1、血血流动力学监测流动力学监测Theory and Practice血流动力学 Swan和Ganz发明通过血流引导的气囊漂浮导管（漂浮导管 或 Swan-Ganz 导管 或 肺动脉导管）继中心静脉压（CVP）之后临床监测的一大新进展 Dr.William Ganz(1919-2009.11.10)Swan-Ganz 导管 通过热稀释法获得心排 假设 PCWP(肺毛细血管嵌压)LAP（左房压）LVEDP(左室舒张末压)LVEDV(左室舒张末容量)相 当于前负荷来通过压力指标来反映容量状态 经食管超声技术（TEE）原理物体（红细胞）移动的速度和已知频率超声波的反射频率成正比 HemoSonicTM1
2、00的超声多普勒探头 通过测定红细胞移动的速度来推算降主动脉的血流量 TEE 优势：准确性高 降主动脉的血流量是CO的70%劣势：误差多，对操作者经验要求高，需严格培训，费用高7监监测生命体征测生命体征MonitoringRespiration RateTemperature8一一些重要的指标些重要的指标MonitoringBlood Pressure(NiBP)no correlation with CO no correlation with oxygen deliveryECGRespiration RateTemperaturePiCCO Technology液液体管理所需要的指标体管
3、理所需要的指标Introduction to the PiCCO-TechnologyCO前负荷 EVLW收缩力指数个个性化的容量管理性化的容量管理-static -dynamicPiCCO 技术监测功能原理热稀释技术脉搏轮廓分析技术收缩力指数前、后负荷参数血管外肺水肺部通透性指数血血流流动动力学力学监测监测PiCCO 技技术术 依据经肺热稀释技术以及脉搏轮廓分析技术原原理理Left HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial therm
4、odilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology FunctionBolus injectionconcentration changes over time(Thermodilution curve)中心静脉处注入冰盐水，依次经过胸腔内各腔室 股动脉导管内有热敏电阻，会记录温度的变化 Introduction to the PiCCO-Technology FunctionLeft heartRight heartLungsRARVLALVPBVEVLWEVLW原原理理胸胸
5、腔内各腔室腔内各腔室Introduction to the PiCCO-Technology Function肺肺内内热热容容积积(PTV)胸胸腔内热容积腔内热容积(ITTV)Total of mixing chambers RARVLALVPBVEVLWEVLW最大混合腔室血血流流动动力学力学监测监测Introduction to PiCCO Technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数Tb x dt(Tb-Ti)x Vi x K TbInjectiontD D=COTD aTb=Blood temperatureTi =Injectat
6、e temperatureVi =Injectate volume Tb.dt=Area under the thermodilution curveK =Correction constant,made up of specific weight and specific heat of blood and injectateCO的计算是通过对热稀释曲线分析，使用 Stewart-Hamilton 方程式 心心排的排的计计算算Introduction to the PiCCO-Technology Thermodilution热稀释曲线下面积反比例反映CO 36,537510热热稀稀释释曲曲
7、线线Normal CO:5.5l/minIntroduction to the PiCCO-Technology Thermodilution36,53736,537Timelow CO:1.9l/minHigh CO:19l/minTimeTimeTemperatureTemperatureTemperature经经肺肺热热稀稀释释 vs.肺肺动动脉脉导导管管Left heartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATH arterial thermo-dilution cathetercentral ven
8、ous bolus injectionRARVPALALVAortaTranspulmonary TD(PiCCO)Pulmonary Artery TD(PAC)In both procedures only part of the injected indicator passes the thermistor.Nonetheless the determination of CO is correct,as it is not the amount of the detected indicator but the difference in temperature over time
9、that is relevant!Introduction to the PiCCO Technology ThermodilutionComparison with the Fick Method0,970,68 0,6237/449Sakka SG et al.,Intensive Care Med 25,2019-/-0,19 0,219/27McLuckie A.et a.,Acta Paediatr 85,20190,960,16 0,3130/150Gdje O et al.,Chest 113(4),20190.980,32 0,2923/218Holm C et al.,Bur
10、ns 27,20190,930,13 0,5260/180Della Rocca G et al.,Eur J Anaest 14,20190,95-0,04 0,4117/102Friedman Z et al.,Eur J Anaest,20190,950,49 0,4545/283Bindels AJGH et al.,Crit Care 4,20000,980,03 0,1718/54Pauli C.et al.,Intensive Care Med 28,201924/120n(Pts/Measurements)0,990,03 0,24Tibby S.et al.,Intensiv
11、e Care Med 23,2019r bias SD(l/min)Comparison with Pulmonary Artery Thermodilution经经肺肺热热稀稀释释技技术术的有效性的有效性Introduction to the PiCCO Technology ThermodilutionMTt:Mean Transit time the mean time required for the indicator to reach the detection pointDSt:Down Slope time the exponential downslope time of t
12、he thermodilution curveRecirculationte-1TbFrom the characteristics of the thermodilution curve it is possible to determine certain time parameters 对对热热稀稀释释曲曲线线做做进进一步分析一步分析 Introduction to the PiCCO-Technology ThermodilutionInjectionIn TbMTtDStTb=blood temperature;lnTb=logarithmic blood temperature;t
13、=timePulmonary Thermal VolumePTV=Dst x COBy using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated 计计算算 ITTV 与与 PTVIntroduction to the PiCCO-Technology ThermodilutionRecirculationte-1TbInjectionIn TbIntrathoracic Thermal VolumeITTV=MTt x COMTtDStPulmonary T
14、hermal Volume(PTV)Intrathoracic Thermal Volume(ITTV)Calculation of ITTV and PTVEinfhrung in die PiCCO-Technologie ThermodilutionITTV=MTt x COPTV=Dst x CO RARVLALVPBVEVLWEVLWGEDV is the difference between intrathoracic and pulmonary thermal volumesGlobal End-diastolic Volume(GEDV)Volumetric preload p
15、arameters GEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroduction to the PiCCO Technology ThermodilutionVolumetric preload parameters ITBVIntrathoracic Blood Volume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroduction to the PiCCO Technology ThermodilutionITBV is the total of the Global End-Diastolic Volume and t
16、he blood volume in the pulmonary vessels(PBV)ITBVTD(ml)ITBV=1.25*GEDV 28.4 mlGEDV vs.ITBV in 57 Intensive Care PatientsIntroduction to the PiCCO-Technology ThermodilutionITBV is calculated from the GEDV by the PiCCO Technology 01000200030000100020003000GEDV(ml)Sakka et al,Intensive Care Med 26:180-1
17、87,2000Summary and Key Points-Thermodilution PiCCO 技术是一种微创的方法，用以监测容量状态和心血管功能 根据经肺热稀释技术可以计算出各种容积参数.CO 由热稀释曲线形状描记.心脏前负荷相关的容积参数可以通过对热稀释曲线进一步分析获得。Introduction to the PiCCO-Technology Haemodynamic MonitoringIntroduction to PiCCO Technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数Transpulmonary Thermodiluti
18、onThe pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curveCalibration of the Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse contour analysisInjectionPulse Contour AnalysisT=blood tempe
19、rature t=timeP=blood pressurePCCO=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 analysisParameters
20、of Pulse Contour Analysis n(Pts/Measurements)0,940,03 0,6312/36Buhre W et al.,J Cardiothorac Vasc Anesth 13(4),201919/7624/51762/18620/36025/38022/96-/-0,40 1,3Mielck et al.,J Cardiothorac Vasc Anesth 17(2),20190,880,31 1,25Zllner C et al.,J Cardiothorac Vasc Anesth 14(2),20000,88-0,2 1,15Gdje O et
21、al.,Crit Care Med 30(1),20190,94-0,02 0,74Della Rocca G et al.,Br J Anaesth 88(3),20190,93-0,14 0,33Felbinger TW et al.,J Clin Anesth 46,2019-/-0,14 0,58Rauch H et al.,Acta Anaesth Scand 46,2019r bias SD(l/min)Comparison with pulmonary artery thermodilutionValidation of Pulse Contour AnalysisIntrodu
22、ction to the PiCCO-Technology Pulse contour analysisThe Stroke Volume Variation is the variation in stroke volume over the ventilatory cycle,measured over the previous 30 second period.Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters o
23、f volume responsiveness Stroke Volume VariationThe increase of preload volume is equal:EDV1 =EDV2 SV1 SV2SVV 提示心脏对容量治疗的反应好坏提示心脏对容量治疗的反应好坏EDVSVSVV smallSVV large EDV1 EDV2 SV1 SV2The pulse pressure variation is the variation in pulse pressure over the ventilatory cycle,measured over the previous 30 s
24、econd period.Parameters of Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Pulse Pressure VariationSummary pulse contour analysis-CO and volume responsiveness PiCCO脉搏轮廓分析技术是由经肺热稀释技术计算进一步获得 PiCCO 技术分析动脉压力曲线每次的搏动，可以提供实时的参数 CO
25、之外，反映容积相关的血流动力学参数SVV(stroke volume variation)和PPV(pulse pressure variation)可以持续获得Introduction to the PiCCO-Technology Pulse contour analysisHaemodynamic MonitoringIntroduction to PiCCO Technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数Contractility is a measure for the performance of the heart muscle
26、 Contractility parameters of PiCCO technology:-dPmx(maximum rate of the increase in pressure)-GEF(Global Ejection Fraction)-CFI(Cardiac Function Index)Contractility Introduction to the PiCCO-Technology Contractility parameterskgContractility parameter from the pulse contour analysisIntroduction to t
27、he PiCCO-Technology Contractility parametersdPmx=maximum velocity of pressure increaseThe contractility parameter dPmx represents the maximum velocity of left ventricular pressure increase.Contractility parameter from the pulse contour analysisIntroduction to the PiCCO-Technology Contractility param
28、etersfemoral 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 de Hert et al.,JCardioThor&VascAnes 2019 n=220y=-120+(0,8*x)r=0,82p 0,00105001000150001000150020002000500dPmx=maximum
29、velocity of pressure increase is calculated as 4 times the stroke volume divided by the global end-diastolic volume reflects both left and right ventricular contractilityGEF=Global Ejection FractionContractility parameters from the thermodilution measurementIntroduction to the PiCCO-Technology Contr
30、actility parameters4 x SVGEF=GEDVLALVRARVCombes et al,Intensive Care Med 30,2019GEF=Global Ejection Fraction Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failuresensitivity00,40,60,8010,20,20,40,60,81 specifity2220191816128D FAC,%D GEF,%510-
31、5-20-10102015-15-10r=076,p0,0001n=47Introduction to the PiCCO-Technology Contractility parametersContractility parameters from the thermodilution measurement is the CI divided by global end-diastolic volume index is-similar to the GEF a parameter of both left and right ventricular contractilityCFI=C
32、ardiac Function IndexCICFI=GEDVIIntroduction to the PiCCO-Technology Contractility parametersContractility parameters from the thermodilution measurementCombes et al,Intensive Care Med 30,2019sensitivity00,40,60,8010,20,20,40,60,81 specificity6543,532D FAC,%D GEF,%510-5-20-10102015-15-10r=079,p0,000
33、1n=47CFI=Cardiac Function IndexIntroduction to the PiCCO-Technology Contractility parametersCFI was compared to the gold standard TEE measured contractility in patients without right heart failureContractility parameters from the thermodilution measurementHaemodynamic MonitoringIntroduction to PiCCO
34、 technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性 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 is an important parameter for controlling volume and catecholamine therapies(MAP CVP)x 80SV
35、R=COAfterload parameterSVR=Systemic Vascular ResistanceMAP=Mean Arterial PressureCVP=Central Venous PressureCO=Cardiac Output80=Factor for correction of unitsIntroduction to the PiCCO Technology Afterload parameter 收缩力指数 dPmx 由脉搏轮廓分析技术获得，用于评估左室心肌功能，给出了心功能重要的信息，可以指导治疗 收缩力指数 GEF 和 CFI 是评估全心功能的重要参数，支持心
36、衰的早期诊断 外周血管阻力 SVR 由血压和心排获得，是一个进一步评估心血管功能的指数，对于容量的控制和血管活性药物的应用提供了重要信息。Summary and Key PointsIntroduction to the PiCCO Technology Contractility and AfterloadHaemodynamic MonitoringIntroduction to PiCCO technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数To Dry or Not to DryITTV ITBV=EVLWThe Extravascular
37、 Lung Water is the difference between the intrathoracic thermal volume and the intrathoracic blood volume.It represents the amount of water in the lungs outside the blood vessels.Calculation of Extravascular Lung Water(EVLW)Introduction to the PiCCO Technology Extravascular Lung Water容量测量小结ITTV=CO*M
38、TtTDaPTV =CO*DStTDaITBV=1.25*GEDVEVLW=ITTV-ITBVGEDV=ITTV-PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWKatzenelson et al,Crit Care Med 32(7),2019 Sakka et al,Intensive Care Med 26:180-187,2000GravimetryDye dilutionEVLW from the PiCCO technology has been shown to hav
39、e a good correlation with the measurement of extravascular lung water via the gravimetry and dye dilution reference methodsValidation 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 lu
40、ng oedemaIntroduction to the PiCCO Technology Extravascular Lung WaterELWI(ml/kg)21 n=5414-21 n=1007-14 n=174 2090100Sakka et al,Chest 2019Introduction to the PiCCO Technology Extravascular Lung WaterIntensive Care daysMitchell et al,Am Rev Resp Dis 145:990-998,1992 Relevance of EVLW AssessmentVolum
41、e management guided by EVLW can significantly reduce time on ventilation and ICU length of stay in critically ill patients,when compared to PCWP oriented therapy,Ventilation DaysPAC Groupn=101*p 0,05PAC GroupEVLW GroupEVLW Group22 days15 days9 days7 days*p 0,05Introduction to the PiCCO Technology Ex
42、travascular Lung WaterHaemodynamic MonitoringIntroduction to PiCCO Technology功能原理热稀释技术脉搏轮廓分析技术收缩力指数后负荷参数血管外肺水肺部通透性指数Differentiating Lung OedemaPVPI=Pulmonary Vascular Permeability Index is the ratio of Extravascular Lung Water to Pulmonary Blood Volume is a measure of the permeability of the lung ve
43、ssels and as such can classify the type of lung oedema(hydrostatic vs.permeability caused)EVLWPVPI=PBVPBVEVLWIntroduction to PiCCO Technology Pulmonary PermeabilitypermeabilityPVPI normal(1-3)PVPI raised(3)Classification of Lung Oedema with the PVPIDifference between the PVPI with hydrostatic and pe
44、rmeability lung oedema:Lung oedemahydrostaticPBVEVLWPBVEVLWPBVEVLWPBVEVLWIntroduction to PiCCO Technology Pulmonary Permeability16 patients with congestive heart failure and acquired pneumonia.In both groups EVLW was 16 ml/kg.Validation of the PVPIPVPI can differentiate between a pneumonia caused an
45、d a cardiac failure caused lung oedema.Benedikz et al ESICM 2019,Abstract 60Cardiac insufficiencyPVPIPneumonia432Introduction to PiCCO Technology Pulmonary PermeabilityEVLWI answers the question:Clinical Relevance of the Pulmonary Vascular Permeability IndexPVPI answers the question:and can therefor
46、e give valuable aid for therapy guidance!肺肺水有多少水有多少?它它是怎么来的是怎么来的?Introduction to PiCCO Technology Pulmonary PermeabilitySummary and Key Points EVLW 用于评估肺间质的含水量，是唯一用于评估床旁肺水肿程度的参数.血气分析和胸片用于评估肺水肿，不能提供有价值的信息 EVLW 可用于评估ICU病人死亡率 肺血管通透性指数PVPI用于鉴别静水压型肺水肿或是通透性肺水肿Introduction to PiCCO Technology EVLW and Pulm
47、onary PermeabilityPiCCO plus 的连接的连接中心静脉导管中心静脉导管注射水温度测量管注射水温度测量管 PV4046 动脉热稀释导管（动脉热稀释导管（PiCCO导管）导管）注射水温度测量电缆注射水温度测量电缆PC80109 PULSION 动脉压力传感器动脉压力传感器 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 连接床旁
48、监护仪连接床旁监护仪PMK-XXX AUX adaptercable PC81200 CI(l/min/m2)ITBVI(ml/m2)TherapyTargetITBVICFIEVLWI(slowly responding)4.5 10 V+!Cattemporary750-8505.5104.53.010 Cat V-temporary750-850 5.5 1010 V+850-100010 V+temporary750-850850850 10 V-temporary750-850 10850EVLWI(ml/kg)V+=volume loading(!=cautiously)V-=vo
49、lume contractionCat=catecholamines/cardiovascular agentsPiCCO诊断治疗树诊断治疗树正常值正常值ParameterRangeUnitCI3.0 5.0l/min/m2SVI40 60ml/m2 GEDI680 800ml/m2ITBI850 1000ml/m2ELWI*3.0 7.0ml/kgPVPI*1.0 3.0 SVV 10%PPV 10%GEF25 35%CFI4.5 6.51/minMAP70 90mmHgSVRI1700 2400dyn*s*cm-5*m*not available in the USA(p 63)Field
50、s of Application Septic Shock Cardiogenic Shock Hypovolaemic Shock Trauma Burns ARDS Cardiac Surgery Neuro Surgery Major Surgery现在有效循环情况如何现在有效循环情况如何?.心输出量心输出量!前负荷怎样补液前负荷怎样补液OR利尿利尿?.全心舒张末期容积全心舒张末期容积!后负荷如何血管活性药物后负荷如何血管活性药物?.系统血管阻力系统血管阻力!还是给与正性肌力药物还是给与正性肌力药物?.左室收缩力指数左室收缩力指数!是否有肺水肿以及程度是否有肺水肿以及程度?.血管外肺水血
