脉搏指示连续心排血量技术在肝移植围术期的应用

目的 评价脉搏指示连续心排血量(PiCCO)技术在肝移植术中的应用价值.方法 25例行原位肝移植术的终末期肝病患者,ASA Ⅲ或Ⅳ级.记录术中PiCCO监测数据,并与Swan-Ganz漂浮导管血流动力学监测结果比较.结果 与切皮前比较,无肝前期各项监测指标无显著变化,无肝期全心舒张末期容积指数(GEDI)、胸腔内血容积指数(ITBI)、每搏输出量指数(SVI)和心脏指数(CI)均显著降低(P<0.01),每搏输出量变异(SVV)和脉压变异(PPV)较大(P<0.01),新肝期CI显著增加(P<0.01),肺血管通透性指数(PVPI)增加(P<0.05).通过温度稀释法共测得数据200组.其中,PiCCO所测得的CI(PCI)与导管法显示的CI相关良好(r=0.84,P<0.01).结论 PiCCO技术能较准确的反映心脏前负荷以及肺血管通透性的变化.     

连续温度稀释法测定心排血量

测定心排血量(CO)的方法有无创和有创两种,但比较公认的是通过插入Swan-Ganz漂浮导管,应用温度稀释法测定CO,传统方法只能间断测量,而连续温度稀释法测定心排血量(CCO),具有无创、正确及连续计算和分析的功能,简便、直观,其动态变化对重危病人的诊断和治疗有重要的指导意义。     

脉搏指示连续心排血量技术在肺移植术中及术后的应用11例

目的 观察脉搏指示连续心排血量(PiCCO)技术在肺移植术中及术后的应用并评价其价值.方法 行肺移植术的患者11例,其中6例行单肺移植术,5例行序贯式双肺移植术.诱导麻醉后,经颈内和锁骨下静脉穿刺置入中心静脉导管和Swan-Ganz漂浮导管,取左侧股动脉穿刺置入PiCCO导管.记录麻醉后双肺通气时、单肺通气时、肺动脉夹闭时、肺动脉开放时、术毕、术后8h和术后24h的血流动力学数据及PiCCO监测数据.结果 单肺通气时和肺动脉夹闭时的心输出量和间断心输出量低于双肺通气时(P<0.05),肺动脉开放时和术毕的心输出量和间断心输出量高于单肺通气时和肺动脉夹闭时(P<0.05),心输出量与间断心输出量的相关系数为0.84(P<0.01).单肺通气时和肺动脉夹闭时的肺动脉压明显高于双肺通气时(P<0.05),肺动脉开放时和术毕的肺动脉压则明显低于单肺通气时和肺动脉夹闭时(P<0.05).单肺通气时和肺动脉夹闭时的脉压变异明显高于双肺通气时(P<0.05).全心舒张末期容积指数、胸腔内血容积指数与每搏输出量指数相关(r=0.69,P<0.01),中心静脉压、肺动脉楔压与每搏输出量指数不相关,血管外肺水指数与肺血管通透性指数相关(r=0.82,P<0.01).结论 肺移植术中及术后应用PiCCO技术可反映血流动力学变化,同时反映心脏前负荷以及肺血管通透性的变化,指导液体输入和呼吸机模式的调整.     

脉搏指示连续心排血量监测（PiCCO）在脓毒症休克患者血流动力学监测中的临床价值

目的探讨脉搏指示连续心排血量监测技术（pulse indicator continuous cardiac output,Pjcc0）在脓毒症休克患者血流动力学监测中的临床价值。方法2012年1～8月,前瞻性队列研究比较常规监测（n=12）与Hcc0监测（n=19）脓毒症休克患者的血流动力学,应用PiccO监测指导脓毒症休克患者的液体复苏、血管收缩药和正性肌力药物的使用。结果2组脓毒症休克患者性别、年龄、原发病、既往病史、多器官功能不全综合征（MODs）的发生和发生MODs器官数、急性生理学及慢性健康状况评分系统（APAcHE）Ⅱ、脓毒症相关器官衰竭评分（s0FA）、应用去甲肾上腺素剂量和入Icu后7天总的输液量差异均无显著性,Picc0组初始平均动脉压（MAP）明显低于常规组[（52．00±5．00）mmHgvs．（59．58±3．42）mmHg,k4．603,P=O．000],而对于Picco组存在心功能损害的患者应用正性肌力药治疗后达到与常规组相同的MAP达标值[（68．00±2．43）mmHgvs．（68．58±2．88）mmHg,t=0．607,P=0．549],2组MAP达标值差异无显著性。结论在Picco监测指导下,可以对于存在心功能损害的患者应用正性肌力药物,而不是仅应用血管收缩药升高血压。     

脉搏轮廓心排血量监测技术在大面积烧伤患者中的应用研究进展

脉搏轮廓心排血量(PiCCO)监测作为一项已广泛用于各类危重症患者的有创监测技术,可获得心排血量等参数,能可靠反映危重症患者的实际血流动力学。大面积烧伤后液体复苏至关重要,PiCCO监测因操作简单、参数全面准确等,现已广泛应用于大面积烧伤患者的循环监测。本文简要介绍PiCCO监测技术,综述其在大面积烧伤患者液体复苏监测及肺水肿诊断、鉴别中的应用及新的理论认识。     

连续心排血量监测仪测量心排血量趋势能力的研究综述

目前有很多种可提供连续读数而非间断读数的心排血量（cardiac output,CO）监测仪。与旧标准相比,Bland－Altman法已成为验证其性能的标准方法。然而,Bland－Altman法只能评价仪器精确度,而不能评价仪器检测心排血量连续变化的能力（趋势能力）。目前对如何进行趋势能力或趋势分析评价尚未达成一致意见。因此,我们进行了文献综述,对1997—2009年之间发表的关于比较连续CO测量方法的文献实施筛选,入选的文献根据测量技术和统计学方法进行分组。我们对分析趋势能力的文献进行了回顾以期寻找一种令人满意的统计学方法。入选的文献共有202篇。最常用的方法是脉搏波形法（69篇）、多普勒法（54篇）、生物阻抗法（38篇）以及经肺或连续热稀释法（27篇）。有41篇文献涉及到CO趋势变化,其中仅23篇提供了深入分析。有几种常用的统计方法：时间曲线图、回归分析、使用CO变化（ACO）的Bland-Altman法以及使用△CO的变化方向来确定一致性的四象限曲线图。该曲线图可通过排除小值数据而进一步精简,采用受试者操作特征曲线来定义排除范围。在动物实验中经常选用可靠的参照标准如主动脉流量探头,并可用回归分析或时间曲线图来显示变化趋势。临床研究中由于数据采集点较少（每个受试者8－10个点）而会存在更多的问题,一致意见是采用有排除范围的四象限曲线图,并应用一致性分析。使用15％排除范围时一致率〉92％表明良好的变化趋势。有人提出一种在极坐标图上显示数据变化趋势（△CO）的新方法,通过与水平轴线所成的角度表示一致性,到中心的距离表示△CO,与Bland-Altman法类似,能够用数据的垂直界限来评价变化趋势。     

连续温度稀释法心排血量的测定

连续温度稀释法心排血量的测定方法改进了Swan-Ganz导管,在相当于右心室处嵌入一热释放器,热释放器在安全范围内连续地按非随机双侧序列将能释放入血,经右心室血液稀释后,随右室收缩,血液流到导管顶端,该处温度感受器由于血温下降的程度而产生一系列电位变化,可产生与注射冷盐水相似的温度稀释曲线,从而计算出肺动脉内血流速度并计算心排血量,本文还讨论了温度释放方法、温度释放器的安全性、影响准确性因素、临床应用。     

连续温度稀释法心排血量的测定

连续温度稀释法心排血量的测定方法改进了Ｓｗａｎ－Ｇａｎｚ导管，在相当于右心室处嵌入一热释放器，热释放器在安全范围内连续地按非随机双侧序列将能释放入血，经右心室血液稀释后，随右室收缩，血液流到导管顶端，该处温度感受器由于血温下降的程度而产生一系列电位变化，可产生与注射冷盐水相似的温度稀释曲线，从而计算出肺动脉内血流速度并计算心排血量，本文还讨论了温度释放方法、温度释放器的安全性、影响准确性因素、临床     

脉搏轮廓心排血量监测技术在严重烧伤治疗中应用的全国专家共识(2018版)

脉搏轮廓心排血量(PiCCO)监测技术作为一种新型血流动力学监测技术,在指导休克复苏、液体管理等方面体现出重要价值。PiCCO监测技术在烧伤患者中的应用日趋增多,但如何在烧伤患者中实施PiCCO监测,正确理解PiCCO监测参数的临床意义,以及基于PiCCO监测参数指导严重烧伤救治,尚缺乏统一认识。中国老年医学学会烧创伤分会组织国内烧创伤领域著名专家学者,以文献进展为主要依据,结合临床经验,撰写制订《PiCCO监测技术在严重烧伤治疗中应用的全国专家共识(2018版)》,为该技术的临床应用提供参考。     

脉搏轮廓心排血量监测技术指导大面积烧伤休克期补液的临床意义

目的 探讨脉搏轮廓心排血量(PiCCO)监测技术在临床大面积烧伤休克期补液治疗中的指导意义。 方法 选择2014年1月—2018年12月笔者单位收治的符合入选标准的大面积烧伤患者65例进行前瞻性对照研究。根据患者入院顺序编号,将35例奇数号、30例偶数号患者分别纳入常规补液组(男25例、女10例)和PiCCO监测补液组(男21例、女9例),其年龄分别为(48±9)、(44±8)岁,均按第三军医大学休克期补液公式进行补液治疗。常规补液组根据中心静脉压、平均动脉压、心率、呼吸频率、尿量及患者的临床症状等休克的一般指标调节补液速度;PiCCO监测补液组行PiCCO监测,在常规补液组监测指标的基础上,根据全心舒张末期容积指数并结合PiCCO的其他相关指标指导补液。比较2组患者伤后8、16、24、32、40、48、56、64、72 h心率及液体正平衡量,伤后48、72 h利尿剂使用量,伤后24、48、72 h补液总量、尿量、血乳酸、血小板计数、血细胞比容,住重症监护病房(ICU)时间,伤后28 d内并发症及死亡的发生情况。对数据行重复测量方差分析、 t检验、Bonferroni校正、Mann-Whitney U检验、 χ ²检验、Fisher确切概率法检验。 结果 伤后8、16、24、32、40、48、56 h,2组患者心率相近( t＝0.775、1.388、2.511、2.203、1.654、2.303、1.808, P>0.05);伤后64、72 h,PiCCO监测补液组患者心率明显低于常规补液组( t＝3.229、3.357, P<0.05或 P<0.01)。伤后8、16、40、56 h,2组患者液体正平衡量相近( t＝0.768、1.670、2.134、2.791, P>0.05);伤后24、32、48、64、72 h,PiCCO监测补液组患者液体正平衡量明显少于常规补液组( t＝3.364、4.047、2.930、2.950、2.976, P<0.05或 P<0.01)。2组患者伤后48、72 h利尿剂使用量相近( Z＝－0.697、－1.239, P>0.05)。伤后24、48、72 h,PiCCO监测补液组患者补液总量分别为(13 864±4 241)、(9 532±2 272)、(8 480±2 180)mL,明显多于常规补液组的(10 388±2 445)、(8 095±1 720)、(7 059±1 297)mL( t＝－3.970、－2.848、－3.137, P<0.05或 P<0.01)。2组患者伤后24 h尿量接近( t＝－1.027, P>0.05);PiCCO监测补液组患者伤后48、72 h尿量分别为(3 051±702)、(3 202±624)mL,明显多于常规补液组的(2 401±588)、(2 582±624)mL( t＝－4.062、－4.001, P<0.01)。伤后24、48、72 h,PiCCO监测补液组患者血乳酸水平明显低于常规补液组( t＝4.758、6.101、3.938, P<0.01)。伤后24、48 h,PiCCO监测补液组患者血小板计数明显高于常规补液组( t＝－2.853、－2.499, P<0.05),血细胞比容明显低于常规补液组( t＝2.698、4.167, P<0.05或 P<0.01);伤后72 h,2组患者血小板计数、血细胞比容相近( t＝－1.363、0.476, P>0.05)。PiCCO监测补液组患者住ICU时间明显短于常规补液组( t＝2.184, P<0.05)。伤后28 d内,常规补液组患者并发症发生率明显高于PiCCO监测补液组( P<0.05),病死率与PiCCO监测补液组相近( P>0.05)。 结论 PiCCO监测技术用于大面积烧伤患者补液的监测,能较快纠正休克,减少因补液不当所致各脏器并发症的发生,缩短住ICU时间,对指导烧伤休克的救治具有重要意义。     

Estimation of the parameters of cardiac function and of blood volume by arterial thermodilution in an infant animal model

BACKGROUND: Experimental studies in adults and in animals have reported that estimation of the intracardiac volumes by arterial thermodilution is a more reliable method of blood volume estimation than pressure measurement. The objective of this study has been to analyze the values of cardiac function and blood volume in an infant animal model using the arterial thermodilution technique. METHODS: A total of 202 measurements of cardiac output were performed by femoral arterial thermodilution in 38 Maryland piglets weighing between 8 and 16 kg, to determine the normal values of blood volume obtained by arterial thermodilution (PiCCO method) in an infant animal model. The following parameters were measured: blood volume [global end-diastolic volume index (GEDVI), total intrathoracic blood index (ITBI), extravascular lung water index (ELWI), systolic volume index (SVI)] and parameters of cardiac and vascular function [systolic volume index (SVI), cardiac function index (CFI), left ventricular contractility (Dp/dtmax), and systemic vascular resistance index) (SVRI)]. RESULTS: The cardiac index, 4.3 +/- 1.2 l x min(-1) x m(2), was within the normal range. The GEDVI, 198 +/- 48.6 ml x m(2), and ITBI, 574.1 +/- 113.4 ml x m(2), were lower than the normal values reported in adults, whereas the ELWI, 16.3 +/- 5.2 ml x kg(-1), was higher. CONCLUSIONS: Intrathoracic and intracardiac volume values obtained by arterial thermodilution are lower than those considered normal in the adult, whereas the extravascular lung water is higher. These values must be taken into account when the PiCCO method is used in small children.     

Cardiac output monitoring

Cardiac output monitoring has become commonplace amongst the standard monitoring in anaesthesia for major surgery and in intensive care. Multiple techniques are used, employing different models to calculate flow, which cannot be directly measured. Each method has differing advantage and disadvantage profiles and so the choice of device should consider a balance of invasiveness, usability, reliability and validity. Trend monitoring is generally emphasized over absolute values.     

Evaluation of an uncalibrated arterial pulse contour cardiac output monitoring system in cirrhotic patients undergoing liver surgery

Background: The pulmonary artery catheter is invasive and may cause seriouscomplications. A safe method of cardiac output (CO) measurementis needed. We have assessed the accuracy and reliability ofa recently marketed self-calibrating arterial pulse contourCO monitoring system (FloTrac/Vigileo^TM) in end-stage liverfailure patients undergoing liver transplant. The pattern ofalterations known as cirrhotic cardiomyopathy, and the transplantprocedure itself, provided an evaluation under varying clinicalconditions. Methods: The cardiac index was measured simultaneously by thermodilution(CI_TD: mean of four readings) using a pulmonary artery catheterand pulse contour analysis (CI_V: mean value computed by theFloTrac/Vigileo^TM over the same time period). Readings weremade at 10 time-points during liver transplant surgery (T1–T5)and on the intensive care unit (T6–T10). CI_V was computedusing the latest Vigileo software version 01.10. Results: A total of 290 paired readings from 29 patients were collected.Mean (SD) CI_TD was 5.2 (1.3) and CI_V was 3.9 (0.9) litre min^–1m^–2, with a corrected for repeated measures bias betweenreadings of 1.3 (0.2) litre min^–1 m^–2 and 95% limitsof agreement of –1.5 (0.2) to 4.1 (0.3) litre min^–1m^–2. The percentage error (2SD_Bias/meanCI_TD) was 54%,which exceeded a 30% limit of acceptance. Low peripheral resistanceand increasing bias were related (r=0.69; P<0.001). The Vigileosystem failed to reliably trend CI data, with a concordancecompared with thermodilution below an acceptable level (at best68% of sequential readings). Conclusions: In cirrhotic patients with hyperdynamic circulation, the Vigileosystem showed a degree of error and unreliability higher thanthat considered acceptable for clinical purposes.     

A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output

This study was undertaken in order to elucidate the differences between various planes of measurement and Doppler techniques (pulsed- vs. continuous-wave Doppler) across the aortic valve to estimate cardiac output. In 45 coronary artery bypass patients, cardiac output was measured each time using four different Doppler techniques (transverse and longitudinal plane, pulsed- and continuous-wave Doppler) and compared with the thermodilution technique. Measurements were performed after induction of anaesthesia and shortly after arrival in the intensive care unit. Optimal imaging was obtained in 91% of the patients, in whom a total of 82 measurements of cardiac output were performed. The respective mean (SD) areas of the aortic valve were 3.77 (0.71) cm2 in the transverse plane and 3.86 (0.89) cm2 in the longitudinal plane. A correlation of 0.87 was found between pulsed-wave Doppler cardiac output and the thermodilution technique in either transverse or longitudinal plane. Correlation coefficients of 0.82 and 0.84 were found between thermodilution cardiac output and transverse and longitudinal continuous-wave Doppler cardiac output, respectively. Although thermodilution cardiac output is a widely accepted clinical standard, transoesophageal Doppler echocardiography across the aortic valve offers adequate estimations of cardiac output. In particular, pulsed-wave Doppler cardiac output in both the transverse and longitudinal plane provides useful data.     

The reproducibility of measurement of right ventricular ejection fraction and cardiac output by the thermodilution technique in patients on mechanical ventilation

Thermodilution determined right ventricular ejection fraction (RVEF) and cardiac output (CO) were measured in 48 critically ill patients requiring mechanical ventilation and inotropic and/or vasoactive drugs. The coefficient of variation on CO and RVEF were calculated from triple determinations. The average coefficient of variation based on 551 triple determinations was 12.6% for RVEF (range 2–51%) and 4.9% for CO (range 0–24%). If a 10% coefficient of variation was chosen as acceptable, 95% of the CO measurements were acceptable. The coefficient of variation on RVEF only fulfilled the 10% criteria in 46% of the measurements, but if the accepted level was raised to a 20% coefficient of variation, 90% of the measurements were acceptable. The measurement of RVEF and CO are used for calculation of e.g. right ventricular end diastolic volume (RVEDV). By applying the average coefficient of variation on RVEF and CO, the accumulated error on calculation of RVEDV was found to be 15%–+20% at worst. Before derived parameters such as RVEDV are interpreted or compared with previously obtained values, the accumulated error should be calculated. To ensure the quality of the measurements, our recommendation is always to calculate the coefficient of variation for each triple determination of RVEF and CO.     

Hemodynamic changes associated with thermodilution cardiac output determination in canine acute blood loss or endotoxemia

Since the technique of thermodilution (TD) cardiac output measurement, per se, causes hemodynamic alterations, the author examined whether the alterations elicited by iced injectate are augmented in the presence of acute blood loss or endotoxemia, compromized conditions frequently associated with critically ill patients. Acute blood loss (N = 8) and endotoxemia (N = 8) were induced by withdrawing arterial blood approximately 20–30 ml kg^-1 over 30 min and by a slow intravenous infusion of E. coli endotoxin 2.5-3.0 mg kg^-l over 10 min, respectively, in anesthetized dogs. The magnitudes of decreases in mean arterial and pulmonary artery pressures during slowing of heart rate (HR) following injection of iced injectate 3 ml were slightly less in acute blood loss than in normovolemia, whereas in endotoxemia the degree of mean arterial pressure decrease during slowing of HR following iced injectate 3 ml was slightly less as compared with that before endotoxemia. However, the alterations in other hemodynamic variables following injection of iced injectate 3 ml were similar between dogs with and without acute blood loss or endotoxemia. No profound hemodynamic changes were observed during any TD cardiac output measurements under both conditions. Cardiac output estimated by TD correlated closely with pulmonary blood flow measured by electromagnetic flowmeter in endotoxemia (r > 0.9) but not during acute blood loss. These results indicate that TD cardiac output determination does not cause serious hemodynamic alterations in endotoxemia or acute blood loss, and can estimate right ventricular output accurately in endotoxemia but not in acute blood loss.     

Measurement of cardiac output by transpulmonary arterial thermodilution using a long radial artery catheter. A comparison with intermittent pulmonary artery thermodilution

Cardiac output can be measured accurately by transpulmonary arterial thermodilution using the PiCCO (Pulsion Medical Systems, Munich, Germany) system with a femoral artery catheter. We have investigated the accuracy of a new 50 cm 4 French gauge radial artery catheter and the ability to use the system with a shorter radial catheter. We studied 18 patients who had undergone coronary artery surgery and made three simultaneous measurements of cardiac output by arterial thermodilution and with a pulmonary artery catheter. The radial catheter was withdrawn in 5 cm increments and the measurements were repeated. We found close agreement between arterial thermodilution and pulmonary artery thermodilution with a mean (SD) bias of 0.38 (0.77) l x min(-1). Arterial thermodilution became unreliable once the catheter had been withdrawn by more than 5 cm. We conclude that cardiac output measurement with arterial thermodilution with a radial catheter is interchangeable with that derived from a pulmonary artery catheter, and that a centrally sited arterial catheter is required for accurate determination of cardiac output by transpulmonary arterial thermodilution.     

Lack of agreement between thermodilution and carbon dioxide-rebreathing cardiac output

BACKGROUND: A continuous, accurate, non-invasive monitor of cardiac output would represent a major step forward in patient management. A cardiac output computer, NICO2, based on the Fick principle and an automatic partial carbon dioxide (CO2)-rebreathing technique has just become available. We compared the performance of this monitor with the standard thermodilution method. METHODS: Thirty patients were investigated after cardiac surgery. Replicate measurements were performed simultaneously with the thermodilution and NICO2 techniques. An Altman-Bland analysis was used to assess repeatability of each of the two methods and to determine the agreement between the two techniques. RESULTS: The repeatabilities of thermodilution and CO2-rebreathing cardiac output were excellent, with coefficients of repeatability of 0.35 l/min and 0.60 l/min. Mean thermodilution and NICO2 cardiac output were 4.4 l/min (SD 0.9, range 2.7-6.1) and 4.6 l/min (SD 1.3, range 1.6-6.9). A comparison of the methods, however, revealed excessive limits of agreement (+/-1.80 l/min). CONCLUSION: The agreement between the NICO2 derived cardiac output and the de facto standard - thermodilution cardiac output - is poor. The methods are not interchangeable with the present version of the NICO2. The repeatability of the partial CO2-rebreathing technique holds promise that a sufficient accuracy may be obtained by suitable modifications of the monitor's algorithms.