血流动力学监测-PICCO(杜斌).ppt

扩容治疗前的右室舒张末容积指数扩容治疗前的右室舒张末面积LVEDA(cm2/m2)有反应者无反应者Tavernieretal9?312?4?Tousignantetal15?520?5?Feisseletal10?410?2?p0.05CVP/PAWP不能预测扩容反应Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147ITBV能够更好地反映前负荷Lichtwarck-Aschoffetal,IntensiveCareMed1992;18:142-147预测扩容反应:PAWP/CVPvs.ITBV前负荷指标与?SV/?CI的相关性所有患者单一患者相关系数,r?SVIart?CIart?CIart(最低值–最高值)?CVP-0.090.00-0.01–0.33?PAWP-0.02-0.01-0.36–0.03?RAEDVI0.28-0.11-0.02–0.37?RVEDVI0.03-0.020.02–0.03?ITBVI0.760.830.67–0.91?GEDVI0.820.870.70–0.93由于脉搏轮廓分析连续测量每搏量和动脉压,可以如下计算得到心输出量(CO)和全身循环阻力(SVR):CO=每搏量x心率SVR=(平均动脉压–中心静脉压)/CO020103心输出量和全身循环阻力每搏量变异(SVV)对于没有心律失常的机械通气患者SVV反映了心脏对因机械通气导致的心脏前负荷周期性变化的敏感性SVV可以用于预测扩容治疗是否会使每搏量增加SVmaxSVminSVmeanSVmax–SVminSVV(30秒)=SVmean对扩容反应的预测性:CVPvs.SVVSensitivity–Specificity--CVP__SVV1放射影像学(radiology)2指示剂稀释技术(indicatordilutiontechnique)4重力测定技术(gravimetrictechnique)3显像技术(imagingtechnique)血管外肺水的测定:EVLW氧合与肺水肿ScilliaP,DelcroixM,LejeuneP,MelotC,StruyvenJ,NaeijeR,GevenoisPA.Hydrostaticpulmonaryedema:evaluationwiththin-sectionCTindogs.Radiology1999;211:161-168静水压升高引起肺水肿CMVFiO20.4血管外肺水与氧合MartinGS,EatonS,MealerM,MossM.Extravascularlungwaterinpatientswithseveresepsis:aprospectivecohortstudy.CritCare2005;9:R74-R82(DOI10.1186/cc3025)血管外肺水与病死率Sturm,In:PracticalApplicationsofFiberopticsinCriticalCareMonitoring,SpringerVerlagBerlin-Heidelberg-NewYork1990,pp129-139BongardFS,Surgery1984当EVLW增加100%时,胸片才会发生改变HelperinBD,Chest1984胸片对EVLW的改变并不敏感Rubenfeldetal,Chest1999确定患者是否符合ARDS影像学表现时,医生之间存在非常明显的差异血管外肺水的测定容量测量小结ITTV=COxMTtTDaPTV=COxDStTDaITBV=1.25xGEDVEVLW=ITTV–ITBVGEDV=ITTV–PTVRAEDVRVEDVLAEDVLVEDVRAEDVRVEDVLAEDVLVEDVPBVRAEDVRVEDVLAEDVLVEDVPTVPTVEVLWEVLWEVLW:PiCCOvs.重力法测定血管外肺水的临床验证Sakkaetal,IntensiveCareMed