最新picco2的临床应用.ppt

最新picco2的临床应用.ppt

《最新picco2的临床应用.ppt》由会员分享，可在线阅读，更多相关《最新picco2的临床应用.ppt（80页珍藏版）》请在冰豆网上搜索。

血血流动力学监测流动力学监测TheoryandPractice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.WilliamGanz（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HemoSonicTM100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，费用高监监测生命体征测生命体征MonitoringRespirationRateTemperature7一一些重要的指标些重要的指标MonitoringBloodPressure（NiBP）nocorrelationwithCOnocorrelationwithoxygendeliveryECGRespirationRateTemperature8PiCCOTechnology液液体管理所需要的指标体管理所需要的指标IntroductiontothePiCCO-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1.功能原理2.热稀释技术3.脉搏轮廓分析技术4.收缩力指数5.前、后负荷参数6.血管外肺水7.肺部通透性指数血血流流动力学力学监测PiCCO技技术依据经肺热稀释技术以及脉搏轮廓分析技术原原理理LeftHeartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHPULSIOCATHCVCPULSIOCATHarterialthermodilutioncathetercentralvenousbolusinjectionIntroductiontothePiCCO-TechnologyFunctionBolusinjectionconcentrationchangesovertime（Thermodilutioncurve）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IntroductiontothePiCCO-TechnologyFunctionLeftheartRightheartLungsRARVLALVPBVEVLWEVLW原原理理胸胸腔内各腔室腔内各腔室IntroductiontothePiCCO-TechnologyFunction肺肺内内热容容积（PTV）胸胸腔内热容积腔内热容积（ITTV）TotalofmixingchambersRARVLALVPBVEVLWEVLW最大混合腔室血血流流动力学力学监测IntroductiontoPiCCOTechnology1.功能原理2.热稀释技术3.脉搏轮廓分析技术4.收缩力指数5.后负荷参数6.血管外肺水7.肺部通透性指数Tbxdt（Tb-Ti）xVixKTbInjectiontDD=COTDaTb=BloodtemperatureTi=InjectatetemperatureVi=InjectatevolumeTb.dt=AreaunderthethermodilutioncurveK=Correctionconstant,madeupofspecificweightandspecificheatofbloodandinjectateCO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算算IntroductiontothePiCCO-TechnologyThermodilution热稀释曲线下面积反比例反映CO36,537510热稀稀释曲曲线NormalCO:

5.5l/minIntroductiontothePiCCO-TechnologyThermodilution36,53736,537TimelowCO:

1.9l/minHighCO:

19l/minTimeTimeTemperatureTemperatureTemperature经肺肺热稀稀释vs.肺肺动脉脉导管管LeftheartRightHeartPulmonaryCirculationLungsBodyCirculationPULSIOCATHarterialthermo-dilutioncathetercentralvenousbolusinjectionRARVPALALVAortaTranspulmonaryTD（PiCCO）PulmonaryArteryTD（PAC）Inbothproceduresonlypartoftheinjectedindicatorpassesthethermistor.NonethelessthedeterminationofCOiscorrect,asitisnottheamountofthedetectedindicatorbutthedifferenceintemperatureovertimethatisrelevant!

IntroductiontothePiCCOTechnologyThermodilutionComparisonwiththeFickMethod0,970,680,6237/449SakkaSGetal.,IntensiveCareMed25,1999-/-0,190,219/27McLuckieA.eta.,ActaPaediatr85,19960,960,160,3130/150GdjeOetal.,Chest113（4）,19980.980,320,2923/218HolmCetal.,Burns27,20010,930,130,5260/180DellaRoccaGetal.,EurJAnaest14,20020,95-0,040,4117/102FriedmanZetal.,EurJAnaest,20020,950,490,4545/283BindelsAJGHetal.,CritCare4,20000,980,030,1718/54PauliC.etal.,IntensiveCareMed28,200224/120n（Pts/Measurements）0,990,030,24TibbyS.etal.,IntensiveCareMed23,1997rbiasSD（l/min）ComparisonwithPulmonaryArteryThermodilution经肺肺热稀稀释技技术的有效性的有效性IntroductiontothePiCCOTechnologyThermodilutionMTt:

MeanTransittimethemeantimerequiredfortheindicatortoreachthedetectionpointDSt:

DownSlopetimetheexponentialdownslopetimeofthethermodilutioncurveRecirculationte-1TbFromthecharacteristicsofthethermodilutioncurveitispossibletodeterminecertaintimeparameters对热稀稀释曲曲线做做进一步分析一步分析IntroductiontothePiCCO-TechnologyThermodilutionInjectionInTbMTtDStTb=bloodtemperature;lnTb=logarithmicbloodtemperature;t=timePulmonaryThermalVolumePTV=DstxCOByusingthetimeparametersfromthethermodilutioncurveandtheCOITTVandPTVcanbecalculated计算算ITTV与与PTVIntroductiontothePiCCO-TechnologyThermodilutionRecirculationte-1TbInjectionInTbIntrathoracicThermalVolumeITTV=MTtxCOMTtDStPulmonaryThermalVolume（PTV）IntrathoracicThermalVolume（ITTV）CalculationofITTVandPTVEinfhrungindiePiCCO-TechnologieThermodilutionITTV=MTtxCOPTV=DstxCORARVLALVPBVEVLWEVLWGEDVisthedifferencebetweenintrathoracicandpulmonarythermalvolumesGlobalEnd-diastolicVolume（GEDV）VolumetricpreloadparametersGEDVRARVLALVPBVEVLWEVLWITTVGEDVPTVIntroductiontothePiCCOTechnologyThermodilutionVolumetricpreloadparametersITBVIntrathoracicBloodVolume（ITBV）GEDVITBVPBVRARVLALVPBVEVLWEVLWIntroductiontothePiCCOTechnologyThermodilutionITBVisthetotaloftheGlobalEnd-DiastolicVolumeandthebloodvolumeinthepulmonaryvessels（PBV）ITBVTD（ml）ITBV=1.25*GEDV28.4mlGEDVvs.ITBVin57IntensiveCarePatientsIIntrantratthoracichoracicBBloodloodVVolumeolume（ITBVITBV）IntroductiontothePiCCO-TechnologyThermodilutionITBViscalculatedfromtheGEDVbythePiCCOTechnology01000200030000100020003000GEDV（ml）Sakkaetal,IntensiveCareMed26:

180-187,2000SummaryandKeyPoints-ThermodilutionPiCCO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