血流動力學監測picco杜斌-wenkub

　

【正文】 diate between the phasic PA and atrial waveforms 100 (4) 12 Spontaneous variation of WP 56 (2) 7 Criterion 3 (total) 381 (14) 45 Poor dynamic response 184 (7) 22 Damped tracing 65 (2) 8 Overinflation 42 (2) 5 Cannot aspirate blood with the catheter in the PA 36 (1) 4 Cannot aspirate blood with the catheter in the wedge position 54 (2) 6 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 Med 1984。 e J, Schirmer U. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in postoperative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiologica Scandinavica 2022。 12(7): 549553 參數 判斷正確數目 /測定數目 正確率 (%) PAWP 31/102 30 CO 49/97 51 SVR 39/88 44 RAP 54/98 55 How good are our clinical skills? Cardiac output Wedge pressure Connors (NEJM ?83) ICU pts 44% 42% Eisenberg (CCM ?84) ICU pts 50% 33% Bayliss (BMJ ?83) CCU pts 71% 62% 臨床重要的血流動力學參數 所有醫生 (n = 417) 心內科醫生 (n = 27) CO 330 (79%) 21 (75%) PAWP 285 (68%) 27 (100%) SvO2 220 (53%) 10 (38%) MPAP 120 (37%) 10 (38%) SV 100 (24%) 3 (13%) RAP 20 (5%) RVEF 20 (5%) RVEDV 18 (4%) Squara P, Bent D, Perret C. Pulmonary artery catheter: does the problem lie in the users? Chest 2022。 121: 20222022 ICU患者的輸液治療 輸液治療的決定因素 ?臨床經驗 ?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. Intensive Care Med 1998。 12(7): 549553 臨床評價 vs. 血流動力學 0%20%40%60%P A W P CO SVR RAP預測準確性Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation pared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984。危重病患者的血流動力學監測 focus on PiCCO 北京協和醫院 杜 斌 血流動力學監測增加患者病死率 58%60%62%64%66%68%70%RHC N o R H C30天病死率300004000050000RHC N o R H C住院費用(USD)1015RHC N o R H C平均住院日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 initial care of critically ill patients. SUPPORT Investigators. JAMA 1996。 12(7): 549553 臨床評價 vs. 血流動力學 結 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. Clinical evaluation pared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984。 24: 147151 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, Jaffe AS, Schuster DP. Clinical evaluation pared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984。 121: 20222022 心臟手術后患者的血流動力學監測 ?問卷調查 (39個問題 ) ?血流動力學監測 ?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, Gro223。 51(3): 347358. 英格蘭與威爾士 ICU的 CO監測技術 76%53%19%33%8%0%20%40%60%80%100%P A C D o p p l e r 鋰稀釋 CO P I C O O 其他 百分比Esdaile B, Raobaikady R. Survey of cardiac output monitoring in intensive care units in England and Wales. Critical Care 2022。 12(3): 164170 WP Technical Problem Corrected by Initial Confirmed 22 8 Overinflation Deflated balloon 8 12 Venous blood Advance 2 cm 30 8 Venous blood Withdrawn 15 6 Venous blood Nothing 8 12 Poor dynamic response Withdrawn 4 cm 24 8 Poor dynamic response Deflated and inflated balloon 23 13 Poor dynamic response Withdrawn 12 8 Poor dynamic response Flushed 36 18 Partial WP Patient coughed 21 4 Partial WP Repositioned 7 20 Partial WP Nothing 14 20 ? Repositioned WP initial – WP confirmed = 11 ? 6 mmHg Range (13, +22) ICU醫生缺乏 PAC的相關知識 ? 目的 : 評價歐洲國家 ICU醫生對 PAC相關知識的了解程度 ? 設計 : 調查問卷 ? 背景 : 86個歐洲大學及非大學醫院 ICU ? 對象 : 從兩個歐洲危重病醫學會目錄中選取 134個 ICU. 其中 86個 ICU的 535名醫生參加問卷調查 ? 干預 : 在每個 ICU中 , 所有醫生均被要求同時完成一項調查問卷 , 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 rightheart catheterization at the bedside: time to act? Crit Care Med 1997。 C ] D T 注射 熱稀釋測量曲線 ? ?D??? dtT KV)T(TCObiibT D a Tb = 血流溫度 Ti = 注射指示劑溫度 Vi = 注射指示劑容積 ∫ ? Tb . dt = 熱稀釋曲線下面積 K = 校正系數 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的每搏參數 ? 通過經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) t [s] P [mm Hg] SV 連續心輸出量測定 : PiCCO 壓力曲線下面積 壓力曲線型狀 PCCO = cal ? HR ? ? ? Systole P(t) SVR + C(p) ? dP dt ( ) dt 動脈順應性參數 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 Author Pt/Obs COTDa – COTDpa Bias ? SD r Von Spiegel, et al. Anaesthesist 1996。 46 30/810 ? L/min .96 Zoolner, et al. Anaesthesist 1998。 14(2) 12/51 ? L/min .96 Zoolner, et al. J Cardiothorac Vasc Anesth 2022。 Diebel et al 16 ? 6 15 ? 5 Wagner and Leatherman 10 ? 3 14 ? 4 182。