PiCCOplus详细介绍-英文版.ppt

,PiCCOModule_highLevel_05_02_eng.ppt,Lyon,16.05.02,Sandra Grohauser,Manager PiCCO Technology,Clinical,application,/,education,Transpulmonary thermodilution method,arterial TD,catheter,(e.g.PV2015L20),CV,bolus,injection,RAEDV,PBV,ETV,LAEDV,LVEDV,ETV,RVEDV,0,1,0,2,0,3,0,4,0,5,0,0,0,0,2,0,4,0,6,C,-,D,T,Injection,s,T,b,injection,t,Transpulmonary thermodilution:Cardiac Output,Stewart-Hamilton,method,T,b,=,Blood,temperature,T,i,=,Injectate,temperature,V,i,=,Injectate,volume,T,b,.,dt,=Area under the thermodilution curve,K=Correction constant,made up of specific weight and,specific heat of blood and,injectate,Methodology of volumetric monitoring(I),ln,c(I),injection,At,recirculation,MTt,t,e,-1,DSt,c(I),MTt,:,Mean,transit,time,half of,the,indicator,passed,the,point of,detection,DSt,:,Downslope,time,exponential,downslope,time of TD,curve,Methodology of volumetric monitoring(II),V,all,=,V1+V2+V3+V4,=,MTt,x Flow,V,3,=,largest volume,=,DSt,x Flow,The,MTt,determines the whole volume the indicator passed through from the point of injection to the point of detection.,The,DSt,determines the largest single volume(min.20%larger!)in a series of mixing chambers,flow,V,3,V,4,V,2,V,1,injection,detection,Methodology of volumetric monitoring(III),RAEDV,LAEDV,LVEDV,RVEDV,PTV,ITTV,PTV,=Pulmonary Thermal Volume,largest thermal volume in the series of mixing chambers(,DSt,Volume),ITTV,=Intrathoracic Thermal Volume,volume from the point of injection to the point of detection(,MTt,Volume),GEDV,=Global,end-diastolic,volume,End-diastolic,volume,of,the,4,heart,chambers,PTV,RAEDV,LAEDV,LVEDV,RVEDV,GEDV,GEDV=ITTV-PTV,Methodology of volumetric monitoring(IV),GEDV,PTV,RAEDV,?,LAEDV,LVEDV,RVEDV,?,?,PTV consists of.?,Methodology of volumetric monitoring(V),Relationship between ITBV,TD,and GEDV,ST,Sakka et al,Intensive,Care,Med,26:180-187,2000,GEDV vs.ITBV in 57 intensive,care,patients,ITBV=1.25*GEDV 28.4 ml,r=0.96,ITBV,TD,(ml),GEDV,ST,(ml),Sakka et al,Intensive,Care,Med,26:180-187,2000,Thermodilution ITBVI,ST,vs.thermo-dye dilution ITBVI,TD,n=209,r=0.97,Bias=-7.6 ml/m,2,SD=57.4 ml/m,2,ITBVI,ST,vs.ITBVI,TD,in 209 intensive,care,patients,ITTV=CO*,MTt,TDa,PTV =CO*,DSt,TDa,ITBV,=1.25*GEDV,EVLW=ITTV-,ITBV,GEDV,=,ITTV-PTV,RAEDV,RVEDV,LAEDV,LVEDV,RAEDV,RVEDV,LAEDV,LVEDV,PBV,RAEDV,RVEDV,LAEDV,LVEDV,PTV,PTV,EVLW,EVLW,Calculation of volumes,Sakka et al,Intensive,Care,Med,26:180-187,2000,Thermodilution EVLWI,ST,vs.thermo-dye dilution EVLWI,TD,Bias=-0.2 ml/kgSD=1.4 ml/kg,n=209,r=0.96,EVLWI,ST,vs.EVLWI,TD,in 209 intensive,care,patients,0,200,400,600,800,1000,1200,2.5,5.0,7.5,10.0,GEDVI(ml/m,2,),CI(l/min/m,2,),Volume,Inotropics,normal,range,normal,cardiac,function,CFI=CI/GEDVI,Cardiac function index(CFI),Comparison of,CO,TDa,and,CO,TDpa,Authorn(patients/measurements),CO,TDa,-,CO,TDpa,r bias,SD,von Spiegel et al,1996 21/48-4.7,1.5%0.97,Anaesthesist,45(11),Mc,Luckie,et al,1996 9/?0.19,0.21 l/min/m,2,Acta,Paediatr,85,Goedje,et al,1998 30/150(triple)0.16,0.31 l/min/m,2,0.96,Chest 113(4),Goedje,et al,1998 30/8100.26,0.7 l/min0.96,Thorac,Cardiovasc,Surg,46,Zllner,et al,199818/160(131 double/29 triple)0.03,1.04 l/min0.91,Anaesthesist,47(11),Goedje,et al,1999 24/216(triple)-0.29,0.66 l/min0.93,Crit,Care Med 27(11),Sakka,et al,199937/449 0.68,0.62 l/min0.97,Intensive Care Med 25,Sakka,et al,200012/51(triple)0.73,0.38 l/min0.98,J,Cardiothorac,Vasc,Anesth,14(2),Bindels,et al,200045/2830.49 0.45 l/min/,m,2,0.95,Crit,Care 4,Holm et al,200123/2180.32,0.29 l/min0.98,Burns 27,Extravascular Lung Water,EVLW,EVLW,Clinical validation,Does it really work?,Sturm,In:,Practical,Applications,of Fiberoptics in,Critical,Care,Monitoring,Springer Verlag Berlin-Heidelberg-,NewYork,1990,pp 129-139,Validation of EVLW(I),EVLW by indicator dilution compared to gravimetric EVLW measurement in brain-dead humans,Katzenelson,et al,SCCM 2002,Abstract,PiCCO EVLW,vs,Gravimetric EVLW in dogs,cardiogenic,+,noncardiogenic,PE,Validation of EVLW(II),Arterial Pulse Contour Analysis,t s,P mm Hg,P(t),P(t),Systole,Diastole,Aortic compliance,Rise of the blood pressure curve dependent on the characteristic Compliance of the Aorta,Fall of the blood pressure curve dependent on the characteristic Compliance of the Aorta,Individual,aortic,compliance,C(p),Measured,blood,pressure,(P(t),MAP,CVP),Reference,CO,value,from,thermodilution,Determination of the individual aortic compliance,C(p,),Area,under,pressure,curve,Shape,of pressure,curve,CCO=cal HR,Systole,P(t,),SVR,+,C(p,),dP,dt,(,),dt,Aortic,compliance,Heart,rate,Patient-specific calibration factor(determined by thermodilution),t s,P mm Hg,Calculation of PCCO,Model,CCO,is,displayed,as last 12s,mean,Comparison of PCCO and,CO,TDpa,Authorn(patients/measurements)PCCO-,CO,TDpa,r bias,SD,Goedje,et al,1998 30/270(triple)0.11,0.6 l/min0.91,Thorac,Cardiovasc,Surg,46,Goedje,et al,1999 24/216(triple)0.07,0.7 l/min/m,2,0.92,Crit,Care Med 27(11),Buhre,et al,199912/36(triple)0.003,0.63 l/min0.94,J,Cardiothorac,Vasc,Anesth,13(4),Goedje,et al,199920/192(triple)-0.1,0.42 l/min0.91,Ann,Thorac,Surg,68(4),Zllner,et al,200019/76(triple)0.31,1.25 l/min0.88,J,Cardiothorac,Vasc,Anesth,14(2),PCCO-,CO,TDa,Gdje,et al,2002*24/517(triple)-0.2,+2.10/-2.50 l/min 0.88,CCM 30(1),*,New PiCCO algorithm during,hemodynamic,instability,PCCO,vs,CO,TDpa,in 30 patients after cardiac surgery,Goedje,et al,Thorac,Cardiovasc,Surg,46:242-249,1998,dPmx,=,dP,/,dtmax,of,arterial,pressure,curve,Estimation,of,left,ventricular,pressure,velocity,increase,Index of left ventricular contractility,t s,P mm Hg,SVmax,SVmin,SVmean,SVmax,SVmin,SVV=,SVmean,SVmax,and,SVmin,are,determined,over,last 30 s,window,Determination of the Stroke Volume Variation(SVV),Only applicable in controlled mechanically ventilated patients,The,increase,of,preload,volume,is,equal,:EDV,1,=EDV,2,SV,1,SV,2,SVV as prediction of the heart reaction to volume steps,EDV,SV,SVV,small,SVV large,EDV,1,EDV,2,SV,1,SV,2,Clinical,Application,Volume,Drugs,Pressures as indicators of cardiac preload,Lichtwarck-Aschoff,et al,Intensive,Care,Med,18:142-147,1992,Lichtwarck-Aschoff,et al,Intensive,Care,Med,18:142-147,1992,ITBV as indicator of cardiac preload,Goedje,et al,Eur,J,Cardiothorac,Surg,13(5):533-539;discussion 539-540,1998,Correlation of preload indicators to SVI and CI(,),Cardiac Preload is,Volume,NOT,Pressure,Volume management requiresvolume measurement,Intrathoracic Blood Volume(ITBV),RAEDV,PBV,LAEDV,RVEDV,LVEDV,SVV clinical studies,Berkenstadt,et al,Anesth,Analg,92:984-989,2001,Sensitifity,Specificity,-CVP,_,SVV,Highest,sensitifity,and specificity for the prognosis of the effect of volume loading,SVV clinical application,SVV is a dynamic parameter,measured continuously,Only applicable in controlled mechanically ventilated patients,SVV prognoses the reaction of the heart on volume loading and,corresponds directly the slope of the Frank Starling curve.,Berkenstadt,et al,Eur,J,Anaesthesiol,17(19):49,2000,Reuter et al,Eur,J.,Anaesthesiol,17(,Suppl,19):163,2000,Reuter et al,Britisch Journal of,Anaesthesia,88(1)124-6,2002,EVLW,Extravascular Lung Water,Direct quantification in ml,Water content of the lungs,High accuracy and reproducibility,Fast bedside determination,Source,Comparison,Correlation,Baudendistel et al,1982,X-ray,score,vs.EVLW,77%,J Trauma 22:983,Sibbald,et al,1983,comparison,cardiac,edema,r=0,66,Chest,83:725,comparison,non,cardiac,edema,r=0,7,Sivak,et al,1983,X-ray,score,vs,EVLW,64%,Crit,Care,Med.11:498,X-ray,score,vs.,EVLW,42%,Laggner,et al,1984,X-ray,score,vs.EVLW,r=0,84,Intensive,Care,Med.10:309,Halperin,et al,1985,X-ray,score,vs.,r=0,51,Chest,88:649,EVLW,Haller et al,1985,X-ray,score,vs.EVLW,66%,Fortschr,.Rntgenstr.142:68,Eisenberg et al,1987,X-ray,score,vs.EVLW,76%,Am,Rev,Resp,Dis 136:662,Takeda,et al,1995,X-ray,score,vs.EVLW,X-ray,insensitive,J,Vet,Med,Sci,57(3):481,Comparison of EVLW and chest X-ray,Bck,Lewis,In:,Practical,Applications,of Fiberoptics in,Critical,Care,Monitoring,Springer Verlag Berlin-Heidelberg-,NewYork,1990,pp 129-139,EVLW and oxygenation,Sturm,In:,Practical,Applications,of Fiberoptics in,Critical,Care,Monitoring,Springer Verlag Berlin-Heidelberg-,NewYork,1990,pp 129-139,Lung water(EVLW)and mortality,Relevance of EVLW-management,After:Mitchell et al,Am,Rev,Resp,Dis 145:990-998,1992,22,days,15,days,9,days,7,days,RHC,group,RHC,group,EVLW,group,EVLW,group,*,*,Ventilation,days,ICU,days,n=101,Relationship of ITBVI to EVLWI,Close correlation to gravimetric EVLW,weak correlation to oxygenation and chest X-ray,Extravascular Lung Water-Conclusion,To reduce increased lung water it is necessary to measure it!,correlates with severity of ARDS and mortality,Combination of EVLW+ITBV:optimal volume management;,reduction of ICU ventilation days and ICU stay,Normal ranges,ParameterRange,Unit,CI3.0 5.0l/min/m,2,SVI40 60ml/m2,SVRI1200 1800dyn*s*cm-5*m,MAP70 90,mmHg,CFI4.5 6.51/min,HR60 901/min,ITBVI850 1000ml/m,2,SVV,10%,EVLWI 3.0 7.0ml/kg,CI(l/min/m2),ITBVI(ml/m2),Therapy,Target,ITBVI,CFI,EVLWI(,slowly,responding,),4.5,10,V+!,Cat,temporary,750-850,5.5,10,4.5,3.0,10,Cat,V-,temporary,750-850,5.5,10,10,V+,850-1000,10,V+,temporary,750-850,850,850,10,V-,temporary,750-850,10,850,EVLWI(ml/kg),V+=,volume,loading,(!=,cautiously,),V-=,volume,contraction,Cat,=,catecholamines,/,cardiovascular,agents,Decision,tree,for,hemodynamic,/,volumetric,monitoring,PiCCO-Advantages,TD-Catheter:Less time required for placement;can be in place up to 10 days;,Quick and simple handling;Short response time,Dynamic and less invasive,beat by beat“measurement;,No right heart catheter(RHC),Reduces ICU stay and costs,Direct clinically applicable parameters,no interpretation necessary,Quantification of extravascular lung water,Measurement of flow,preload,afterload,and contractility,Easy to apply in paediatric patients,.Simple Safe,Speedy,Specific,PiCCO Technology.,