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1、危重病患者的血流动力学监测危重病患者的血流动力学监测focus on PiCCO北京协和医院杜斌血流动力学监测增加患者病死率血流动力学监测增加患者病死率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,Lynn J,Knaus WA.The effectiveness of right heart catheterization in the ini
2、tial care of critically ill patients.SUPPORT Investigators.JAMA 1996;276(11):889-897 血流动力学监测为何不能改善预后血流动力学监测为何不能改善预后不恰当的适应症PAC的副作用或并发症获得数据的方法不正确n仪器定标错误,或传感器位置错误获得的数据不能反映血流动力学状态错误使用数据(对数据的解读错误)作出治疗决定前未考虑其他相关因素nCXR,尿量,血清白蛋白采用的治疗措施无效或有害无需血流动力学监测时未及时拔除PACPAC的使用减少的使用减少:Illinois,USA2000年年2001年年降低降低%出院患者数1,
3、636,0461,684,089PAC使用数5,9695,02215.8PAC使用率(/1000)3.652.98年龄0 17岁2195765 74岁1,7391,37521 75岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterization has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132)临床评价临床评价 vs.血流动力学血流动力学目的:评价肺动
4、脉导管(PAC)得到的血流动力学指标是否能够改变患者的治疗设计:前瞻性观察患者:103例留置PAC的患者方法:n插管前,请医生对一些血流动力学指标的范围,诊断及治疗方案进行预测n插管后,复习患者病例,记录插管时及置管8小时内的血流动力学Eisenberg 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):5
5、49-553临床评价临床评价 vs.血流动力学血流动力学Eisenberg 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临床评价临床评价 vs.血流动力学血流动力学结果留置PAC后n计划治疗方案需要改变58%u应用未预计到的治疗方案30%Eisenberg PR,Jaffe AS,Sch
6、uster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553临床评价临床评价 vs.血流动力学血流动力学结论单纯根据临床表现难以准确预测血流动力学指标PAC监测数据通常能够改变治疗方案Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary
7、 artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553血流动力学参数改变治疗决定血流动力学参数改变治疗决定Squara P,Bennett D,Perret C.Pulmonary artery catheter:does the problem lie in the users?Pulmonary artery catheter:does the problem lie in the users?Chest 2002;12
8、1:2009-2015ICU患者的输液治疗患者的输液治疗输液治疗的决定因素临床经验中心静脉压或肺动脉楔压Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151临床判断缺乏准确性临床判断缺乏准确性:PAWP01015191915100预计预计PAWP(mmHg)测定测定PAWP(mmHg)Eisenberg PL,Jaffe AS,Schuster D
9、P.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553No change in planned therapy after catheterizationChange in planned therapy after catheterization0临床判断缺乏准确性临床判断缺乏准确性:CO04.57.0预计预计CO(L/min)测定测定C
10、O(L/min)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):549-5534.57.0临床判断缺乏准确性临床判断缺乏准确性Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary arte
11、ry catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553参数参数判断正确数目判断正确数目/测定数目测定数目正确率正确率(%)PAWP31/10230CO49/9751SVR39/8844RAP54/9855How good are our clinical skills?Cardiac outputWedge pressureConnors(NEJM 83)ICU pts44%42%Eisenberg(CCM 84)ICU pts50%
12、33%Bayliss(BMJ 83)CCU pts71%62%临床重要的血流动力学参数临床重要的血流动力学参数所有医生所有医生(n=417)心内科医生心内科医生(n=27)CO330(79%)21(75%)PAWP285(68%)27(100%)SvO2220(53%)10(38%)MPAP120(37%)10(38%)SV100(24%)3(13%)RAP20(5%)RVEF20(5%)RVEDV18(4%)Squara P,Bennett D,Perret C.Pulmonary artery catheter:does the problem lie in the users?Pulmo
13、nary artery catheter:does the problem lie in the users?Chest 2002;121:2009-2015心脏手术后患者的血流动力学监测心脏手术后患者的血流动力学监测问卷调查(39个问题)n血流动力学监测n容量替代n正性肌力药物/升压药物n输血德国的80个ICU主任问卷回收率69%Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic
14、 therapy in post-operative cardiac surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.心脏手术后患者的血流动力学监测心脏手术后患者的血流动力学监测血流动力学监测血流动力学监测比例比例(%)基本监测100肺动脉导管(PAC)58.2经食道超声(TEE)38.1PICCO13.0Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer
15、 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):347-358.英格兰与威尔士英格兰与威尔士ICU的的CO监测技术监测技术Esdaile B,Raobaikady R.Survey of cardiac output m
16、onitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)英格兰与威尔士英格兰与威尔士ICU的的CO监测技术监测技术CO监测技术 2种69%首选经食道多普勒监测CO41%常规监测ScvO220%Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131)Are We Using PAC Correctly?PAWP测定中的技术问题测定中的技术问题Morris AH,Chapman RH,Gardner RM.Frequency of technical problems encountered in the measurement of pulmonary artery wedge
