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1、,Click to edit Master text styles,,Second level,,Third level,,Fourth level,,Fifth level,,,*,Click to edit Master title style,,,肺動脈漂浮導(dǎo)管的應(yīng)用,,,,,Contents,Introduction,PAC Placement,,Hemodynamic Monitoring,Controversy on PAC,,,Parameter integration,Cases Discussion,,What is Pulmonary Artery Cathete
2、r ?,,Full name: Swan-Ganz Catheter,,,,Used it to monitor a patient’s hemodynamics when we cant answer the question using noninvasive/clinical measures,,,,,,,,,Clinical use of the PAC 〔Diagnosis〕,Differentiation among causes of shock,,,Cardiogenic,,Hypovolemic,,Distributive (sepsis),,Obstructive (mas
3、sive pulmonary embolism),,,Differentiation of pulmonary edema,,Cardiogenic,,Noncardiogenic,,,Evaluation of pulmonary hypertension,,Diagnosis of left-to-right intracardiac shunt,,Diagnosis of pericardial tamponade,,,Clinical use of the PAC〔Therapy〕,Management of perioperative patient with unstable ca
4、rdiac status,,Management of complicated myocardial infarction,,Management of severe preeclampsia,,Guide to pharmacologic therapy,,,Vasopressors,；,Inotropes,；,Vasodilators,,Guide to nonpharmacologic therapy,,,Fluid management,；,Burns,；,,Renal failure,；,Sepsis,；,,Heart failure,；,Decompensated cirrhosi
5、s,,Ventilator management,,,Assessment of best PEEP for DO,2,,,Contents,Introduction,PAC Placement,,Hemodynamic Monitoring,Controversy on PAC,,,Parameter integration,Cases Discussion,,Structure of PAC,,,,PAC,,,首選：右頸內(nèi)靜脈,,Comparison among PA catheter insertion sites,,PAC insertion,,Right internal
6、jugular vein,,,Shortest and straightest path to the heart,,,Left subclavian,,Does not require the PAC to pass and course at an acute angle,,to enter the SVC,,,Femoral veins,,Distant sites,,Passing a PAC into the heart can be difficult,,Fluoroscopic assistance may be necessary,,Compressible and prefe
7、rable if the risk of hemorrhage is high,,,PAC insertion,,After inserting the PAC as far as the,20cm,mark,，,the balloon is inflated with air.,,,Inflation should be slow and controlled (1 mL/s) and should not surpass the recommended volume (1.5 mL).,,,Always inflate the balloon before advancing the PA
8、C and always deflate the balloon before withdrawing the PAC.,,,,CRX,：,check the position of the PAC,,,PA diastolic pressure,~,PAWP,,PAC on CRX〔PA〕,,,Placement of the catheter,,,Right Atrium,>>20 cm,,Normal right atrial presssure is 0-6cmHg.,,Normal oxygen content 15%〔ml/dL),,Normal O2 saturation 75%
9、,,Waveforms of CVP,,EKG-RAP,,EKG,,Mechanical event,RAP,80 – 100 milliseconds after P wave,RA systole,a,wave,,RA diastole,x,descent,After QRS,Tricuspid valve closure,c,wave,After peak of T wave,RA filling/tricuspid valve closed,v,wave,,RA emptying at opening of tricuspid valve/onset of right ventri
10、cle diastole,y,descent,,Right Atrium,,Right ventricular waveform,,RV systolic=17-30cmHg,,RV diastolic=0-6cmHg,,RV O2 content=15%〔ml/dL),,RV O2 saturation 75%,,Pulmonary artery waveform,,Normal PA pressure, systolic 15-30,,Normal PA pressure, diastolic 5-13,,O2 content 15%〔ml/dL),,O2 saturation 75%,,
11、EKG-PAP,,EKG,Mechanical event,PAP,T wave,Right ventricle ejection of blood into pulmonary vasculature,Systolic? PAS 15 –30 mm Hg,80 milliseconds after onset of QRS,,Indirect indicator of LVEDP,End-diastolic? (PAEDP 8 – 12 mm Hg),,Mean (9 – 18 mm Hg),PAS: pulmonary artery systolic,,LVEDP: left ven
12、tricular end-diastolic pressure,,PAEDP: pulmonary artery end-diastolic pressure,,,,Pulmonary artery waveform,,,PAWP waveform,,,PAWP waveform,,,EKG-PAWP,,EKG,,Mechanical event,PAWP,Aligned with the end of the QRS,Left atrial (LA) systole,a,wave,,LA diastole,x,descent,T-P interval,LA filling/mitral va
13、lve closed,v,wave,,LA emptying at opening of mitral valve/onset of left ventricle diastole,y,descent,,PAWP waveform,,,,ECG -- CVP -- PAWP,,,How do u know u r in Zone 3？,,Catheter should be below the left atrium on CRX,,If there is marked respiratory vairation in the PAWP tracing you are likely not i
14、n Zone 3,,If PAD> PAWP then you are likely not in Zone 3,,Rapid Flush Test〔方波試驗(yàn)〕,,,Phlebostatic Axis,,,PAC,并發(fā)癥、可能原因、預(yù)防及處理,,PAC,并發(fā)癥、可能原因、預(yù)防及處理,,Contents,Introduction,PAC Placement,,Hemodynamic Monitoring,Controversy on PAC,,,Parameter integration,,Hemodynamic values of normal adults,,Hemodynamic
15、Monitoring,,,CO CI,,SV SVI,,RAP(CVP),,PAP,,PAWP,Cardiac,,output,Pressure,SvO2,,Cardiac Output 〔CO〕,定義： 在,1min,內(nèi)從心室射,,出的血液總量,,公式：,CO = HR x SV,,CO,=,4~8,,L/min,,Cardiac Output Index 〔CI〕,CI ＝ CO / BSA,,,正常值: 2.8 – 4.2 L/min/m2,,,CI更能表達(dá)患者的個體差異性,,,,,每搏量,(SV),,與 每搏量指數(shù),(SVI),SV,定義：每次心跳所射出的血液量,,SV = CO
16、/ HR,,SV,正常值：,50-110ml/beat,,SVI,＝,SV / BSA,,SVI,正常值：,30-65ml/m,2,/beat,,,What Elevates the Right Atrial Pressure?,RV infarct,,Pulmonary hypertension,,Pulmonary stenosis,,Left to right shunt,,Tricuspid valvular disease,,Left heart failure,,Prominent RA pulsations,Prominent a wave:,,,Tricuspid stenos
17、is,,,Cannon a wave:,,,AV dissociation,,,Ventricular tachycardia,,,Prominent v wave:,,,Tricuspid regurgitation or VSD,,,What Increases RV Pressures?,,RV failure,,Pulmonary hypertension,,Pulmonary stenosis,,Pulmonary Embolism,,Cardiomyopathy,,Cardiac tamponade,,Cardiac constriction,,What Elevates PA p
18、ressure?,,Volume Overload (backflow),,Primary lung disease,,Primary pulmonary hypertension,,Pulmonary Embolism,,Left to right shunt,,Mitral Valve Disease,,用壓力推測心室舒張末期容量的前提,,,,,導(dǎo)管位置 無二尖瓣 心室順應(yīng)性,,正確 疾病 正常,,,,,,,PAWP ~ LAP ~ LVEDP ~ LVEDV
19、~ Preload,,,PAWP and LVEDP may be discordant,Conditions in which PAWP>LVEDP,,Mitral stenosis,,Mitral valve regurgitation,,Left atrial myxoma,,Pulmonary embolus,,,,Conditions in which PAWP25 mmHg) LVEDP,,,Systemic and pulmonary va
20、scular resistance,80*(MPAP-LAP)/,肺血流量,80*(MAP-RAP)/CO,R=U/I,PVR,SVR,歐姆定理,,,Systemic Vascular Resistance,,Causes of,?,SVR,,,Volume infusions,,Hypovolemia,,Low CO states,,LV failure,,Hypothermia,,Vasopressors,,Increased blood viscosity,Causes of,?,SVR,,,Diuretics,,Sepsis,,Vasodilators,,Peripheral vaso
21、dilation,,Loss of vasomotor tone,,Pulmonary Vascular Resistance,,Causes of,?,PVR,,,Hypoxia,,PEEP,,Pulmonary edema,,Pulmonary hypertension,,ARDS,,Pulmonary emboli,,Valvular heart disease,,Congenital heart defects,Causes of ?PVR,,,,Vasodilator therapy,,,Prostaglandins,,,Correction of hypoxia,,,Prostac
22、yclin〔依前列醇〕,,SvO,2,,Contents,Introduction,PAC Placement,,Hemodynamic Monitoring,Controversy on PAC,,,Parameter integration,Cases Discussion,,,,,,,,PAC為何不能改善預(yù)后？,,問,,題,,何,,在,1,2,3,4,5,不恰當(dāng)?shù)倪m應(yīng)癥,PAC,相關(guān)的并發(fā)癥,數(shù)據(jù)的可靠性,不恰當(dāng)?shù)闹委?數(shù)據(jù)解讀的準(zhǔn)確性,,We still need PAC ？,,,到底是誰的問題？,,Iberti et al (JAMA 1990),,美國和加拿大13家醫(yī)院
23、496MD,,47％的受試者對PAC不能作出正確答復(fù),,,Gnaegi A et al (CCM1997),,134個ICU的535 MD,,68％的醫(yī)生所具有的知識不能滿足PAC使用,,,Squara P et al (Chest 2002),,僅有38％的醫(yī)生按照給出的PAC數(shù)據(jù)選擇了正確的治 療方案，但仍有多達(dá)35％的醫(yī)師選擇了錯誤的治療方案,,臨床評價 VS 血流動力學(xué),,103例PAC,,,醫(yī)生在置管前對血流動力學(xué)指標(biāo)的范圍及治療方案進(jìn)行預(yù)測,,,預(yù)測準(zhǔn)確性：PAWP 30%； CO SVR RAP 50%,,,留置PAC后：,,治療方案需要重新修正 58%,,應(yīng)用
24、未預(yù)計(jì)到的治療 30%,,結(jié)論：,,1 單純根據(jù)臨床評價難以準(zhǔn)確預(yù)測血流動力學(xué)指標(biāo),,2 PAC監(jiān)測將改變治療策略,Crit Care Med. 1984 Jul;12(7):549-53,.,,Benefit or Harm？,,,能否替代PAC？,,,可以替代,心輸出量參數(shù),,,不可替代,壓力參數(shù),,S,CV,O,2,,近似替代,S,V,O,2,,Contents,Introduction,PAC Placement,,Hemodynamic Monitoring,Controversy on PAC,,,,Parameter integration,Cases D
25、iscussion,,PAC要答復(fù)的四個問題,,PAC,前負(fù)荷,后負(fù)荷,心功能,氧平衡,,PAC參數(shù)整合：前負(fù)荷,,CVP〔RAP〕 / PAWP,,,Any given level of filling pressure: not reliable！,,,Static markers of cardiac preload fail to predict volume responsiveness,,,Fluid challnge,,,CVP 2-5 rule PAWP 3-7 rule,,,△CO / △CI / △SV > 10%,,PAC參數(shù)整合：后負(fù)荷,,,左室射血的阻抗及外 周阻
26、力,,,,SAP MAP SVR,后負(fù)荷,,右室射血的阻抗及外 周阻力,,,,PAP MPAP PVR,,PAC參數(shù)整合：心臟收縮力,,CO并不是心臟射血功能的可靠指標(biāo),,,每搏輸出量〔SV〕/每搏指數(shù)〔SVI〕,,,SV/SVI增加的原因：代償；SVR下降,,,SV/SVI降低的原因：,,前負(fù)荷下降：出血,,心肌收縮力下降：心功能不全〔EF%〕,,后負(fù)荷增加：SVR增加,,PAC參數(shù)整合：氧代謝,,,Oxygen Delivery: What are the components?,Oxygen Delivery,,DO,2,,Cardiac Output,,Heart Rate,
27、Stroke Volume,CaO,2,PaO,2,SaO,2,Hb,Preload,Afterload,Contractility,CVP,,PCWP,PVR,,SVR,EF%,,PAC目標(biāo)指導(dǎo)性治療,,A,2,,B,,DO,2,>600mL/min/m,2,,C,,VO,2,>170mL/min/m,2,Shoemaker,,WC,et al,.,Chest. 1988 Dec;94(6):1176-86.,,PAC目標(biāo)指導(dǎo)性治療,,Crit Care Med. 2002 Aug;30(8):1686-92,2,,,,DO,2,>600mL/min/m,2,,,,VO,2,>170mL/m
28、in/m,2,,,,PAWP<18mmHg,,,,基于,PAC,參數(shù)的常見危重病的診斷,,基于PAC參數(shù)的急性右心衰診斷,,前負(fù)荷,CVP,,PAWP,正常,,,后負(fù)荷,MPAP,正常或,,MAP,正?；?,,心臟,HR,,SI,,,氧代謝,PaO2/FiO2,,DO2,,VO2,,基于PAC參數(shù)的急性左心衰診斷,,前負(fù)荷,CVP,,PAWP,,,后負(fù)荷,PVR/SVR,,MAP,正常或,,,心臟,HR,,SI,,,氧代謝,PaO2/FiO2,,DO2,,VO2,,基于PAC參數(shù)的感染性休克診斷,,前負(fù)荷,CVP,,PAWP,,,后負(fù)荷,SVR,,MAP,正?；?,,心臟,HR,,SI,,,氧
29、代謝,PaO2/FiO2,,DO2,,VO2,,基于PAC參數(shù)的失血性休克診斷,,前負(fù)荷,CVP,,PAWP,,,后負(fù)荷,SVR,,MAP,正?；?,,心臟,HR,,SI,,,氧代謝,PaO2/FiO2,,DO2,正?；?,VO2,,基于PAC參數(shù)的急性肺栓塞診斷,,前負(fù)荷,CVP,,PAWP,,,后負(fù)荷,MPAP,,MAP,正?；?,,心臟,HR,,SI,,,氧代謝,PaO2/FiO2,,DO2,,VO2,,PAC,病例,,Case 1 Fluid challenge,,,Case 2 Fluid challenge,,,Case 2 Diuretic,,,Case 2 Di
30、uretic,,,Case3 Vasodilator Therapy,,71/M,,Anterior wall myocardial infarction,,PE: BP 132/82 HR 116 R 28.,,+2 edema of the lower extremities,,Lab: Na 132 Scr 88,,ECG: anterior lead S-T elevations,,CRX: cardiomegaly with pulmonary edema,,The patient was admitted to the ICU and PAC was placed for
31、optimization of cardiac status,,Nitroprusside was titrated,,Case3 Vasodilator Therapy,,,Case 4 Cardiac tonic,,,Case 4 Cardiac tonic,,,Case 5 Septic Shock,,52/F,,ESWL ; urinary tract infections,,BP 100/45 HR 120 RR 40 T 39,,WBC 13100, Na 138, K 5.1, Glu 16, scr 180,,CRX : normal ； EKG : sin
32、us tachycardia.,,Urine Cultures ； started on mezlocillin and gentamicin.,,On day2，SBP dropped to 70 mmHg ；,,ABG 〔Fi02 60%〕: pH 7.38, PaO2 42, PaCO2 49 Sa02 75%.,,CRX showed diffuse bilateral infiltrates.,,Transferred to the ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors.,,PAC was inserted.,,The patient remained oliguric, uremic and therefore hemodialysis was started. MV was maintained with high FiO2 and PEEP,,Case 5 Septic Shock,,,Thank You !,
肺動脈漂浮導(dǎo)管 PAC
