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1、血流动力学监测,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 HemoSon
2、icTM100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,监测生命体征,Monitoring,Respiration Rate,Temperature,8,一些重要的指标,Monitoring,Blood Pressure (NiBP), no correlation with CO no correlation with oxygen delivery,ECG,Respiration Rate,Temperature,PiCCO Technology,液
3、体管理所需要的指标,Introduction to the PiCCO-Technology,CO,前负荷,EVLW,收缩力指数,个性化的容量管理,static - dynamic,PiCCO 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,血流动力学监测,PiCCO 技术 依据经肺热稀释技术以及脉搏轮廓分析技术,原理,Left Heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH,PULSIOCATH,CVC,PULSIOCATH arter
4、ial thermodilution catheter,central venous bolus injection,Introduction to the PiCCO-Technology Function,Bolus injection,concentration 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 Function,Left heart,Right heart,Lungs,原理,胸腔内
5、各腔室,Introduction to the PiCCO-Technology Function,肺内热容积 (PTV),胸腔内热容积 (ITTV),Total of mixing chambers,最大混合腔室,血流动力学监测,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,Tb,Injection,t,D,=,COTD a,Tb = Blood temperature Ti = Injectate temperature Vi
6、 = Injectate volume Tb . dt = Area under the thermodilution curve K = Correction constant, made up of specific weight and specific heat of blood and injectate,CO的计算是通过对热稀释曲线分析， 使用 Stewart-Hamilton 方程式,心排的计算,Introduction to the PiCCO-Technology Thermodilution,热稀释曲线下面积反比例反映CO,36,5,37,5,10,热稀释曲线,Normal
7、 CO: 5.5l/min,Introduction to the PiCCO-Technology Thermodilution,36,5,37,36,5,37,Time,low CO: 1.9l/min,High CO: 19l/min,Time,Time,Temperature,Temperature,Temperature,经肺热稀释 vs. 肺动脉导管,Left heart,Right Heart,Pulmonary Circulation,Lungs,Body Circulation,PULSIOCATH arterial thermo-dilution catheter,cent
8、ral venous bolus injection,RA,RV,PA,LA,LV,Aorta,Transpulmonary 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 te
9、mperature over time that is relevant!,Introduction to the PiCCO Technology Thermodilution,Comparison with the Fick Method,0,97,0,68 0,62,37/449,Sakka SG et al., Intensive Care Med 25, 1999,- / -,0,19 0,21,9/27,McLuckie A. et a., Acta Paediatr 85, 1996,0,96,0,16 0,31,30/150,Gdje O et al., Chest 113 (
10、4), 1998,0.98,0,32 0,29,23/218,Holm C et al., Burns 27, 2001,0,93,0,13 0,52,60/180,Della Rocca G et al., Eur J Anaest 14, 2002,0,95,-0,04 0,41,17/102,Friedman Z et al., Eur J Anaest, 2002,0,95,0,49 0,45,45/283,Bindels AJGH et al., Crit Care 4, 2000,0,98,0,03 0,17,18/54,Pauli C. et al., Intensive Car
11、e Med 28, 2002,24/120,n (Pts / Measurements),0,99,0,03 0,24,Tibby S. et al., Intensive Care Med 23, 1997,r,bias SD(l/min),Comparison with Pulmonary Artery Thermodilution,经肺热稀释技术的有效性,Introduction to the PiCCO Technology Thermodilution,MTt: Mean Transit time the mean time required for the indicator to
12、 reach the detection point,DSt: Down Slope time the exponential downslope time of the thermodilution curve,Recirculation,t,e-1,Tb,From the characteristics of the thermodilution curve it is possible to determine certain time parameters,对热稀释曲线做进一步分析,Introduction to the PiCCO-Technology Thermodilution,
13、Injection,In Tb,MTt,DSt,Tb = blood temperature; lnTb = logarithmic blood temperature; t = time,Pulmonary Thermal Volume PTV = Dst x CO,By using the time parameters from the thermodilution curve and the CO ITTV and PTV can be calculated,计算 ITTV 与 PTV,Introduction to the PiCCO-Technology Thermodilutio
14、n,Recirculation,t,e-1,Tb,Injection,In Tb,Intrathoracic Thermal Volume ITTV = MTt x CO,MTt,DSt,Pulmonary Thermal Volume (PTV),Intrathoracic Thermal Volume (ITTV),Calculation of ITTV and PTV,Einfhrung in die PiCCO-Technologie Thermodilution,ITTV = MTt x CO,PTV = Dst x CO,GEDV is the difference between intrathoracic and pulmonary thermal volumes,Global End-diastolic Volume (GEDV),Volumetric preload parameters GEDV,ITTV,GEDV,PTV,Introduction to the PiCCO T
