肺動(dòng)脈漂浮導(dǎo)管_PAC

1、 肺動(dòng)脈漂浮導(dǎo)管的應(yīng)用肺動(dòng)脈漂浮導(dǎo)管的應(yīng)用 精選課件ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion精選課件 What is Pulmonary Artery Catheter ?v Full name: Swan-Ganz Catheterv Used it to monitor a patients hemodynamics when we cant answer the question using noninva

2、sive/clinical measures 精選課件Clinical use of the PAC （Diagnosis） v Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) v Differentiation of pulmonary edema Cardiogenic Noncardiogenic v Evaluation of pulmonary hypertensionv Diagno

3、sis of left-to-right intracardiac shunt v Diagnosis of pericardial tamponade 精選課件Clinical use of the PAC（Therapy）v Management of perioperative patient with unstable cardiac status v Management of complicated myocardial infarction v Management of severe preeclampsia v Guide to pharmacologic therapy V

4、asopressors； Inotropes ； Vasodilatorsv Guide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis v Ventilator management Assessment of best PEEP for DO2精選課件ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Par

5、ameter integrationCases Discussion精選課件Structure of PAC精選課件PAC精選課件首選：右頸內(nèi)靜脈首選：右頸內(nèi)靜脈精選課件Comparison among PA catheter insertion sites精選課件PAC insertion vRight internal jugular vein Shortest and straightest path to the heartvLeft subclavian Does not require the PAC to pass and course at an acute angle to

6、enter the SVC vFemoral veins Distant sites Passing a PAC into the heart can be difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is high精選課件PAC insertionv After inserting the PAC as far as the 20cm mark，the balloon is inflated with air.v Inflati

7、on should be slow and controlled (1 mL/s) and should not surpass the recommended volume (1.5 mL). v Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC. v CRX：check the position of the PAC v PA diastolic pressure PAWP 精選課件PAC on CRX（PA）精選課件Pl

8、acement of the catheter 精選課件Right Atrium20 cmNormal right atrial presssure is 0-6cmHg. Normal oxygen content 15%（ml/dL)Normal O2 saturation 75%精選課件Waveforms of CVP 精選課件EKG-RAPEKG Mechanical event RAP80 100 milliseconds after P wave RA systolea wave RA diastole x descent After QRS Tricuspid valve clo

9、sure c wave After peak of T wave RA filling/tricuspid valve closed v wave RA emptying at opening of tricuspid valve/onset of right ventricle diastole y descent 精選課件Right Atrium精選課件 Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75%精選課件 Pul

10、monary artery waveform Normal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 15%（ml/dL)O2 saturation 75%精選課件EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolic PAS 15 30 mm Hg80 milliseconds after onset of QRS Indirect in

11、dicator of LVEDPEnd-diastolic (PAEDP 8 12 mm Hg) Mean (9 18 mm Hg) PAS: pulmonary artery systolicLVEDP: left ventricular end-diastolic pressurePAEDP: pulmonary artery end-diastolic pressure精選課件Pulmonary artery waveform 精選課件 PAWP waveform精選課件PAWP waveform精選課件EKG-PAWPEKG Mechanical event PAWPAligned w

12、ith the end of the QRS Left atrial (LA) systole a wave LA diastole x descent T-P interval LA filling/mitral valve closedv wave LA emptying at opening of mitral valve/onset of left ventricle diastoley descent 精選課件PAWP waveform精選課件ECG - CVP - PAWP精選課件 How do u know u r in Zone 3？v Catheter should be b

13、elow the left atrium on CRXv If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3v If PAD PAWP then you are likely not in Zone 3精選課件Rapid Flush Test（方波試驗(yàn)）精選課件 Phlebostatic Axis精選課件PACPAC并發(fā)癥、可能原因、預(yù)防及處理并發(fā)癥、可能原因、預(yù)防及處理并發(fā)癥可能原因預(yù)防處理心律失常沒有保護(hù)的導(dǎo)管尖在心內(nèi)膜移動(dòng)導(dǎo)管在右房或右室內(nèi)形成多余環(huán)操作導(dǎo)管太多

14、，時(shí)間太長(zhǎng)前送導(dǎo)管時(shí)保持氣囊充氣，輕盈前送射胸片以最少的操作快速、輕柔插入導(dǎo)管必要時(shí)使用利多卡因，發(fā)生室顫立即除顫回撤導(dǎo)管消除多余環(huán)血栓/栓塞導(dǎo)管周圍纖維性管套形成形成血栓導(dǎo)管內(nèi)血栓導(dǎo)管阻塞肺動(dòng)脈分支使用肝素浸泡的導(dǎo)管使用帶側(cè)壁的套管滴注肝素肝素鹽水持續(xù)沖洗，4-6 小時(shí)手工沖洗一次高危病人全身抗凝保持導(dǎo)管尖位于主肺動(dòng)脈抗凝，可能時(shí)溶栓肺梗塞/肺動(dòng)脈破裂導(dǎo)管尖向遠(yuǎn)端移位（尤其在頭 24 小時(shí)）導(dǎo)管嵌頓時(shí)間過(guò)長(zhǎng)導(dǎo)管血栓栓塞導(dǎo)管放好后即刻或 24 小時(shí)后拍胸片，消除右房或右室內(nèi)導(dǎo)管環(huán)持續(xù)監(jiān)測(cè)肺動(dòng)脈波形短期嵌頓（ 30 秒 ，用 PAEDP 代替 PAWP使用肝素浸泡過(guò)的導(dǎo)管，用肝素液適當(dāng)沖洗回撤導(dǎo)

15、管尖至肺動(dòng)脈加強(qiáng)護(hù)理必要時(shí)手術(shù)修復(fù)精選課件PACPAC并發(fā)癥、可能原因、預(yù)防及處理并發(fā)癥、可能原因、預(yù)防及處理并發(fā)癥可能原因預(yù)防處理感染插入導(dǎo)管、安裝設(shè)備、取血標(biāo)本或交換導(dǎo)管時(shí)感染嚴(yán)格無(wú)菌操作所有三通均套上無(wú)菌帽在導(dǎo)管上使用無(wú)菌袖套使用前檢查換能器頂蓋，不反復(fù)使用一次性頂蓋更換病人時(shí)消毒換能器除顫后更換換能器頂蓋不要在換能器內(nèi)使用 5%糖液或用之作沖洗液操作時(shí)間太長(zhǎng)每 48 小時(shí)更換所有設(shè)備每天觀察傷口并消毒減少導(dǎo)管放置時(shí)間每天在插管部位涂抹碘酊，加蓋無(wú)菌敷料近早拔出導(dǎo)管（必要時(shí) 4 天更換一次）心臟填塞導(dǎo)管尖造成穿孔輕柔操作在氣囊充氣下送管預(yù)阻力決不能前送導(dǎo)管心包穿刺逆轉(zhuǎn)肝素作用導(dǎo)管打圈或打

16、結(jié)右房或右室擴(kuò)大插管時(shí)間太長(zhǎng)操作較多至導(dǎo)管變軟使用小號(hào)（5F）導(dǎo)管在軟化前輕送導(dǎo)管，用冰鹽水沖洗導(dǎo)管或插入導(dǎo)引鋼絲更換新導(dǎo)管氣囊破裂過(guò)度充氣用液體充盈氣囊回抽注射器主動(dòng)放氣監(jiān)測(cè) PAEDP 而不是 PAWP減少嵌頓次數(shù)按導(dǎo)管注明的數(shù)量充盈氣囊使用空氣或 CO2 充盈氣囊通過(guò)撤走注射器讓空氣自動(dòng)逸出氣囊精選課件ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration精選課件 Hemodynamic values of normal adults精選課件Hemod

17、ynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCardiac outputPressureSvO2精選課件 Cardiac Output （CO）定義： 在1min內(nèi)從心室射 出的血液總量公式：CO = HR x SVCO = 48 L/min精選課件Cardiac Output Index （CI） CI CO / BSA 正常值: 2.8 4.2 L/min/m2 CI更能體現(xiàn)患者的個(gè)體差異性精選課件每搏量每搏量 (SV) 與與 每搏量指數(shù)每搏量指數(shù)(SVI)SV定義：每次心跳所射出的血液量SV = CO / HR SV正常值：50-110ml

18、/beatSVISV / BSA SVI正常值：30-65ml/m2/beat精選課件What Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTricuspid valvular diseasevLeft heart failure精選課件Prominent RA pulsationsvProminent a wave: Tricuspid stenosisvCannon a wave: AV dissociation Ve

19、ntricular tachycardiavProminent v wave: Tricuspid regurgitation or VSD精選課件What Increases RV Pressures?vRV failurevPulmonary hypertensionvPulmonary stenosisvPulmonary EmbolismvCardiomyopathyvCardiac tamponadevCardiac constriction精選課件What Elevates PA pressure?vVolume Overload (backflow)vPrimary lung d

20、iseasevPrimary pulmonary hypertensionvPulmonary EmbolismvLeft to right shuntvMitral Valve Disease精選課件用壓力推測(cè)心室舒張末期容量的前提用壓力推測(cè)心室舒張末期容量的前提 導(dǎo)管位置導(dǎo)管位置 無(wú)二尖瓣無(wú)二尖瓣 心室順應(yīng)性心室順應(yīng)性 正確正確 疾病疾病 正常正常 PAWP LAP LVEDP LVEDV Preload精選課件PAWP and LVEDP may be discordantv Conditions in which PAWPLVEDP Mitral stenosis Mitral val

21、ve regurgitation Left atrial myxoma Pulmonary embolus v Conditions in which PAWP25 mmHg) LVEDP精選課件Systemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理歐姆定理精選課件Systemic Vascular ResistancevCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaV

22、asopressorsIncreased blood viscosityvCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tone精選課件Pulmonary Vascular ResistancevCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsvCauses of PVRVas

23、odilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）精選課件SvO2精選課件ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion精選課件精選課件精選課件精選課件PAC為何不能改善預(yù)后？問(wèn)問(wèn)題題何何在在12345不恰當(dāng)?shù)倪m應(yīng)癥不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)的并發(fā)癥相關(guān)的并發(fā)癥數(shù)據(jù)的可靠性數(shù)據(jù)的可靠性不恰當(dāng)?shù)闹委煵磺‘?dāng)?shù)闹委煍?shù)據(jù)解讀的準(zhǔn)確性數(shù)據(jù)解讀的

24、準(zhǔn)確性精選課件We still need PAC ？精選課件到底是誰(shuí)的問(wèn)題？v Iberti et al (JAMA 1990) 美國(guó)和加拿大13家醫(yī)院 496MD 47的受試者對(duì)PAC不能作出正確回答v Gnaegi A et al (CCM1997) 134個(gè)ICU的535 MD 68的醫(yī)生所具有的知識(shí)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(cuò)誤的治療方案精選課件臨床評(píng)價(jià) VS 血流動(dòng)力學(xué)v 103例PACv 醫(yī)生在置管前對(duì)血流動(dòng)力學(xué)指標(biāo)的范圍及治療方案進(jìn)行預(yù)測(cè)v 預(yù)測(cè)準(zhǔn)確

25、性：PAWP 30%； CO SVR RAP 50%v 留置PAC后： 治療計(jì)劃需要重新修正 58% 應(yīng)用未預(yù)計(jì)到的治療 30%v 結(jié)論： 1 單純根據(jù)臨床評(píng)價(jià)難以準(zhǔn)確預(yù)測(cè)血流動(dòng)力學(xué)指標(biāo) 2 PAC監(jiān)測(cè)將改變治療策略Crit Care Med. 1984 Jul;12(7):549-53.精選課件Benefit or Harm？精選課件能否替代PAC？可以替代可以替代心輸出量參數(shù)心輸出量參數(shù)不可替代不可替代壓力參數(shù)壓力參數(shù)SCVO2近似替代近似替代SVO2精選課件ContentsIntroductionPAC Placement Hemodynamic MonitoringControvers

26、y on PAC Parameter integrationCases Discussion精選課件PAC要回答的四個(gè)問(wèn)題精選課件PAC參數(shù)整合：前負(fù)荷v CVP（RAP） / PAWP Any given level of filling pressure: not reliable！ Static markers of cardiac preload fail to predict volume responsivenessv Fluid challnge CVP 2-5 rule PAWP 3-7 rule CO / CI / SV 10%精選課件PAC參數(shù)整合：后負(fù)荷v左室射血的阻抗及

27、外左室射血的阻抗及外 周阻力周阻力v SAP MAP SVR后負(fù)荷后負(fù)荷v右室射血的阻抗及外右室射血的阻抗及外 周阻力周阻力v PAP MPAP PVR精選課件PAC參數(shù)整合：心臟收縮力v CO并不是心臟射血功能的可靠指標(biāo)v 每搏輸出量（SV）/每搏指數(shù)（SVI）v SV/SVI增加的原因：代償；SVR下降v 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增加精選課件PAC參數(shù)整合：氧代謝精選課件Oxygen Delivery: What are the components?Oxygen DeliveryDO2Cardiac Output

28、Heart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%精選課件PAC目標(biāo)指導(dǎo)性治療 CI 4.5L/min/m2 DO2600mL/min/m2 VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.精選課件PAC目標(biāo)指導(dǎo)性治療Crit Care Med. 2002 Aug;30(8):1686-92v CI 4.5L/min/m2v DO2600mL/min/m2v VO2170mL/min/m2v PAWP

29、18mmHg精選課件基于基于PAC參數(shù)的常見危重病的診斷參數(shù)的常見危重病的診斷精選課件基于PAC參數(shù)的急性右心衰診斷前負(fù)荷前負(fù)荷CVPPAWP正常后負(fù)荷后負(fù)荷MPAP正常或MAP正?；蛐呐K心臟HRSI氧代謝氧代謝PaO2/FiO2DO2VO2精選課件基于PAC參數(shù)的急性左心衰診斷前負(fù)荷前負(fù)荷CVPPAWP后負(fù)荷后負(fù)荷PVR/SVR MAP正常或心臟心臟HRSI氧代謝氧代謝PaO2/FiO2DO2VO2精選課件基于PAC參數(shù)的感染性休克診斷前負(fù)荷前負(fù)荷CVPPAWP后負(fù)荷后負(fù)荷SVR MAP正?；蛐呐K心臟HRSI氧代謝氧代謝PaO2/FiO2DO2VO2精選課件基于PAC參數(shù)的失血性休克診斷前負(fù)

30、荷前負(fù)荷CVPPAWP后負(fù)荷后負(fù)荷SVR MAP正?；蛐呐K心臟HRSI氧代謝氧代謝PaO2/FiO2DO2正常或VO2精選課件基于PAC參數(shù)的急性肺栓塞診斷前負(fù)荷前負(fù)荷CVPPAWP后負(fù)荷后負(fù)荷MPAPMAP正常或心臟心臟HRSI氧代謝氧代謝PaO2/FiO2DO2VO2精選課件PAC病例病例精選課件Case 1 Fluid challenge精選課件Case 2 Fluid challenge精選課件Case 2 Diuretic 精選課件Case 2 Diuretic精選課件Case3 Vasodilator Therapyv 71/Mv Anterior wall myocardial infarctionv PE: BP 132/82 HR 116 R 2