肺動(dòng)脈漂浮導(dǎo)管-PAC

1、 肺動(dòng)脈漂浮導(dǎo)管的應(yīng)用 ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion2 What is Pulmonary Artery Catheter ?Full name: Swan-Ganz CatheterUsed it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clinical measure

2、s 3Clinical use of the PAC （Diagnosis） Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) Differentiation of pulmonary edema Cardiogenic Noncardiogenic Evaluation of pulmonary hypertensionDiagnosis of left-to-right intracardia

3、c shunt Diagnosis of pericardial tamponade 4Clinical use of the PAC（Therapy）Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarction Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors； Inotropes ； VasodilatorsGuide to

4、 nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO25ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion6Structure of PAC7

5、PAC8首選：右頸內(nèi)靜脈9Comparison among PA catheter insertion sites10PAC insertion Right internal jugular vein Shortest and straightest path to the heartLeft 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 b

6、e difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is high11PAC insertionAfter 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 v

7、olume (1.5 mL). Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC. CRX：check the position of the PAC PA diastolic pressure PAWP 12PAC on CRX（PA）13Placement of the catheter14Right Atrium20 cmNormal right atrial presssure is 0-6cmHg. Normal o

8、xygen content 15%（ml/dL)Normal O2 saturation 75%15Waveforms of CVP16EKG-RAPEKG Mechanical event RAP80 100 milliseconds after P wave RA systoleawave RA diastole xdescent After QRS Tricuspid valve closure c wave After peak of T wave RA filling/tricuspid valve closed vwave RA emptying at opening of tri

9、cuspid valve/onset of right ventricle diastole ydescent 17Right Atrium18 Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75%19 Pulmonary artery waveformNormal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 15%（ml/dL

10、)O2 saturation 75%20EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolicPAS 15 30 mm Hg80 milliseconds after onset of QRS Indirect indicator of LVEDPEnd-diastolic(PAEDP 8 12 mm Hg) Mean (9 18 mm Hg) PAS: pulmonary artery systolicLVEDP: left ventri

11、cular end-diastolic pressurePAEDP: pulmonary artery end-diastolic pressure21Pulmonary artery waveform22 PAWP waveform23PAWP waveform24EKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial (LA) systole awave LA diastole xdescent T-P interval LA filling/mitral valve closedvwave

12、LA emptying at opening of mitral valve/onset of left ventricle diastoleydescent 25PAWP waveform26ECG - CVP - PAWP27 How do u know u r in Zone 3？Catheter should be below the left atrium on CRXIf there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3If PAD PAWP then you

13、 are likely not in Zone 328Rapid Flush Test（方波試驗(yàn)）29 Phlebostatic Axis30PAC并發(fā)癥、可能原因、預(yù)防及處理31PAC并發(fā)癥、可能原因、預(yù)防及處理32ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration33 Hemodynamic values of normal adults34Hemodynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCard

14、iac outputPressureSvO235 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/min36Cardiac 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37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 / HR SV正常值：50-110ml/beatSVISV / BSA SVI正常值：30-65ml/m2/beat38What Elevates the Right

15、Atrial Pressure?RV infarctPulmonary hypertensionPulmonary stenosisLeft to right shuntTricuspid valvular diseaseLeft heart failure39Prominent RA pulsationsProminent a wave: Tricuspid stenosisCannon a wave: AV dissociation Ventricular tachycardiaProminent v wave: Tricuspid regurgitation or VSD40What I

16、ncreases RV Pressures?RV failurePulmonary hypertensionPulmonary stenosisPulmonary EmbolismCardiomyopathyCardiac tamponadeCardiac constriction41What Elevates PA pressure?Volume Overload (backflow)Primary lung diseasePrimary pulmonary hypertensionPulmonary EmbolismLeft to right shuntMitral Valve Disea

17、se42用壓力推測(cè)心室舒張末期容量的前提 導(dǎo)管位置 無(wú)二尖瓣 心室順應(yīng)性 正確 疾病 正常 PAWP LAP LVEDP LVEDV Preload43PAWP and LVEDP may be discordantConditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus Conditions in which PAWP25 mmHg) LVEDP44Systemic and pulmonary vascular resistance

18、80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理45Systemic Vascular ResistanceCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tone46Pulmonary Vascular Resis

19、tanceCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）47SvO248ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC

20、Parameter integrationCases Discussion49505152PAC為何不能改善預(yù)后？問(wèn)題何在12345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)闹委煍?shù)據(jù)解讀的準(zhǔn)確性53We still need PAC ？54到底是誰(shuí)的問(wèn)題？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

21、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55臨床評(píng)價(jià) VS 血流動(dòng)力學(xué)103例PAC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)預(yù)測(cè)準(zhǔn)確性：PAWP 30%； CO SVR RAP 50%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%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):549-53.56Benefit or Harm？57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)SCVO2近似替代SVO258ContentsIntrodu

22、ctionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion59PAC要回答的四個(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡60PAC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 responsivenessFluid challnge CVP 2-5 r

23、ule PAWP 3-7 rule CO / CI / SV 10%61PAC參數(shù)整合：后負(fù)荷左室射血的阻抗及外 周阻力 SAP MAP SVR后負(fù)荷右室射血的阻抗及外 周阻力 PAP MPAP PVR62PAC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63PAC參數(shù)整合：氧代謝64Oxygen Delivery: What are the components?Oxygen DeliveryDO2Car

24、diac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%65PAC目標(biāo)指導(dǎo)性治療A CI 4.5L/min/m2B DO2600mL/min/m2C VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.66PAC目標(biāo)指導(dǎo)性治療Crit Care Med. 2002 Aug;30(8):1686-92CI 4.5L/min/m2DO2600mL/min/m2VO2170mL/min/m2PA

25、WP18mmHg67基于PAC參數(shù)的常見(jiàn)危重病的診斷68基于PAC參數(shù)的急性右心衰診斷前負(fù)荷CVPPAWP正常后負(fù)荷MPAP正?；騇AP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO269基于PAC參數(shù)的急性左心衰診斷前負(fù)荷CVPPAWP后負(fù)荷PVR/SVR MAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO270基于PAC參數(shù)的感染性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SVR MAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO271基于PAC參數(shù)的失血性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SVR MAP正常或心臟HRSI氧代謝PaO2/FiO2DO2正?；騐O272基于PA

26、C參數(shù)的急性肺栓塞診斷前負(fù)荷CVPPAWP后負(fù)荷MPAPMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO273PAC病例74Case 1 Fluid challenge75Case 2 Fluid challenge76Case 2 Diuretic 77Case 2 Diuretic78Case3 Vasodilator Therapy71/MAnterior wall myocardial infarctionPE: BP 132/82 HR 116 R 28. +2 edema of the lower extremitiesLab: Na 132 Scr 88ECG: anterior l