1、Introduction to PiCCO Technology PiCCO技术的介绍1.Principles of function 理论知识2.Thermodilution 热稀释法3.Pulse contour analysis 脉搏轮廓分析法4.Contractility parameters 收缩力参数5.Afterload parameters 后负荷参数6.Extravascular lung water 血管外肺水7.Pulmonary permeability 肺通透性指数血流动力学监测血流动力学监测Theory and PracticePiCCO TechnologyPar
2、ameters for guiding volume therapyIntroduction to the PiCCO-TechnologyCO心排量Volumetric preload容量负荷 EVLW肺水Contractility收缩力Differentiated Volume Management-static -dynamic -PiCCO Technology is a combination of transpulmonary thermodilution and pulse contour analysisPiCCO技术是经肺热稀释法和脉搏轮廓分析法的结合Principles o
3、f MeasurementLeft HeartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATHPULSIOCATHCVCPULSIOCATH arterial thermodilution cathetercentral venous bolus injectionIntroduction to the PiCCO-Technology FunctionBolus injectionconcentration changes over time(Thermodilution curve)After central v
4、enous injection the cold bolus sequentially passes through the various intrathoracic compartments 中心静脉弹丸注射后，冰盐水会通过胸腔内的各个腔室。The temperature change over time is registered by a sensor at the tip of the arterial catheter 动脉导管尖端的感受器探测到注射液温度的改变。Introduction to the PiCCO-Technology FunctionLeft heartRight
5、 heartLungsRARVLALVPBVEVLWEVLWPrinciples of MeasurementIntrathoracic Compartments(mixing chambers)Introduction to the PiCCO-Technology FunctionPulmonary Thermal Volume(PTV)肺内肺内热热稀稀释释容容积积Intrathoracic Thermal Volume(ITTV)胸腔内热容积胸腔内热容积Total of mixing chambers 所有的混合腔室 RARVLALVPBVEVLWEVLWLargest single m
6、ixing chamber最大的单一混合腔室Haemodynamic MonitoringE.Introduction to PiCCO Technology1.Principles of function 2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary PermeabilityTb x dt(Tb-Ti)x Vi x K TbInjectiontD D=COTD aTb=Blood temp
7、eratureTi =Injectate temperatureVi =Injectate volume Tb.dt=Area under the thermodilution curveK =Correction constant,made up of specific weight and specific heat of blood and injectateThe CO is calculated by analysis of the thermodilution curve using the modified Stewart-Hamilton algorithm 心排量是通过分析热
8、稀释曲线得来的，应用Stewart-Hamilton定律。Calculation of the Cardiac OutputIntroduction to the PiCCO-Technology ThermodilutionThe area under the thermodilution curve is inversely proportional to the CO.热稀释曲线下的面积是与CO呈反比的。36,537510Thermodilution curvesNormal CO:5.5l/minIntroduction to the PiCCO-Technology Thermodi
9、lution36,53736,537Timelow CO:1.9l/minHigh CO:19l/minTimeTimeTemperatureTemperatureTemperatureTranspulmonary vs.Pulmonary Artery ThermodilutionLeft heartRight HeartPulmonary CirculationLungsBody CirculationPULSIOCATH arterial thermo-dilution cathetercentral venous bolus injectionRARVPALALVAortaTransp
10、ulmonary TD(PiCCO)Pulmonary Artery TD(PAC)In both procedures only part of the injected indicator passes the thermistor.在这两种方式中只有一部分注射液会通过热敏感受器。Nonetheless the determination of CO is correct,as it is not the amount of the detected indicator but the difference in temperature over time that is relevant
11、!但是CO正确与否的决定性因素，并不是指示剂的量，而是随着时间变化导致的温度变化，这两者相关的。Introduction to the PiCCO Technology ThermodilutionComparison with the Fick Method0,970,68 0,6237/449Sakka SG et al.,Intensive Care Med 25,1999-/-0,19 0,219/27McLuckie A.et a.,Acta Paediatr 85,19960,960,16 0,3130/150Gdje O et al.,Chest 113(4),19980.980
12、,32 0,2923/218Holm C et al.,Burns 27,20010,930,13 0,5260/180Della Rocca G et al.,Eur J Anaest 14,20020,95-0,04 0,4117/102Friedman Z et al.,Eur J Anaest,20020,950,49 0,4545/283Bindels AJGH et al.,Crit Care 4,20000,980,03 0,1718/54Pauli C.et al.,Intensive Care Med 28,200224/120n(Pts/Measurements)0,990
13、,03 0,24Tibby S.et al.,Intensive Care Med 23,1997r bias SD(l/min)Comparison with Pulmonary Artery ThermodilutionValidation of the Transpulmonary ThermodilutionIntroduction to the PiCCO Technology ThermodilutionMTt:Mean Transit time the mean time required for the indicator to reach the detection poin
14、tDSt:Down Slope time the exponential downslope time of the thermodilution curveRecirculationte-1TbFrom the characteristics of the thermodilution curve it is possible to determine certain time parameters 从热稀释曲线的特点来看，它是可以决定某些时间参数的。Extended analysis of the thermodilution curve Introduction to the PiCCO
15、-Technology ThermodilutionInjectionIn TbMTtDStTb=blood temperature;lnTb=logarithmic blood temperature;t=timePulmonary Thermal VolumePTV=Dst x COBy using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated 通过热稀释曲线的时间参数，可以计算出ITTV和PTV.Calculation of ITTV and PTVI
16、ntroduction to the PiCCO-Technology ThermodilutionRecirculationte-1TbInjectionIn TbIntrathoracic Thermal VolumeITTV=MTt x COMTtDStPulmonary Thermal Volume(PTV)Intrathoracic Thermal Volume(ITTV)Calculation of ITTV and PTVEinfhrung in die PiCCO-Technologie ThermodilutionITTV=MTt x COPTV=Dst x CO RARVL
17、ALVPBVEVLWEVLWGEDV is the difference between intrathoracic and pulmonary thermal volumes.GEDV就是胸腔内热容积和肺内热容积的差值。Global End-diastolic Volume(GEDV)Volumetric preload parameters GEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroduction to the PiCCO Technology ThermodilutionVolumetric preload parameters ITBVIntrath
18、oracic Blood Volume(ITBV)GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroduction to the PiCCO Technology ThermodilutionITBV is the total of the Global End-Diastolic Volume and the blood volume in the pulmonary vessels(PBV)ITBVTD(ml)ITBV=1.25*GEDV 28.4 mlGEDV vs.ITBV in 57 Intensive Care PatientsVolumetric preloa
19、d parameters ITBVIntroduction to the PiCCO-Technology ThermodilutionITBV is calculated from the GEDV by the PiCCO Technology 01000200030000100020003000GEDV(ml)Sakka et al,Intensive Care Med 26:180-187,2000Summary and Key Points-Thermodilution PiCCO Technology is a less invasive method for monitoring
20、 the volume status and cardiovascular function.PiCCO技术是一种监测容量状态和心肌功能的微创技术。Transpulmonary thermodilution allows calculation of various volumetric parameters.经肺热稀释法可以计算各种容量参数。The CO is calculated from the shape of the thermodilution curve.CO是通过热稀释曲线的面积计算而得的。The volumetric parameters of cardiac preload
21、 can be calculated through advanced analysis of the thermodilution curve.心脏前负荷的容量参数是通过进一步分析热稀释曲线获得的。For the thermodilution measurement only a fraction of the total injected indicator needs to pass the detection site,as it is only the change in temperature over time that is relevant.对于热稀释测量来讲，只需要一部分的
22、指示剂通过监测点，同样只需要在相关的时间里面温度有所改变即可。Introduction to the PiCCO-Technology Haemodynamic MonitoringE.Introduction to PiCCO Technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary PermeabilityTranspulmonar
23、y ThermodilutionThe pulse contour analysis is calibrated through the transpulmonary thermodilution and is a beat to beat real time analysis of the arterial pressure curve.脉搏轮廓分析法是通过经肺热稀释法计算，同时也是实时分析动脉压力曲线得出的。Calibration of the Pulse Contour AnalysisIntroduction to the PiCCO-Technology Pulse contour
24、analysisInjectionPulse Contour AnalysisT=blood temperature 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 th
25、e PiCCO-Technology Pulse contour analysisParameters of Pulse Contour Analysis n(Pts/Measurements)0,940,03 0,6312/36Buhre W et al.,J Cardiothorac Vasc Anesth 13(4),199919/7624/51762/18620/36025/38022/96-/-0,40 1,3Mielck et al.,J Cardiothorac Vasc Anesth 17(2),20030,880,31 1,25Zllner C et al.,J Cardio
26、thorac Vasc Anesth 14(2),20000,88-0,2 1,15Gdje O et al.,Crit Care Med 30(1),20020,94-0,02 0,74Della Rocca G et al.,Br J Anaesth 88(3),20020,93-0,14 0,33Felbinger TW et al.,J Clin Anesth 46,2002-/-0,14 0,58Rauch H et al.,Acta Anaesth Scand 46,2002r bias SD(l/min)Comparison with pulmonary artery therm
27、odilutionValidation of Pulse Contour AnalysisIntroduction 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.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。Parameters of Pulse Contour
28、AnalysisIntroduction to the PiCCO-Technology Pulse Contour AnalysisDynamic parameters of volume responsiveness Stroke Volume VariationThe pulse pressure variation is the variation in pulse pressure over the ventilatory cycle,measured over the previous 30 second period.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
29、秒的值。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 The PiCCO technology pulse contour analysis is calibrated by transpulmona
30、ry thermodilution PiCCO技术脉搏轮廓分析基于热稀释法来计算的 PiCCO technology analyses the arterial pressure curve beat by beat thereby providing real time parameters.PiCCO技术分析实时动脉压力曲线，因此它提供了实时的监测数据。Besides cardiac output,the dynamic parameters of volume responsiveness SVV(stroke volume variation)and PPV(pulse pressur
31、e variation)are determined continuously.除了心输出量，SVV和PPV都是连续性的参数。Introduction to the PiCCO-Technology Pulse contour analysisHaemodynamic MonitoringE.Introduction to PiCCO Technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extrava
32、scular Lung Water7.Pulmonary PermeabilityContractility is a measure for the performance of the heart muscle 收缩力指数是评估心肌功能的参数Contractility parameters of PiCCO technology:PiCCO技术监测心肌收缩力的参数:-dPmx(maximum rate of the increase in pressure)-GEF(Global Ejection Fraction)-CFI(Cardiac Function Index)Contracti
33、lity Introduction to the PiCCO-Technology Contractility parameterskgContractility parameter from the pulse contour analysisIntroduction to the PiCCO-Technology Contractility parametersdPmx=maximum velocity of pressure increaseThe contractility parameter dPmx represents the maximum velocity of left v
34、entricular pressure increase.收缩力参数dPmx指的是左心室压力曲线上的最大值。Contractility parameter from the pulse contour analysisIntroduction to the PiCCO-Technology Contractility parametersfemoral dP/max mmHg/sLV dP/dtmax mmHg/sdPmx was shown to correlate well with direct measurement of velocity of left ventricular pr
35、essure increase in 70 cardiac surgery patients dPmx的值与左心室压力的测量值在70个心脏手术的病例中，呈现很好的正相关。de Hert et al.,JCardioThor&VascAnes 2006 n=220y=-120+(0,8*x)r=0,82p 0,00105001000150001000150020002000500dPmx=maximum velocity of pressure increase is calculated as 4 times the stroke volume divided by the global en
36、d-diastolic volume GEF是4倍的SV除以全心舒张末期容量 reflects both left and right ventricular contractility它反应的是全心功能参数GEF=Global Ejection FractionContractility parameters from the thermodilution measurementIntroduction to the PiCCO-Technology Contractility parameters4 x SVGEF=GEDVLALVRARVCombes et al,Intensive Ca
37、re Med 30,2004GEF=Global Ejection Fraction Comparison of the GEF with the gold standard TEE measured contractility in patients without right heart failure.GEF和金标准TEE同时在右心功能正常的病例中的对比。sensitivity00,40,60,8010,20,20,40,60,81 specifity2220191816128D FAC,%D GEF,%510-5-20-10102015-15-10r=076,p0,0001n=47In
38、troduction to the PiCCO-Technology Contractility parametersContractility parameters from the thermodilution measurement is the CI divided by global end-diastolic volume indexCFI是CI除以全心舒张末期容量指数 is-similar to the GEF a parameter of both left and right ventricular contractility它与GEF相似，是反映全心功能的参数CFI=Car
39、diac Function IndexCICFI=GEDVIIntroduction to the PiCCO-Technology Contractility parametersContractility parameters from the thermodilution measurementCombes et al,Intensive Care Med 30,2004sensitivity00,40,60,8010,20,20,40,60,81 specificity6543,532D FAC,%D GEF,%510-5-20-10102015-15-10r=079,p0,0001n
40、=47CFI=Cardiac Function IndexIntroduction to the PiCCO-Technology Contractility parametersCFI was compared to the gold standard TEE measured contractility in patients without right heart failure.CFI与金标准的TEE在右心功能正常病人中的对比Contractility parameters from the thermodilution measurementHaemodynamic Monitori
41、ngE.Introduction to PiCCO technology1.Functions2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary Permeability is calculated as the difference between MAP and CVP divided by CO as an afterload parameter it represents a furthe
42、r determinant of the cardiovascular situation 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。is an important parameter for controlling volume and catecholamine therapies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)x 80SVR=COAfterload parameterSVR=Systemic Vascular ResistanceMAP=Mean Arterial PressureCVP=Central Venous Pressu
43、reCO=Cardiac Output80=Factor for correction of unitsIntroduction to the PiCCO Technology Afterload parameter The parameter dPmx from the pulse contour analysis as a measure of the left ventricular myocardial contractility gives important information regarding cardiac function and therapy guidance.脉搏
44、轮廓分析得出的参数dPmx能提示左心室心肌收缩力的重要信息，这关乎心肌的功能和治疗方向。The contractility parameters GEF and CFI are important parameters for assessing the global systolic function and supporting the early diagnosis of myocardial insufficiency.心功能指数GEF和CFI是非常重要的参数，可以用来评估整体收缩期的心肌功能以及对于心肌损伤的早期诊断。The Systemic Vascular Resistance
45、SVR calculated from blood pressure and cardiac output is a further parameter of the cardiovascular situation,and gives additional information for controlling volume and catecholamine therapies.SVR是基于血压和心输出量来分析的，这是评估心血管功能重要的参数，能提示容量管理和儿茶酚胺类药物的治疗。Summary and Key PointsIntroduction to the PiCCO Technol
46、ogy Contractility and AfterloadHaemodynamic MonitoringE.Introduction to PiCCO technology1.Principles of function2.Thermodilution3.Pulse contour analysis4.Contractility parameters5.Afterload parameters6.Extravascular Lung Water7.Pulmonary PermeabilityITTV ITBV=EVLWThe Extravascular Lung Water is the
47、difference between the intrathoracic thermal volume and the intrathoracic blood volume.It represents the amount of water in the lungs outside the blood vessels.EVLW是胸腔内热容积和胸腔内血容积的差值。它反应肺血管外的水有多少。Calculation of Extravascular Lung Water(EVLW)Introduction to the PiCCO Technology Extravascular Lung Wate
48、rKatzenelson et al,Crit Care Med 32(7),2004 Sakka et al,Intensive Care Med 26:180-187,2000GravimetryDye dilutionEVLW from the PiCCO technology has been shown to have a good correlation with the measurement of extravascular lung water via the gravimetry and dye dilution reference methods.PiCCO技术测得的EV
49、LW与通过重力实验与染料稀释法测得的血管外肺水有很好的相关性Validation 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 lung oedemaIntroduction to the PiCCO Technology Extravascular Lung WaterELWI(ml/kg)21 n=5414-21
50、 n=1007-14 n=174 2090100Sakka et al,Chest 2002Introduction to the PiCCO Technology Extravascular Lung WaterIntensive Care daysMitchell et al,Am Rev Resp Dis 145:990-998,1992 Relevance of EVLW AssessmentVolume management guided by EVLW can significantly reduce time on ventilation and ICU length of st
