危重病患者的血流动力学监测focusonPiCCO北京协和医院杜斌血流动力学监测增加患者病死率58%60%62%64%66%68%70%RHCNoRHC30天病死率300004000050000RHCNoRHC住院费用(USD)1015RHCNoRHC平均住院日ConnorsAFJr,SperoffT,DawsonNV,ThomasC,HarrelFEJr,WagnerD,DesbjensN,GoldmanL,WuAW,CaliffRM,FulkersonWJJr,VidailletH,BrosteS,BellamyP,LynnJ,KnausWA.Theeffectivenessofrightheartcatheterizationintheinitialcareofcriticallyillpatients.SUPPORTInvestigators.JAMA1996;276(11):889-897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PACPAC的使用减少:Illinois,USA2000年2001年降低%出院患者数1,636,0461,684,089PAC使用数5,9695,02215.8PAC使用率(/1000)3.652.98年龄0–17岁2195765–74岁1,7391,37521>75岁1,9171,62015.5性别男性3,4922,97015女性2,4732,05217AppavuS,CowenJ,BunyerM.Theuseofpulmonaryarterycatheterizationhasdeclined.CriticalCare2005;9(Suppl1):P69(DOI10.1186/cc3132)临床评价vs.血流动力学目的: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EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553临床评价vs.血流动力学0%20%40%60%PAWPCOSVRRAP预测准确性EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553临床评价vs.血流动力学结果留置PAC后计划治疗方案需要改变58%应用未预计到的治疗方案30%EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;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EisenbergPR,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553血流动力学参数改变治疗决定38%80%35%10%0%20%40%60%80%100%最初判断了解PAC资料后作出选择医生的比例与专家意见相同可能有害的意见SquaraP,BennettD,PerretC.Pulmonaryarterycatheter:doestheproblemlieintheusers?Pulmonaryarterycatheter:doestheproblemlieintheusers?Chest2002;121:2009-2015ICU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BoldtJ,LenzM,KumleB,PapsdorfM.Volumereplacementstrategiesonintensivecareunits:resultsfromapostalsurvey.IntensiveCareMed1998;24:147-151临床判断缺乏准确性:PAWP01015191915100预计PAWP(mmHg)测定PAWP(mmHg)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-553NochangeinplannedtherapyaftercatheterizationChangeinplannedtherapyaftercatheterization0临床判断缺乏准确性:CO04.57.0预计CO(L/min)测定CO(L/min)EisenbergPL,JaffeAS,SchusterDP.Clinicalevaluationcomparedtopulmonaryarterycatheterizationinthehemodynamicassessmentofcriticallyillpatients.CritCareMed1984;12(7):549-5534.57.0临床判断缺乏准确性EisenbergPL,JaffeAS,Schus...
