.Chest 1991;99:1451PAC in critically ill patients:A prospective analysis of outcome changes associated with cathe
18、ter-prompted changes in therapyMimoz O et al.Crit Care Med 1994;22:573Hemodynamic and pulmonary fluid status in the trauma patient:are we slipping?Veale WN Jr,et al.Am Surg.2005;71:621临床判断缺乏准确性临床判断缺乏准确性医生常常相信自己的判断,但自信与准确性之间并无相关性与经验较少的医生相比,尽管有经验的医生更为自信,但他们的判断并不准确医生不应盲目根据自己对心脏功能的判断,作为治疗决策的依据Dawson NV
19、et al.Hemodynamic assessment in managing the critically ill:is physician confidence warranted?Med Decis Making 1993;13:258-266临床判断血流动力学的准确性临床判断血流动力学的准确性Clinical SettingAccurate Assessment,%Unanticipated Changes in Therapy Based on PAC,%Connors,et al62 noncardiac medical intensive care patients4848Ei
20、senberg,et al103 critically ill patients5030Tuchschmidt and Sharma35 noncardiac medical intensive care patients 4265Steingrub,et al154 combined medical/surgical intensive care patients 5147Connors,et alCardiac and noncardiac medical intensive care 6647临床重要的血流动力学参数临床重要的血流动力学参数所有医生所有医生(n=417)心内科医生心内科医
21、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%)Squara P,Bennett D,Perret C.Chest 2002;121:2009-2015心脏手术后患者的血流动力学监测心脏手术后患者的血流动力学监测问卷调查(39个问题)n血流动力学监测n容量替代n正性肌力药物/升压药物n输血德国的80个ICU主任问卷回收率69%Kastrup M,Markewitz A,Spies C,Ca
22、rl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.心脏手术后患者的血流动力学监测心脏手术后患者的血流动力学监测血流动力学监测血流动力学监测比例比例(%)基
23、本监测100肺动脉导管(PAC)58.2经食道超声(TEE)38.1PICCO13.0Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinav
24、ica 2007;51(3):347-358.英格兰与威尔士英格兰与威尔士ICU的的CO监测技术监测技术Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)英格兰与威尔士英格兰与威尔士ICU的的CO监测技术监测技术CO监测技术 2种69%首选经食道多普勒监测CO41%常规监测ScvO220%Esdaile B,Raobaikady R.
25、Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)Are We Using PAC Correctly?PAWP测定中的技术问题测定中的技术问题Morris AH,Chapman RH,Gardner RM.Frequency of technical problems encountered in the measurement of pulmonary artery wedg
26、e pressure.Crit Care Med 1984;12(3):164-170N(%)measurements%of technical problemsNo problem1868(69)Technical problems843(31)Criterion 1(total)(12)(38)Unable to obtain an“atrial waveform”1238Criterion 2(total)156(6)19WP waveform intermediate between the phasic PA and atrial waveforms100(4)12Spontaneo
27、us variation of WP56(2)7Criterion 3(total)381(14)45Poor dynamic response184(7)22Damped tracing65(2)8Overinflation42(2)5Cannot aspirate blood with the catheter in the PA36(1)4Cannot aspirate blood with the catheter in the wedge position54(2)6PAWP测定中的技术问题测定中的技术问题Morris AH,Chapman RH,Gardner RM.Frequen
28、cy of technical problems encountered in the measurement of pulmonary artery wedge pressure.Crit Care Med 1984;12(3):164-170WPTechnical ProblemCorrected byInitialConfirmed228OverinflationDeflated balloon812Venous bloodAdvance 2 cm308Venous bloodWithdrawn156Venous bloodNothing812Poor dynamic responseW
29、ithdrawn 4 cm248Poor dynamic responseDeflated and inflated balloon2313Poor dynamic responseWithdrawn128Poor dynamic responseFlushed3618Partial WPPatient coughed214Partial WPRepositioned720Partial WPNothing1420?RepositionedWP initial WP confirmed=11 6 mmHgRange(-13,+22)PAWP测定中的技术问题测定中的技术问题Morris AH,C
30、hapman RH,Gardner RM.Frequency of wedge pressure errors in the ICU.Crit Care Med 1985;13(9):705-708ProblemDescriptionsNumber(%)Damped tracingReduced high-frequency content40(43%)Poor dynamic responseAbsent oscillation,low frequency,or inadequate duration of oscillations after a sudden pressure decre
31、ase from approximately 300 mmHg to vascular levels58(62%)Over inflationSlow,frequently linear increase in pressure after balloon inflation10(9%)Partial WPWaveform intermediate between phasic PA and atrial waveforms22(25%)PAWP测定中的技术问题测定中的技术问题Distribution of WP measurements and frequency of a WP error
32、 4 mmHgTrauma ICURespiratory ICUN%(95%CI)N%(95%CI)Total WP attempts10917%(11 26%)17710%(6 15%)WP ultimately confirmed80158Initial WP without technical problems468%(3 16%)1334%(1 8%)Initial WP with technical problems5326%(18 44%)4031%(17 47%)No WP obtained104Morris AH,Chapman RH,Gardner RM.Frequency
33、of wedge pressure errors in the ICU.Crit Care Med 1985;13(9):705-708ICU医生缺乏医生缺乏PAC的相关知识的相关知识目的:评价欧洲国家ICU医生对PAC相关知识的了解程度设计:调查问卷背景:86个欧洲大学及非大学医院ICU对象:从两个欧洲危重病医学会目录中选取134个ICU.其中86个ICU的535名医生参加问卷调查干预:在每个ICU中,所有医生均被要求同时完成一项调查问卷,包括31个多选题,涉及床旁留置PAC的所有方面Gnaegi A,Feihl F,Perret C.Intensive care physicians in
34、sufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220ICU医生缺乏医生缺乏PAC的相关知识的相关知识Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220PAC相关知
35、识调查问卷的内容分类1压力或心输出量测定的技术问题2相关指标的计算3血流动力学指标的解读4留置导管5导管相关并发症的识别,预防及治疗6应用PAC指导治疗7其他ICU医生缺乏医生缺乏PAC的相关知识的相关知识In-TrainingPostgraduate Training CompletedPrimary Medical SpecialtyAnesthesiology69.9 13.777.0 12.6Internal Medicine67.9 14.378.3 11.5Others62.4 16.369.8 15.2Opinion of Respondents on Their Knowled
36、ge of PACsInadequate57.6 15.355.0 17.3Minimal65.7 14.371.9 14.1Adequate73.2 13.179.2 10.7Superfluous-83.3 0Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220ICU医生缺乏医生缺乏PAC的相关知识的相关知识60.665.
37、46977.380.874.373.878.283.378.95060708090Never 10/mthInserting PACs:Frequency in the Last 6 MthsMean ScoresIn-TrainingPostgraduate Training CompletedGnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997
38、;25:213-220ICU医生缺乏医生缺乏PAC的相关知识的相关知识55.862.667.971.173.663.970.275.279.581.95060708090Never 10/mthUsing PAC Data for Guiding Therapy:Frequency in the Last 6 MthsMean ScoresIn-TrainingPostgraduate Training CompletedGnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-hea
39、rt catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220ICU医生缺乏医生缺乏PAC的相关知识的相关知识63.470.975.977.473.367.67379.979.678.85060708090Never 10/mthSupervising PAC Insertion:Frequency in the Last 6 MthsMean ScoresIn-TrainingPostgraduate Training CompletedGnaegi A,Feihl F,Perret C.Intensiv
40、e care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220Is There an Easy Alternative to This Dilemma?Central venous catheterInjectate temperature sensor housing PV4046 Arterial thermodilution catheter Injectate temperature senso
41、r cablePC80109 PULSION disposable pressure transducer PV8115PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625 DPT Monitor cablePMK-206Interface cablePC80150 Connection cableto bedside monitorPMK-XXX AUX adaptercable PC81200 PiCCO的技术原理的技术原理PiCCO技术由下列两种技术组
42、成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:a.经肺热稀释技术经肺热稀释技术b.动脉脉搏轮廓分析技术动脉脉搏轮廓分析技术心输出量的测定心输出量的测定:经肺热稀释技术经肺热稀释技术中心静脉内注射指示剂后,动脉导管尖端的热敏电阻测量温度下降的变化曲线通过分析热稀释曲线,使用Stewart-Hamilton公式计算得出心输出量(CO)Tb注射注射t心输出量的测定心输出量的测定:经肺热稀释技术经肺热稀释技术经肺热稀释测量只需要在中心静脉内注射冷(8C)或室温(24C)生理盐水中心静中心静脉注射脉注射右心右心左心左心肺肺PiCCO导导管如插在管如插在股动脉内股动脉内热稀释法测
43、定热稀释法测定CO:PiCCO vs.PACPCCO动脉热稀释动脉热稀释测量位置测量位置静脉注射静脉注射RAEDVPBVEVLWLAEDVLVEDVEVLWRVEDV常规热稀释常规热稀释测量位置测量位置s010203040500,00,20,40,6 C-D DT注射注射热热稀稀释释测测量量曲曲线线D-dtTKV)T(TCObiibTDa Tb=血流温度血流温度Ti =注射指示剂温度注射指示剂温度Vi =注射指示剂容积注射指示剂容积 Tb.dt=热稀释曲线下面积热稀释曲线下面积K=校正系数校正系数动脉脉搏轮廓分析动脉脉搏轮廓分析动脉脉搏轮廓分析通过动脉压力波型的形状获得连续的每搏参数通过经肺热
44、稀释法的初始校正后,该公式可以在每次心脏搏动时计算出每搏量(SV)t sP mm HgSV连续心输出量测定连续心输出量测定:PiCCO压力曲线压力曲线下面积下面积压力曲线型压力曲线型状状PCCO=cal HR SystoleP(t)SVR+C(p)dPdt()dt动脉顺应动脉顺应性参数性参数心心率率与病人有关的校与病人有关的校正因子正因子 t sP mm HgPCCO is displayed as last 12s mean心输出量的测定心输出量的测定:PiCCO vs.热稀释热稀释AuthorPt/ObsCOTDa COTDpaBias SDrVon Spiegel,et al.Anaes
45、thesist 1996;45(11)21/48-4.7 1.5%.97McLuckie,et al.Acta Paediatr 1996;859/?0.19 0.21 L/min/m2Goedje,et al.Chest 1998;113(4)30/1500.16 0.31 L/min/m2.96Goedje,et al.Thorac Cardiovasc Surg 1998;4630/8100.26 0.71 L/min.96Zoolner,et al.Anaesthesist 1998;47(11)18/1600.03 1.04 L/min.91Goedje,et al.Crit Car
46、e Med 1999;27(11)24/216-0.29 0.66 L/min.93Sakka,et al.Intensive Care Med 1999;2537/4490.68 0.62 L/min.97Sakka,et al.J Cardiothorac Vasc Anesth 2000;14(2)12/510.73 0.38 L/min.96Zoolner,et al.J Cardiothorac Vasc Anesth 2000;14(2)19/760.21 0.73 L/min.96Bindels,et al.Crit Care 2000;445/2830.49 0.45 L/mi
47、n/m2.95PiCCO的技术原理的技术原理PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:a.经肺热稀释技术经肺热稀释技术b.动脉脉搏轮廓分析技术动脉脉搏轮廓分析技术PiCCO容量参数容量参数全心舒张末期容积GEDV胸腔内血容积ITBV血管外肺水EVLW通过对热稀释曲线的分析,可以得到这些容量参数ln c(I)注射注射At再循环再循环MTtte-1DStc(I)全心舒张末期容积全心舒张末期容积(GEDV)全心舒张末期容积(GEDV)是心脏4个腔室内的血容量胸腔内血容积胸腔内血容积(ITBV)胸腔内血容积(ITBV)是心脏4个腔室的容积+肺
48、血管内的血液容量血管外肺水血管外肺水(EVLW)血管外肺水(EVLW)是肺内含有的水量,可以在床旁定量判断肺水肿的程度容量的测量原理容量的测量原理ln c(I)注射注射At再循环的影响再循环的影响MTtte-1DStc(I)MTt:Mean transit time平均传输时间平均传输时间 half of the indicator passed the point of detection DSt:Downslope time下降时间下降时间 exponential downslope time of TD curve容量的测量原理容量的测量原理Vall=V1+V2+V3+V4 =MTt x
49、 FlowMeier et al.J Appl Physiol.1954V3=最大腔的容积最大腔的容积 =DSt x FlowNewman et al.Circulation.1951指示剂由注射点到检测点的平均传输指示剂由注射点到检测点的平均传输时间时间MTt由两点间的总容积决定由两点间的总容积决定下降时间下降时间DSt由其中最大的腔室决由其中最大的腔室决定定(比其它腔至少大比其它腔至少大 20%成立成立!)flowV3V4V2V1注射注射检测检测胸腔内的容积组成胸腔内的容积组成GEDVPTVRAEDVPBVLAEDVLVEDVRVEDVEVLWEVLWITTVPTV=肺内热容积肺内热容积,
50、在一系列混合腔室中具有最大的热容积在一系列混合腔室中具有最大的热容积(DSt 容积容积)ITTV=胸腔内总热容积胸腔内总热容积,从注射点到测量的热容积之和从注射点到测量的热容积之和(MTt 容积容积)GEDV=全心舒张末期容积全心舒张末期容积=ITTV PTV容量的测量原理容量的测量原理RAEDVPTVLAEDVLVEDVRVEDV胸腔总热容积胸腔总热容积(ITTV)ITTV=CO x MTtTDa肺内总热容积肺内总热容积(PTV)PTV =CO x DStTDa全心舒张末期容积全心舒张末期容积GEDV=ITTV PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLV
