血流動力學監(jiān)測picco杜斌

1、危重病患者的血流動力學監(jiān)測focus on PiCCO,北京協(xié)和醫(yī)院杜斌,血流動力學監(jiān)測增加患者病死率,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, Ly

2、nn J, Knaus WA. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 1996; 276(11): 889-897,血流動力學監(jiān)測為何不能改善預后,不恰當?shù)倪m應癥PAC的副作用或并發(fā)癥獲得數(shù)據(jù)的方法不正確儀器定標錯誤, 或

3、傳感器位置錯誤獲得的數(shù)據(jù)不能反映血流動力學狀態(tài)錯誤使用數(shù)據(jù)(對數(shù)據(jù)的解讀錯誤)作出治療決定前未考慮其他相關因素CXR, 尿量, 血清白蛋白采用的治療措施無效或有害無需血流動力學監(jiān)測時未及時拔除PAC,PAC的使用減少: Illinois, USA,Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Cri

4、tical Care 2005; 9(Suppl 1): P69 (DOI 10.1186/cc3132),PAC的使用減少: Illinois, USA,Appavu S, Cowen J, Bunyer M. The use of pulmonary artery catheterization has declined. Critical Care 2005; 9(Suppl 1): P69 (DOI 10.1186/cc3132

5、),臨床評價 vs. 血流動力學,目的: 評價肺動脈導管(PAC)得到的血流動力學指標是否能夠改變患者的治療設計: 前瞻性觀察患者: 103例留置PAC的患者方法:插管前, 請醫(yī)生對一些血流動力學指標的范圍, 診斷及治療方案進行預測插管后, 復習患者病例, 記錄插管時及置管8小時內(nèi)的血流動力學,Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared t

6、o pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553,臨床評價 vs. 血流動力學,Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonar

7、y artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553,臨床評價 vs. 血流動力學,結(jié)果留置PAC后計劃治療方案需要改變58%應用未預計到的治療方案30%,Eisenberg PR, Jaffe AS, Schuster DP. Clinic

8、al evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553,臨床評價 vs. 血流動力學,結(jié)論單純根據(jù)臨床表現(xiàn)難以準確預測血流動力學指標PAC監(jiān)測數(shù)據(jù)通常能夠改變治療方案,Eisenberg

9、 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,血流動力學數(shù)據(jù)的解釋,臨床場景(n = 44)心臟外科術后1

10、6ARDS 9全身性感染 9心源性休克 5其他情況 5,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

11、of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741,血流動力學數(shù)據(jù)的解釋,Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer program for interpreting pulmonary ar

12、tery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741,血流動力學數(shù)據(jù)的解釋,Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, Bakker J, Perret C. A computer pr

13、ogram for interpreting pulmonary artery catheterization data: results of the European HEMODYN resident study. Intensive Care Med 2003; 29: 735-741,血流動力學參數(shù)改變治療決定,Squara P, Bennett D, Perret C. Pulmonary artery catheter: d

14、oes the problem lie in the users? Chest 2002; 121: 2009-2015,ICU患者的輸液治療,輸液治療的決定因素臨床經(jīng)驗中心靜脈壓或肺動脈楔壓,Boldt J, Lenz M, Kumle B, Papsdorf M. Volume replacement strategies on intensive care units: results from a postal survey

15、. Intensive Care Med 1998; 24: 147-151,臨床判斷缺乏準確性: PAWP,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0,10,15,19,19,15,10,0,預計PAWP (mmHg),測定PAWP (mmHg),Eisenberg PL,

16、 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,,,No change in planned therapy after c

17、atheterization,Change in planned therapy after catheterization,,,,,,,0,,,,,,臨床判斷缺乏準確性: CO,,,,,,,,,,,,,,,,0,4.5,7.0,預計CO (L/min),測定CO (L/min),Eisenberg PL, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary

18、artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,7.0,臨床判斷缺乏準確性

19、,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): 549-553,How good are our clinica

20、l skills?,Cardiac outputWedge pressure,Bayliss(BMJ ‘83)CCU pts71% 62%,臨床判斷缺乏準確性,Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patientsEisenberg PR,

21、 et al. Crit Care Med 1984; 12: 349Assessing 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 th

22、e ICUSteingrub, et al. Chest 1991; 99: 1451PAC in critically ill patients: A prospective analysis of outcome changes associated with catheter-prompted changes in therapyMimoz O et al. Crit Care Med 1994; 22: 573Hem

23、odynamic and pulmonary fluid status in the trauma patient: are we slipping?Veale WN Jr, et al. Am Surg.2005; 71: 621,臨床判斷缺乏準確性,醫(yī)生常常相信自己的判斷, 但自信與準確性之間并無相關性與經(jīng)驗較少的醫(yī)生相比, 盡管有經(jīng)驗的醫(yī)生更為自信, 但他們的判斷并不準確醫(yī)生不應盲目根據(jù)自己對心臟功能的判斷, 作為治療決策的

24、依據(jù),Dawson NV et al. Hemodynamic assessment in managing the critically ill: is physician confidence warranted? Med Decis Making 1993; 13: 258-266,臨床判斷血流動力學的準確性,臨床重要的血流動力學參數(shù),Squara P, Bennett D, Perret C. Pulmonary artery

25、catheter: does the problem lie in the users? Chest 2002; 121: 2009-2015,心臟手術后患者的血流動力學監(jiān)測,問卷調(diào)查(39個問題)血流動力學監(jiān)測容量替代正性肌力藥物 / 升壓藥物輸血德國的80個ICU主任問卷回收率69%,Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Große J, Schirme

26、r 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):

27、347-358.,心臟手術后患者的血流動力學監(jiān)測,Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Große J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patien

28、ts in Germany: results from a postal survey. Acta Anaesthesiologica Scandinavica 2007; 51(3): 347-358.,英格蘭與威爾士ICU的CO監(jiān)測技術,Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England and

29、 Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131),英格蘭與威爾士ICU的CO監(jiān)測技術,CO監(jiān)測技術? 2種69%首選經(jīng)食道多普勒監(jiān)測CO41%常規(guī)監(jiān)測ScvO220%,Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in Eng

30、land and Wales. Critical Care 2005; 9(Suppl 1): P68 (DOI 10.1186/cc3131),Are We Using PAC Correctly?,,PAWP測定中的技術問題,Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of pulm

31、onary artery wedge pressure. Crit Care Med 1984; 12(3): 164-170,PAWP測定中的技術問題,Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure. Crit Care

32、 Med 1984; 12(3): 164-170,WP initial – WP confirmed = 11 ? 6 mmHgRange (-13, +22),PAWP測定中的技術問題,Morris AH, Chapman RH, Gardner RM. Frequency of wedge pressure errors in the ICU. Crit Care Med 1985; 13(9): 705-708,PAWP測定中

33、的技術問題,Morris AH, Chapman RH, Gardner RM. Frequency of wedge pressure errors in the ICU. Crit Care Med 1985; 13(9): 705-708,ICU醫(yī)生缺乏PAC的相關知識,目的: 評價歐洲國家ICU醫(yī)生對PAC相關知識的了解程度設計: 調(diào)查問卷背景: 86個歐洲大學及非大學醫(yī)院ICU對象: 從兩個歐洲危重病醫(yī)學會目錄中選取13

34、4個ICU. 其中86個ICU的535名醫(yī)生參加問卷調(diào)查干預: 在每個ICU中, 所有醫(yī)生均被要求同時完成一項調(diào)查問卷, 包括31個多選題, 涉及床旁留置PAC的所有方面,Gnaegi A, Feihl F, Perret C. Intensive care physician’s insufficient knowledge of right-heart catheterization at the bedside: time to

35、 act? Crit Care Med 1997; 25: 213-220,ICU醫(yī)生缺乏PAC的相關知識,Gnaegi A, Feihl F, Perret C. Intensive care physician’s insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213

36、-220,ICU醫(yī)生缺乏PAC的相關知識,Gnaegi A, Feihl F, Perret C. Intensive care physician’s insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220,ICU醫(yī)生缺乏PAC的相關知識,Gnaegi A, Fe

37、ihl F, Perret C. Intensive care physician’s insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220,ICU醫(yī)生缺乏PAC的相關知識,Gnaegi A, Feihl F, Perret C. Intensive care p

38、hysician’s insufficient knowledge of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220,ICU醫(yī)生缺乏PAC的相關知識,Gnaegi A, Feihl F, Perret C. Intensive care physician’s insufficient knowledge

39、 of right-heart catheterization at the bedside: time to act? Crit Care Med 1997; 25: 213-220,Is There an Easy Alternative to This Dilemma?,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Central venous catheter,

40、Injectate temperature sensor housing PV4046,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Arterial thermodilution catheter,Injectate temperature sensor cablePC80109,PULSION disposable pressure transducer PV8115,,,,PCCI,AP,1

41、3.03 16.28 TB37.0,AP 140117 92(CVP) 5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI) 625,,,,,,,,,,,,,,,,,,,,,,,,,DPT Monitor cablePMK-206,Interface cablePC80150,,,,,,Connection ca

42、bleto bedside monitorPMK - XXX,AUX adaptercable PC81200,PiCCO的技術原理,PiCCO技術由下列兩種技術組成, 用于更有效地進行血流動力和容量治療, 使大多數(shù)病人不必使用肺動脈導管:,心輸出量的測定: 經(jīng)肺熱稀釋技術,中心靜脈內(nèi)注射指示劑后, 動脈導管尖端的熱敏電阻測量溫度下降的變化曲線通過分析熱稀釋曲線, 使用Stewart-Hamilton公式計算得出心輸出量(CO

43、),心輸出量的測定: 經(jīng)肺熱稀釋技術,經(jīng)肺熱稀釋測量只需要在中心靜脈內(nèi)注射冷(< 8?C)或室溫(< 24?C)生理鹽水,中心靜脈注射,右心,左心,肺,PiCCO導管如插在股動脈內(nèi),熱稀釋法測定CO: PiCCO vs. PAC,動脈脈搏輪廓分析,動脈脈搏輪廓分析通過動脈壓力波型的形狀獲得連續(xù)的每搏參數(shù)通過經(jīng)肺熱稀釋法的初始校正后, 該公式可以在每次心臟搏動時計算出每搏量(SV),,,,,,SV,連續(xù)心輸出量測定: Pi

44、CCO,,壓力曲線下面積,壓力曲線型狀,動脈順應性參數(shù),,,,心率,,與病人有關的校正因子,,,,,,,,,t [s],P [mm Hg],,,PCCO is displayed as last 12s mean,心輸出量的測定: PiCCO vs. 熱稀釋,PiCCO的技術原理,PiCCO技術由下列兩種技術組成, 用于更有效地進行血流動力和容量治療, 使大多數(shù)病人不必使用肺動脈導管:,PiCCO容量參數(shù),全心舒張末期容積GEDV

45、胸腔內(nèi)血容積ITBV血管外肺水EVLW通過對熱稀釋曲線的分析, 可以得到這些容量參數(shù),全心舒張末期容積(GEDV),全心舒張末期容積(GEDV)是心臟4個腔室內(nèi)的血容量,胸腔內(nèi)血容積(ITBV),胸腔內(nèi)血容積(ITBV)是心臟4個腔室的容積 + 肺血管內(nèi)的血液容量,血管外肺水(EVLW),血管外肺水(EVLW)是肺內(nèi)含有的水量, 可以在床旁定量判斷肺水腫的程度,,容量的測量原理,,,,,,,,,,,,,,ln c (I)

46、,注射,At,再循環(huán)的影響,MTt,t,,,,e,-1,DSt,c (I),MTt: Mean transit time平均傳輸時間 ≈ half of the indicator passed the point of detection,DSt: Downslope time下降時間≈ exponential

47、downslope time of TD curve,容量的測量原理,Vall = V1 + V2 + V3 + V4 = MTt x FlowMeier et al. J Appl Physiol. 1954,V3 = 最大腔的容積 = DSt x FlowNewman et al. Circulation. 1951,指示劑由注射點到檢測點的平均傳輸時間MTt由兩點間的總?cè)莘e決定,下降時間DSt由其中

48、最大的腔室決定 (比其它腔至少大 20% 成立!),,,flow,,V3,V4,V2,V1,,注射,檢測,胸腔內(nèi)的容積組成,,,,,,,,,,,GEDV,PTV,,,,,,RAEDV,,,PBV,,LAEDV,,LVEDV,RVEDV,EVLW,EVLW,ITTV,PTV = 肺內(nèi)熱容積, 在一系列混合腔室中具有最大的熱容積 (DSt – 容積)ITTV = 胸腔內(nèi)總熱容積, 從注射點到測量的熱容積之和 (MTt – 容積)GEDV

49、= 全心舒張末期容積 = ITTV – PTV,容量的測量原理,,,,,,RAEDV,PTV,,LAEDV,,LVEDV,RVEDV,胸腔總熱容積(ITTV)ITTV = CO x MTtTDa,肺內(nèi)總熱容積(PTV)PTV = CO x DStTDa,全心舒張末期容積GEDV = ITTV – PTV,,ITBV的測量原理,Sakka et al, Intensive Care Med 2000; 26: 180-187,I

50、TBV = 1.25 * GEDV – 28.4 [ml],r = 0.96,ITBVTD (ml),GEDVST (ml),GEDV vs. ITBV in 57 intensive care patients,ITBV準確性的臨床驗證,Sakka et al, Intensive Care Med 26: 180-187, 2000,n = 209r = 0.97,Bias = -7.6 ml/m2SD = 57.4 m

51、l/m2,ITBVIST vs. ITBVITD in 209 intensive care patients,容量測量小結(jié),ITTV = CO x MTtTDa,PTV = CO x DStTDa,ITBV = 1.25 x GEDV,GEDV = ITTV – PTV,,,PiCCO前負荷指標,在反映心臟前負荷的敏感性和特異性方面, 已經(jīng)證實ITBV和GEDV不但優(yōu)于CVP及PAWP, 也優(yōu)于RVEDVITBV和GEDV最主要的

52、優(yōu)點是不受機械通氣的影響而產(chǎn)生錯誤, 因此能夠在任何情況下提供前負荷情況的正確信息經(jīng)由GEDV和SV計算得到的全心射血分數(shù)(GEF), 在一定程度上反映了心肌收縮功能GEF = 4 x SV / GEDV,容量負荷反應組與無反應組的CVP,擴容治療前的肺動脈楔壓,¶ p < 0.05,擴容治療前的右室舒張末容積指數(shù),擴容治療前的右室舒張末面積,¶ p < 0.05,CVP/PAWP不能預測擴容反應,L

53、ichtwarck-Aschoff et al, Intensive Care Med 1992; 18: 142-147,ITBV能夠更好地反映前負荷,Lichtwarck-Aschoff et al, Intensive Care Med 1992; 18: 142-147,預測擴容反應: PAWP/CVP vs. ITBV,1. Michard F, Boussat S, Chemla D, Anguel N, Mercat A,

54、 Lecarpentier Y, Richard C, Pinsky MR, Teboul JL. Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory Failure. Am J Respir Crit Care Med 2000

55、; 162: 134-138. 2. Rex S, Brose S, Metzelder S, Huneke R, Schalte G, Autschbach R, Rossaint R, Buhre W. Prediction of fluid responsiveness in patients during cardiac surgery. Br J Anaesth 2004; 93: 782-788,前負荷指標與?SV / ?

56、CI的相關性,Goedje et al, Eur J Cardiothorac Surg 1998; 13 (5): 533-539;discussion 539-540,心輸出量和全身循環(huán)阻力,由于脈搏輪廓分析連續(xù)測量每搏量和動脈壓, 可以如下計算得到心輸出量(CO)和全身循環(huán)阻力(SVR):CO = 每搏量 x 心率SVR = (平均動脈壓 – 中心靜脈壓) / CO,每搏量變異(SVV),對于沒有心律失常的機械通氣患者SV

57、V反映了心臟對因機械通氣導致的心臟前負荷周期性變化的敏感性SVV可以用于預測擴容治療是否會使每搏量增加,,SVmax,SVmin,,SVmean,SVmax – SVmin,,SVV (30秒) =,SVmean,,,對擴容反應的預測性: CVP vs. SVV,Sensitivity,1 – Specificity,Berkenstadt et al, Anesth Analg 2001; 92: 984-989,- - - CVP

58、__ SVV,血管外肺水的測定: EVLW,放射影像學(radiology)指示劑稀釋技術(indicator dilution technique)顯像技術(imaging technique)重力測定技術(gravimetric technique),氧合與肺水腫,靜水壓升高引起肺水腫CMVFiO2 0.4,Scillia P, Delcroix M, Lejeune P, Melot C, Struyven J, N

59、aeije R, Gevenois PA. Hydrostatic pulmonary edema: evaluation with thin-section CT in dogs. Radiology 1999; 211: 161-168,血管外肺水與氧合,Martin GS, Eaton S, Mealer M, Moss M. Extravascular lung water in patients with severe sep

60、sis: a prospective cohort study. Crit Care 2005; 9: R74-R82 (DOI 10.1186/cc3025),血管外肺水與病死率,Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990

61、, pp 129-139,血管外肺水的測定,當EVLW增加> 100%時, 胸片才會發(fā)生改變Bongard FS, Surgery 1984胸片對EVLW的改變并不敏感Helperin BD, Chest 1984確定患者是否符合ARDS影像學表現(xiàn)時, 醫(yī)生之間存在非常明顯的差異Rubenfeldet al, Chest 1999,容量測量小結(jié),ITTV = CO x MTtTDa,PTV = CO x DStTDa,

62、ITBV = 1.25 x GEDV,EVLW = ITTV – ITBV,GEDV = ITTV – PTV,,,,EVLW: PiCCO vs. 重力法測定,Sturm, In: Practical Applications of Fiberoptics in Critical Care Monitoring, Springer Verlag Berlin - Heidelberg - NewYork 1990, pp 129-1

63、39,血管外肺水的臨床驗證,Sakka et al, Intensive Care Med 26: 180-187, 2000,Bias = -0.2 ml/kgSD = 1.4 ml/kg,n = 209r = 0.96,EVLWIST vs. EVLWITD in 209 intensive care patients,減少血管外肺水: 臨床試驗,Mitchell et al, Am Rev Resp Dis 145:

64、990-998, 1992,血管外肺水,血管外肺水(EVLW)通過經(jīng)肺熱稀釋法得到, 已被染料稀釋法和重量法證實已證實血管外肺水(EVLW)與ARDS的嚴重程度, 病人機械通氣的天數(shù), 住ICU的時間及死亡率明確相關, 其評估肺水腫遠遠優(yōu)于胸部X線肺血管通透性指數(shù)(PVPI)一定程度上反映了肺水腫形成的原因PVPI = EVLW / PBV,隱匿性肺水腫的檢測,原發(fā)性與繼發(fā)性ARDS/ALI的鑒別,患者人群(n = 10)原發(fā)性

65、ARDS/ALI (n = 4): 肺炎, 誤吸繼發(fā)性ARDS/ALI (n = 6): 全身性感染評價指標ITBVIEVLWIPVPI (EVLW/ITBV),Morisawa K, Taira Y, Takahashi H, Matsui K, Ouchi M, Fujinawa N, Noda K. Do the data obtained by the PiCCO system enable one to differ

66、entiate between direct ALI/ARDS and indirect ALI/ARDS? Critical Care 2006, 10(Suppl 1):P326 (doi: 10.1186/cc4673),原發(fā)性與繼發(fā)性ARDS/ALI的鑒別,Morisawa K, Taira Y, Takahashi H, Matsui K, Ouchi M, Fujinawa N, Noda K. Do the data ob

67、tained by the PiCCO system enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS? Critical Care 2006, 10(Suppl 1):P326 (doi: 10.1186/cc4673),SIRS及ARDS: 肺血管通透性與肺水腫,Tagami T, Kushimoto S, Atsumi T, Mats

68、uda K, Miyazaki Y, Oyama R, Koido Y, Kawai M, Yokota H, Yamamoto Y. Investigation of the pulmonary vascular permeability index and extravascular lung water in patients with SIRS and ARDS under the PiCCO system. Critical