肺動脈漂浮導管PAC培訓課程課件

1、肺動脈漂浮導管PAC肺動脈漂浮導管PAC優(yōu)選肺動脈漂浮導管PAC優(yōu)選肺動脈漂浮導管PACContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC Place What is Pulmonary Artery Catheter ?Full name: Swan-Ganz CatheterUsed it to monitor a patients hemodynamics when we

2、 cant answer the question using noninvasive/clinical measures What is Pulmonary Artery Clinical use of the PAC （Diagnosis） Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) Differentiation of pulmonary edema Cardiogenic Nonca

3、rdiogenic Evaluation of pulmonary hypertensionDiagnosis of left-to-right intracardiac shunt Diagnosis of pericardial tamponade Clinical use of the PAC （DiagnClinical use of the PAC（Therapy）Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarctio

4、n Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors； Inotropes ； VasodilatorsGuide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO2Clinical use of th

5、e PAC（TherapContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC Place出的血液總量VO2170mL/min/m2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35的醫(yī)師選擇了錯誤的治療方案每搏量 (SV) 與 每搏量指數(shù)(SVI)EKG : sinus tachycardia.Vasopressors；ABG （Fi02 60%）: pH

6、7.應用未預計到的治療 30%EKG : sinus tachycardia.Clinical use of the PAC（Therapy）Mechanical eventCases DiscussionPAWP600mL/min/m2Hemodynamic MonitoringLeft subclavian臨床評價 VS 血流動力學Cases DiscussionPAWP waveformDifferentiation of pulmonary edemaCases DiscussionCongenital heart defectsPAC insertionAfter inserting

7、 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 PAC and always deflate the balloon before withdrawing the PAC. CRX：check the pos

8、ition of the PAC PA diastolic pressure PAWP 1984 Jul;12(7):549-53.PAC insePAC on CRX（PA）PAC on CRX（PA）Placement of the catheterPlacement of the catheterRight Atrium20 cmNormal right atrial presssure is 0-6cmHg. Normal oxygen content 15%（ml/dL)Normal O2 saturation 75%Right Atrium20 cmWaveforms of CVP

9、Waveforms of CVPEKG-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 tricuspid valve/onset of right ventricle diastole ydesc

10、ent EKG-RAPEKG Mechanical event Right AtriumRight Atrium Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75% Right ventricular wavefor Pulmonary artery waveformNormal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 1

11、5%（ml/dL)O2 saturation 75% Pulmonary artery waveforEKG-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 ar

12、tery systolicLVEDP: left ventricular end-diastolic pressurePAEDP: pulmonary artery end-diastolic pressureEKG-PAPEKG Mechanical event Pulmonary artery waveformPulmonary artery waveform PAWP waveform PAWP waveformPAWP waveformPAWP waveformEKG-PAWPEKG Mechanical event PAWPAligned with the end of the QR

13、S Left atrial (LA) systole awave LA diastole xdescent T-P interval LA filling/mitral valve closedvwave LA emptying at opening of mitral valve/onset of left ventricle diastoleydescent EKG-PAWPEKG Mechanical eventPAWP waveformPAWP waveformECG - CVP - PAWPECG - CVP - PAWP How do u know u r in Zone 3？Ca

14、theter 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 are likely not in Zone 3 How do u know u r in Zone 3？CInflation should be slow and controlled (1 mL/s) and should not surpass the recommended vol

15、ume (1.Assessment of best PEEP for DO2If PAD PAWP then you are likely not in Zone 3Cases DiscussionLeft atrial (LA) systoleSV定義：每次心跳所射出的血液量PAC參數(shù)整合：氧代謝Mechanical eventCases DiscussionPulmonary EmbolismCauses of PVR治療計劃需要重新修正 58%Cases Discussion2 PAC監(jiān)測將改變治療策略On day2，SBP dropped to 70 mmHg ；Introductio

16、nPAP MPAP PVRO2 content 15%（ml/dL)Rapid Flush Test（方波試驗）Inflation should be slow and c Phlebostatic Axis Phlebostatic AxisPAC并發(fā)癥、可能原因、預防及處理PAC并發(fā)癥、可能原因、預防及處理PAC并發(fā)癥、可能原因、預防及處理PAC并發(fā)癥、可能原因、預防及處理ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationContentsIntrod

17、uctionPAC Place Hemodynamic values of normal adults Hemodynamic values of normHemodynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCardiac outputPressureSvO2Hemodynamic MonitoringRAP(CVP) 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 Cardiac Output （CO）Cardiac Output Index （CI）

18、CI CO / BSA 正常值: 2.8 4.2 L/min/m2 CI更能體現(xiàn)患者的個體差異性Cardiac Output Index （CI） CI 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/beat每搏量 (SV) 與 每搏量指數(shù)(SVI)SV定義：每次心跳Management of complicated myocardial infarctionNormal right atrial presssure is 0-6cmHg.O2

19、 saturation 75%Parameter integrationPAC要回答的四個問題End-diastolic(PAEDP 8 12 mm Hg)SV/SVI增加的原因：代償；1984 Jul;12(7):549-53.Diagnosis of pericardial tamponadePAC insertionTransferred to the ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors.Parameter integrationProstacyc

20、lin（依前列醇）Transferred to the ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors.基于PAC參數(shù)的失血性休克診斷PAC參數(shù)整合：后負荷Prominent RA pulsationsWhat Elevates the Right Atrial Pressure?RV infarctPulmonary hypertensionPulmonary stenosisLeft to right shuntTricuspid valvular diseas

21、eLeft heart failureManagement of complicated myocProminent RA pulsationsProminent a wave: Tricuspid stenosisCannon a wave: AV dissociation Ventricular tachycardiaProminent v wave: Tricuspid regurgitation or VSDProminent RA pulsationsPromineWhat Increases RV Pressures?RV failurePulmonary hypertension

22、Pulmonary stenosisPulmonary EmbolismCardiomyopathyCardiac tamponadeCardiac constrictionWhat Increases RV Pressures?RVWhat Elevates PA pressure?Volume Overload (backflow)Primary lung diseasePrimary pulmonary hypertensionPulmonary EmbolismLeft to right shuntMitral Valve DiseaseWhat Elevates PA pressur

23、e?Volu用壓力推測心室舒張末期容量的前提 導管位置 無二尖瓣 心室順應性 正確 疾病 正常 PAWP LAP LVEDP LVEDV Preload用壓力推測心室舒張末期容量的前提 SVI正常值：30-65ml/m2/beatFluid challngeTricuspid valve closurePAP MPAP PVRHemodynamic MonitoringCO = 48 L/minSVISV / BSA心肌收縮力下降：心功能不全（EF%）Rapid Flush Test（方波試驗）Always inflate the balloon before advancing the PA

24、C and always deflate the balloon before withdrawing the PAC.Case 5 Septic ShockShortest and straightest path to the heartPAWP LAP LVEDP LVEDV PreloadPAC Placement預測準確性：PAWP 30%；EKG : sinus tachycardia.Conditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmona

25、ry embolus Conditions in which PAWP25 mmHg) LVEDPSVI正常值：30-65ml/m2/beatPAWP andSystemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理Systemic and pulmonary vasculaSystemic Vascular ResistanceCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermi

26、aVasopressorsIncreased blood viscosityCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor toneSystemic Vascular ResistanceCaPulmonary Vascular ResistanceCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital hear

27、t defectsCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）Pulmonary Vascular ResistanceCSvO2SvO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC PlacePAC was inserted.Pulmonary

28、stenosis1984 Jul;12(7):549-53.PAC要回答的四個問題CO SVR RAP 50%Cases Discussion基于PAC參數(shù)的急性左心衰診斷Assessment of best PEEP for DO2基于PAC參數(shù)的急性左心衰診斷HypothermiaHemodynamic MonitoringLow CO statesPAC參數(shù)整合：氧代謝1 單純根據(jù)臨床評價難以準確預測血流動力學指標LA diastoleRA systoleNitroprusside was titratedCRX : normal ；Pulmonary edemaIncreased bl

29、ood viscosityESWL ; urinary tract infectionsPAC was inserted.肺動脈漂浮導管PAC培訓課程課件肺動脈漂浮導管PAC培訓課程課件PAC為何不能改善預后？問題何在12345不恰當?shù)倪m應癥PAC相關(guān)的并發(fā)癥數(shù)據(jù)的可靠性不恰當?shù)闹委煍?shù)據(jù)解讀的準確性PAC為何不能改善預后？問12345不恰當?shù)倪m應癥PAC相關(guān)Causes of SVR基于PAC參數(shù)的急性右心衰診斷Parameter integrationDO2600mL/min/m2PAC要回答的四個問題用壓力推測心室舒張末期容量的前提Femoral veinsTransferred to t

30、he ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors.Hemodynamic MonitoringFluoroscopic assistance may be necessaryProstacyclin（依前列醇）Cases DiscussionPAC insertionPAC on CRX（PA）Benefit or Harm？ESWL ; urinary tract infectionsTricuspid valve closureIntroductionCan

31、non a wave:Nitroprusside was titratedAssessment of best PEEP for DO280 milliseconds after onset of QRSWe still need PAC ？Causes of SVRWe still need PA到底是誰的問題？Iberti et al (JAMA 1990) 美國和加拿大13家醫(yī)院 496MD 47的受試者對PAC不能作出正確回答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

32、 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35的醫(yī)師選擇了錯誤的治療方案到底是誰的問題？Iberti et al (JAMA 199臨床評價 VS 血流動力學103例PAC醫(yī)生在置管前對血流動力學指標的范圍及治療方案進行預測預測準確性：PAWP 30%； CO SVR RAP 50%留置PAC后： 治療計劃需要重新修正 58% 應用未預計到的治療 30%結(jié)論： 1 單純根據(jù)臨床評價難以準確預測血流動力學指標 2 PAC監(jiān)測將改變治療策略Crit Care Med. 1984 Jul;12(7):549-53.臨床評價 VS 血流動力學103例PACCri

33、t CareNoncardiogenicCannon a wave:PAC為何不能改善預后？Decompensated cirrhosisWe still need PAC ？Cannon a wave:O2 content 15%（ml/dL)心肌收縮力下降：心功能不全（EF%）正確 疾病 正常Normal PA pressure, diastolic 5-13IntroductionCases DiscussionParameter integrationSVI正常值：30-65ml/m2/beat80 milliseconds after onset of QRSWhat Increas

34、es RV Pressures?Left heart failureMechanical eventSVI正常值：30-65ml/m2/beatNormal PA pressure, diastolic 5-13Systemic and pulmonary vascular resistanceBenefit or Harm？NoncardiogenicBenefit 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)SCVO2近似替代SVO2能否替代PAC？心輸出量參數(shù)壓力參數(shù)SVO2Controversy on PAC1, Glu 16, scr 180What Incr

35、eases RV Pressures?Decreased LV complianceFluid challngeCO = 48 L/min80 milliseconds after onset of QRSOn day2，SBP dropped to 70 mmHg ；Conditions in which PAWP 10%PAC參數(shù)整合：前負荷CVP（RAP） / PAWPPAC參數(shù)整合：后負荷左室射血的阻抗及外 周阻力 SAP MAP SVR后負荷右室射血的阻抗及外 周阻力 PAP MPAP PVRPAC參數(shù)整合：后負荷左室射血的阻抗及外 周阻力后負荷右室射PAC參數(shù)整合：心臟收縮力CO并

36、不是心臟射血功能的可靠指標每搏輸出量（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： 前負荷下降：出血 心肌收縮力下降：心功能不全（EF%） 后負荷增加：SVR增加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PAC參數(shù)整合：氧代謝PAC參數(shù)整合：氧代謝Oxygen Delivery: What are the components?Oxygen DeliveryDO2Cardiac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCW

37、PPVRSVREF%Oxygen Delivery: What are thePAC目標指導性治療A CI 4.5L/min/m2B DO2600mL/min/m2C VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.PAC目標指導性治療A CI 4.5L/min/m2B PAC目標指導性治療Crit Care Med. 2002 Aug;30(8):1686-92CI 4.5L/min/m2DO2600mL/min/m2VO2170mL/min/m2PAWP 10%PAEDP: pulmonary artery

38、end-diastolic pressureMitral Valve DiseaseLoss of vasomotor toneConditions in which PAWPLVEDPCardiogenicLA diastoleO2 saturation 75%PAWP18mmHgCompressible and preferable if the risk of hemorrhage is high基于PAC參數(shù)的常見危重病的診斷RA diastoleGuide to nonpharmacologic therapyRV O2 saturation 75%IntroductionShortest and straig