簡介:危重病患者的血流動力學(xué)監(jiān)測FOCUSONPICCO,北京協(xié)和醫(yī)院杜斌,血流動力學(xué)監(jiān)測增加患者病死率,CONNORSAFJR,SPEROFFT,DAWSONNV,THOMASC,HARRELFEJR,WAGNERD,DESBJENSN,GOLDMANL,WUAW,CALIFFRM,FULKERSONWJJR,VIDAILLETH,BROSTES,BELLAMYP,LYNNJ,KNAUSWATHEEFFECTIVENESSOFRIGHTHEARTCATHETERIZATIONINTHEINITIALCAREOFCRITICALLYILLPATIENTSSUPPORTINVESTIGATORSJAMA199627611889897,血流動力學(xué)監(jiān)測為何不能改善預(yù)后,不恰當(dāng)?shù)倪m應(yīng)癥PAC的副作用或并發(fā)癥獲得數(shù)據(jù)的方法不正確儀器定標(biāo)錯誤,或傳感器位置錯誤獲得的數(shù)據(jù)不能反映血流動力學(xué)狀態(tài)錯誤使用數(shù)據(jù)對數(shù)據(jù)的解讀錯誤作出治療決定前未考慮其他相關(guān)因素CXR,尿量,血清白蛋白采用的治療措施無效或有害無需血流動力學(xué)監(jiān)測時未及時拔除PAC,PAC的使用減少ILLINOIS,USA,APPAVUS,COWENJ,BUNYERMTHEUSEOFPULMONARYARTERYCATHETERIZATIONHASDECLINEDCRITICALCARE20059SUPPL1P69DOI101186/CC3132,PAC的使用減少ILLINOIS,USA,APPAVUS,COWENJ,BUNYERMTHEUSEOFPULMONARYARTERYCATHETERIZATIONHASDECLINEDCRITICALCARE20059SUPPL1P69DOI101186/CC3132,臨床評價VS血流動力學(xué),目的評價肺動脈導(dǎo)管PAC得到的血流動力學(xué)指標(biāo)是否能夠改變患者的治療設(shè)計前瞻性觀察患者103例留置PAC的患者方法插管前,請醫(yī)生對一些血流動力學(xué)指標(biāo)的范圍,診斷及治療方案進行預(yù)測插管后,復(fù)習(xí)患者病例,記錄插管時及置管8小時內(nèi)的血流動力學(xué),EISENBERGPR,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,臨床評價VS血流動力學(xué),EISENBERGPR,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,臨床評價VS血流動力學(xué),結(jié)果留置PAC后計劃治療方案需要改變58應(yīng)用未預(yù)計到的治療方案30,EISENBERGPR,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,臨床評價VS血流動力學(xué),結(jié)論單純根據(jù)臨床表現(xiàn)難以準(zhǔn)確預(yù)測血流動力學(xué)指標(biāo)PAC監(jiān)測數(shù)據(jù)通常能夠改變治療方案,EISENBERGPR,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,血流動力學(xué)數(shù)據(jù)的解釋,臨床場景N44心臟外科術(shù)后16ARDS9全身性感染9心源性休克5其他情況5,SQUARAP,FOURQUETE,JACQUETL,BROCCARDA,UHLIGT,RHODESA,BAKKERJ,PERRETCACOMPUTERPROGRAMFORINTERPRETINGPULMONARYARTERYCATHETERIZATIONDATARESULTSOFTHEEUROPEANHEMODYNRESIDENTSTUDYINTENSIVECAREMED200329735741,血流動力學(xué)數(shù)據(jù)的解釋,SQUARAP,FOURQUETE,JACQUETL,BROCCARDA,UHLIGT,RHODESA,BAKKERJ,PERRETCACOMPUTERPROGRAMFORINTERPRETINGPULMONARYARTERYCATHETERIZATIONDATARESULTSOFTHEEUROPEANHEMODYNRESIDENTSTUDYINTENSIVECAREMED200329735741,血流動力學(xué)數(shù)據(jù)的解釋,SQUARAP,FOURQUETE,JACQUETL,BROCCARDA,UHLIGT,RHODESA,BAKKERJ,PERRETCACOMPUTERPROGRAMFORINTERPRETINGPULMONARYARTERYCATHETERIZATIONDATARESULTSOFTHEEUROPEANHEMODYNRESIDENTSTUDYINTENSIVECAREMED200329735741,血流動力學(xué)參數(shù)改變治療決定,SQUARAP,BENNETTD,PERRETCPULMONARYARTERYCATHETERDOESTHEPROBLEMLIEINTHEUSERSCHEST200212120092015,ICU患者的輸液治療,輸液治療的決定因素臨床經(jīng)驗中心靜脈壓或肺動脈楔壓,BOLDTJ,LENZM,KUMLEB,PAPSDORFMVOLUMEREPLACEMENTSTRATEGIESONINTENSIVECAREUNITSRESULTSFROMAPOSTALSURVEYINTENSIVECAREMED199824147151,臨床判斷缺乏準(zhǔn)確性PAWP,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0,10,15,19,19,15,10,0,預(yù)計PAWPMMHG,測定PAWPMMHG,EISENBERGPL,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,,,NOCHANGEINPLANNEDTHERAPYAFTERCATHETERIZATION,CHANGEINPLANNEDTHERAPYAFTERCATHETERIZATION,,,,,,,0,,,,,,臨床判斷缺乏準(zhǔn)確性CO,,,,,,,,,,,,,,,,0,45,70,預(yù)計COL/MIN,測定COL/MIN,EISENBERGPL,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45,70,臨床判斷缺乏準(zhǔn)確性,EISENBERGPL,JAFFEAS,SCHUSTERDPCLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSCRITCAREMED1984127549553,HOWGOODAREOURCLINICALSKILLS,CARDIACOUTPUTWEDGEPRESSURE,BAYLISSBMJ‘83CCUPTS7162,臨床判斷缺乏準(zhǔn)確性,CLINICALEVALUATIONCOMPAREDTOPULMONARYARTERYCATHETERIZATIONINTHEHEMODYNAMICASSESSMENTOFCRITICALLYILLPATIENTSEISENBERGPR,ETALCRITCAREMED198412349ASSESSINGHEMODYNAMICSTATUSINCRITICALLYILLPATIENTSDOPHYSICIANSUSECLINICALINFORMATIONOPTIMALLYCONNORSAF,ETALJCRITCARE19872174THERAPEUTICIMPACTOFPACINTHEICUSTEINGRUB,ETALCHEST1991991451PACINCRITICALLYILLPATIENTSAPROSPECTIVEANALYSISOFOUTCOMECHANGESASSOCIATEDWITHCATHETERPROMPTEDCHANGESINTHERAPYMIMOZOETALCRITCAREMED199422573HEMODYNAMICANDPULMONARYFLUIDSTATUSINTHETRAUMAPATIENTAREWESLIPPINGVEALEWNJR,ETALAMSURG200571621,臨床判斷缺乏準(zhǔn)確性,醫(yī)生常常相信自己的判斷,但自信與準(zhǔn)確性之間并無相關(guān)性與經(jīng)驗較少的醫(yī)生相比,盡管有經(jīng)驗的醫(yī)生更為自信,但他們的判斷并不準(zhǔn)確醫(yī)生不應(yīng)盲目根據(jù)自己對心臟功能的判斷,作為治療決策的依據(jù),DAWSONNVETALHEMODYNAMICASSESSMENTINMANAGINGTHECRITICALLYILLISPHYSICIANCONFIDENCEWARRANTEDMEDDECISMAKING199313258266,臨床判斷血流動力學(xué)的準(zhǔn)確性,臨床重要的血流動力學(xué)參數(shù),SQUARAP,BENNETTD,PERRETCPULMONARYARTERYCATHETERDOESTHEPROBLEMLIEINTHEUSERSCHEST200212120092015,心臟手術(shù)后患者的血流動力學(xué)監(jiān)測,問卷調(diào)查39個問題血流動力學(xué)監(jiān)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,KASTRUPM,MARKEWITZA,SPIESC,CARLM,ERBJ,GRO?EJ,SCHIRMERUCURRENTPRACTICEOFHEMODYNAMICMONITORINGANDVASOPRESSORANDINOTROPICTHERAPYINPOSTOPERATIVECARDIACSURGERYPATIENTSINGERMANYRESULTSFROMAPOSTALSURVEYACTAANAESTHESIOLOGICASCANDINAVICA2007513347358,心臟手術(shù)后患者的血流動力學(xué)監(jiān)測,KASTRUPM,MARKEWITZA,SPIESC,CARLM,ERBJ,GRO?EJ,SCHIRMERUCURRENTPRACTICEOFHEMODYNAMICMONITORINGANDVASOPRESSORANDINOTROPICTHERAPYINPOSTOPERATIVECARDIACSURGERYPATIENTSINGERMANYRESULTSFROMAPOSTALSURVEYACTAANAESTHESIOLOGICASCANDINAVICA2007513347358,英格蘭與威爾士ICU的CO監(jiān)測技術(shù),ESDAILEB,RAOBAIKADYRSURVEYOFCARDIACOUTPUTMONITORINGININTENSIVECAREUNITSINENGLANDANDWALESCRITICALCARE20059SUPPL1P68DOI101186/CC3131,英格蘭與威爾士ICU的CO監(jiān)測技術(shù),CO監(jiān)測技術(shù)?2種69首選經(jīng)食道多普勒監(jiān)測CO41常規(guī)監(jiān)測SCVO220,ESDAILEB,RAOBAIKADYRSURVEYOFCARDIACOUTPUTMONITORINGININTENSIVECAREUNITSINENGLANDANDWALESCRITICALCARE20059SUPPL1P68DOI101186/CC3131,AREWEUSINGPACCORRECTLY,,PAWP測定中的技術(shù)問題,MORRISAH,CHAPMANRH,GARDNERRMFREQUENCYOFTECHNICALPROBLEMSENCOUNTEREDINTHEMEASUREMENTOFPULMONARYARTERYWEDGEPRESSURECRITCAREMED1984123164170,PAWP測定中的技術(shù)問題,MORRISAH,CHAPMANRH,GARDNERRMFREQUENCYOFTECHNICALPROBLEMSENCOUNTEREDINTHEMEASUREMENTOFPULMONARYARTERYWEDGEPRESSURECRITCAREMED1984123164170,WPINITIAL–WPCONFIRMED11?6MMHGRANGE13,22,PAWP測定中的技術(shù)問題,MORRISAH,CHAPMANRH,GARDNERRMFREQUENCYOFWEDGEPRESSUREERRORSINTHEICUCRITCAREMED1985139705708,PAWP測定中的技術(shù)問題,MORRISAH,CHAPMANRH,GARDNERRMFREQUENCYOFWEDGEPRESSUREERRORSINTHEICUCRITCAREMED1985139705708,ICU醫(yī)生缺乏PAC的相關(guān)知識,目的評價歐洲國家ICU醫(yī)生對PAC相關(guān)知識的了解程度設(shè)計調(diào)查問卷背景86個歐洲大學(xué)及非大學(xué)醫(yī)院ICU對象從兩個歐洲危重病醫(yī)學(xué)會目錄中選取134個ICU其中86個ICU的535名醫(yī)生參加問卷調(diào)查干預(yù)在每個ICU中,所有醫(yī)生均被要求同時完成一項調(diào)查問卷,包括31個多選題,涉及床旁留置PAC的所有方面,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ICU醫(yī)生缺乏PAC的相關(guān)知識,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ICU醫(yī)生缺乏PAC的相關(guān)知識,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ICU醫(yī)生缺乏PAC的相關(guān)知識,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ICU醫(yī)生缺乏PAC的相關(guān)知識,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ICU醫(yī)生缺乏PAC的相關(guān)知識,GNAEGIA,FEIHLF,PERRETCINTENSIVECAREPHYSICIAN’SINSUFFICIENTKNOWLEDGEOFRIGHTHEARTCATHETERIZATIONATTHEBEDSIDETIMETOACTCRITCAREMED199725213220,ISTHEREANEASYALTERNATIVETOTHISDILEMMA,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,CENTRALVENOUSCATHETER,INJECTATETEMPERATURESENSORHOUSINGPV4046,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,ARTERIALTHERMODILUTIONCATHETER,INJECTATETEMPERATURESENSORCABLEPC80109,PULSIONDISPOSABLEPRESSURETRANSDUCERPV8115,,,,PCCI,AP,13031628TB370,AP14011792CVP5SVRI2762PCCI324HR78SVI42SVV5DPMX1140GEDI625,,,,,,,,,,,,,,,,,,,,,,,,,DPTMONITORCABLEPMK206,INTERFACECABLEPC80150,,,,,,CONNECTIONCABLETOBEDSIDEMONITORPMKXXX,AUXADAPTERCABLEPC81200,PICCO的技術(shù)原理,PICCO技術(shù)由下列兩種技術(shù)組成,用于更有效地進行血流動力和容量治療,使大多數(shù)病人不必使用肺動脈導(dǎo)管,心輸出量的測定經(jīng)肺熱稀釋技術(shù),中心靜脈內(nèi)注射指示劑后,動脈導(dǎo)管尖端的熱敏電阻測量溫度下降的變化曲線通過分析熱稀釋曲線,使用STEWARTHAMILTON公式計算得出心輸出量CO,心輸出量的測定經(jīng)肺熱稀釋技術(shù),經(jīng)肺熱稀釋測量只需要在中心靜脈內(nèi)注射冷100時,胸片才會發(fā)生改變BONGARDFS,SURGERY1984胸片對EVLW的改變并不敏感HELPERINBD,CHEST1984確定患者是否符合ARDS影像學(xué)表現(xiàn)時,醫(yī)生之間存在非常明顯的差異RUBENFELDETAL,CHEST1999,容量測量小結(jié),ITTVCOXMTTTDA,PTVCOXDSTTDA,ITBV125XGEDV,EVLWITTV–ITBV,GEDVITTV–PTV,,,,EVLWPICCOVS重力法測定,STURM,INPRACTICALAPPLICATIONSOFFIBEROPTICSINCRITICALCAREMONITORING,SPRINGERVERLAGBERLINHEIDELBERGNEWYORK1990,PP129139,血管外肺水的臨床驗證,SAKKAETAL,INTENSIVECAREMED26180187,2000,BIAS02ML/KGSD14ML/KG,N209R096,EVLWISTVSEVLWITDIN209INTENSIVECAREPATIENTS,減少血管外肺水臨床試驗,MITCHELLETAL,AMREVRESPDIS145990998,1992,血管外肺水,血管外肺水EVLW通過經(jīng)肺熱稀釋法得到,已被染料稀釋法和重量法證實已證實血管外肺水EVLW與ARDS的嚴(yán)重程度,病人機械通氣的天數(shù),住ICU的時間及死亡率明確相關(guān),其評估肺水腫遠(yuǎn)遠(yuǎn)優(yōu)于胸部X線肺血管通透性指數(shù)PVPI一定程度上反映了肺水腫形成的原因PVPIEVLW/PBV,隱匿性肺水腫的檢測,原發(fā)性與繼發(fā)性ARDS/ALI的鑒別,患者人群N10原發(fā)性ARDS/ALIN4肺炎,誤吸繼發(fā)性ARDS/ALIN6全身性感染評價指標(biāo)ITBVIEVLWIPVPIEVLW/ITBV,MORISAWAK,TAIRAY,TAKAHASHIH,MATSUIK,OUCHIM,FUJINAWAN,NODAKDOTHEDATAOBTAINEDBYTHEPICCOSYSTEMENABLEONETODIFFERENTIATEBETWEENDIRECTALI/ARDSANDINDIRECTALI/ARDSCRITICALCARE2006,10SUPPL1P326DOI101186/CC4673,原發(fā)性與繼發(fā)性ARDS/ALI的鑒別,MORISAWAK,TAIRAY,TAKAHASHIH,MATSUIK,OUCHIM,FUJINAWAN,NODAKDOTHEDATAOBTAINEDBYTHEPICCOSYSTEMENABLEONETODIFFERENTIATEBETWEENDIRECTALI/ARDSANDINDIRECTALI/ARDSCRITICALCARE2006,10SUPPL1P326DOI101186/CC4673,SIRS及ARDS肺血管通透性與肺水腫,TAGAMIT,KUSHIMOTOS,ATSUMIT,MATSUDAK,MIYAZAKIY,OYAMAR,KOIDOY,KAWAIM,YOKOTAH,YAMAMOTOYINVESTIGATIONOFTHEPULMONARYVASCULARPERMEABILITYINDEXANDEXTRAVASCULARLUNGWATERINPATIENTSWITHSIRSANDARDSUNDERTHEPICCOSYSTEMCRITICALCARE200610SUPPL1P352DOI101186/CC4699,血管外肺水的測定,胸片,氧合障礙及PAWP與EVLW之間的相關(guān)性很差床旁測定EVLW為危重病患者的診斷,隨訪及治療評估提供了新的方法,
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