协和杜斌--血流动力学监测 Focus on PICCO

正性肌力药物 / 升压药物
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, Groß e J, Schirmer 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): 347358.
临床判断缺乏准确性: CO
测定CO (L/min)
7.0
4.5
0
0
4.5
7.0
预计CO (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): 549-553
ICU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
英格兰与威尔士ICU的CO监测技术
CO监测技术 2种
69%
首选经食道多普勒监测CO
41%
常规监测ScvO2
20%
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)
临床评价 vs. 血流动力学
60%
预测准确性wenku.baidu.com
40%
20%
0% PAWP CO SVR RAP
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
目的: 评价肺动脉导管(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:


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 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): 549-553
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
住院费用 (USD)
70% 68% 66% 64% 62% 60% 58% RHC No RHC
50000
40000
30天病死率
30000 RHC No RHC
15
平均住院日
10 RHC No RHC
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

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

CXR, 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PAC
英格兰与威尔士ICU的CO监测技术
100% 80% 60% 40% 20% 0% PAC Doppler 锂稀释 CO PICOO 其他 19% 8% 76%
百分比
53% 33%
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)
71%
62%
临床重要的血流动力学参数
所有医生(n = 417) CO PAWP SvO2 MPAP SV RAP RVEF RVEDV 330 (79%) 285 (68%) 220 (53%) 120 (37%) 100 (24%) 20 (5%) 20 (5%) 18 (4%) 心内科医生(n = 27) 21 (75%) 27 (100%) 10 (38%) 10 (38%) 3 (13%)
心脏手术后患者的血流动力学监测
血流动力学监测 基本监测 肺动脉导管(PAC) 经食道超声(TEE) PICCO 比例(%) 100 58.2 38.1 13.0
Kastrup M, Markewitz A, Spies C, Carl M, Erb J, Groß e J, Schirmer 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): 347358.
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): 549-553
临床评价 vs. 血流动力学
结
留置PAC后
计划治疗方案需要改变
应用未预计到的治疗方案
果
58%
30%
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 vs. 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 artery catheterization in the hemodynamic assessment of critically ill patients. Crit Care Med 1984; 12(7): 549-553
临床判断缺乏准确性: PAWP
测定PAWP (mmHg)
19 15 10
No change in planned therapy after catheterization Change in planned therapy after catheterization
0
0
10
15
19
预计PAWP (mmHg)
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; 276(11): 889-897
临床判断缺乏准确性
参数 PAWP CO SVR RAP 判断正确数目/测定数目 31/102 49/97 39/88 54/98 正确率(%) 30 51 44 55
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): 549-553
Appavu 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 vs. 血流动力学
PAC的使用减少: Illinois, USA
2000年 出院患者数 PAC使用数 PAC使用率(/1000) 年龄 0 – 17岁 65 – 74岁 > 75岁 性别 男性 女性 1,636,046 5,969 3.65 21 1,739 1,917 3,492 2,473 2001年 1,684,089 5,022 2.98 9 1,375 1,620 2,970 2,052 57 21 15.5 15 17 15.8 降低%
血流动力学参数改变治疗决定
100% 与专家意见相同 80% 可能有害的意见 80%
作出选择医生的比例
60% 40% 20% 0% 最初判断 了解 PAC资料后 38% 35%
10%
Squara P, Bennett D, Perret C. Pulmonary artery catheter: does the problem lie in the users? Chest 2002; 121: 2009-2015
Squara P, Bennett D, Perret C. Pulmonary 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
问卷调查(39个问题)
血流动力学监测 容量替代
How good are our clinical skills?
Connors (NEJM ‘83) ICU pts
Eisenberg (CCM ‘84) ICU pts
Bayliss (BMJ ‘83) CCU pts
Cardiac output
Wedge pressure
44%
42%
50%
33%