肺動脈漂浮導(dǎo)管_PAC

肺動脈漂浮導(dǎo)管的應(yīng)用 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion WhatisPulmonaryArteryCatheter Fullname Swan GanzCatheterUsedittomonitorapatient shemodynamicswhenwecantanswerthequestionusingnoninvasive clinicalmeasures ClinicaluseofthePAC Diagnosis DifferentiationamongcausesofshockCardiogenicHypovolemicDistributive sepsis Obstructive massivepulmonaryembolism DifferentiationofpulmonaryedemaCardiogenicNoncardiogenicEvaluationofpulmonaryhypertensionDiagnosisofleft to rightintracardiacshuntDiagnosisofpericardialtamponade ClinicaluseofthePAC Therapy ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapyVasopressors Inotropes VasodilatorsGuidetononpharmacologictherapyFluidmanagement Burns Renalfailure Sepsis Heartfailure DecompensatedcirrhosisVentilatormanagementAssessmentofbestPEEPforDO2 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion StructureofPAC PAC 首選 右頸內(nèi)靜脈 ComparisonamongPAcatheterinsertionsites PACinsertion RightinternaljugularveinShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh PACinsertion AfterinsertingthePACasfarasthe20cmmark theballoonisinflatedwithair Inflationshouldbeslowandcontrolled 1mL s andshouldnotsurpasstherecommendedvolume 1 5mL AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC CRX checkthepositionofthePACPAdiastolicpressure PAWP PAConCRX PA Placementofthecatheter RightAtrium 20cmNormalrightatrialpresssureis0 6cmHg Normaloxygencontent15 ml dL NormalO2saturation75 WaveformsofCVP EKG RAP RightAtrium Rightventricularwaveform RVsystolic 17 30cmHgRVdiastolic 0 6cmHgRVO2content 15 ml dL RVO2saturation75 Pulmonaryarterywaveform NormalPApressure systolic15 30NormalPApressure diastolic5 13O2content15 ml dL O2saturation75 EKG PAP Pulmonaryarterywaveform PAWPwaveform PAWPwaveform EKG PAWP PAWPwaveform ECG CVP PAWP HowdouknowurinZone3 CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD PAWPthenyouarelikelynotinZone3 RapidFlushTest 方波試驗 PhlebostaticAxis 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 PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration Hemodynamicvaluesofnormaladults HemodynamicMonitoring COCISVSVI RAP CVP PAPPAWP Cardiacoutput Pressure SvO2 CardiacOutput CO 定義 在1min內(nèi)從心室射出的血液總量公式 CO HRxSVCO 4 8L min CardiacOutputIndex CI CI CO BSA正常值 2 8 4 2L min m2CI更能體現(xiàn)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 HRSV正常值 50 110ml beatSVI SV BSASVI正常值 30 65ml m2 beat WhatElevatestheRightAtrialPressure RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure ProminentRApulsations Prominentawave TricuspidstenosisCannonawave AVdissociationVentriculartachycardiaProminentvwave TricuspidregurgitationorVSD WhatIncreasesRVPressures RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction WhatElevatesPApressure VolumeOverload backflow PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease 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 Preload PAWPandLVEDPmaybediscordant ConditionsinwhichPAWP LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolusConditionsinwhichPAWP25mmHg LVEDP Systemicandpulmonaryvascularresistance 80 MPAP LAP 肺血流量 80 MAP RAP CO R U I PVR SVR 歐姆定理 SystemicVascularResistance Causesof SVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosity Causesof SVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone PulmonaryVascularResistance Causesof PVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefects Causesof PVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin 依前列醇 SvO2 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion PAC為何不能改善預(yù)后 問題何在 1 2 3 4 5 不恰當?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?shù)闹委?數(shù)據(jù)解讀的準確性 WestillneedPAC 到底是誰的問題 Ibertietal JAMA1990 美國和加拿大13家醫(yī)院496MD47 的受試者對PAC不能作出正確回答GnaegiAetal CCM1997 134個ICU的535MD68 的醫(yī)生所具有的知識不能滿足PAC使用SquaraPetal Chest2002 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 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)指標的范圍及治療方案進行預(yù)測預(yù)測準確性 PAWP30 COSVRRAP50 留置PAC后 治療計劃需要重新修正58 應(yīng)用未預(yù)計到的治療30 結(jié)論 1單純根據(jù)臨床評價難以準確預(yù)測血流動力學(xué)指標2PAC監(jiān)測將改變治療策略 CritCareMed 1984Jul 12 7 549 53 BenefitorHarm 能否替代PAC Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion PAC要回答的四個問題 PAC參數(shù)整合 前負荷 CVP RAP PAWPAnygivenleveloffillingpressure notreliable StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallngeCVP2 5rulePAWP3 7rule CO CI SV 10 PAC參數(shù)整合 后負荷 左室射血的阻抗及外周阻力SAPMAPSVR 后負荷 右室射血的阻抗及外周阻力PAPMPAPPVR 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 氧代謝 OxygenDelivery Whatarethecomponents OxygenDeliveryDO2 CardiacOutput HeartRate StrokeVolume CaO2 PaO2 SaO2 Hb Preload Afterload Contractility CVPPCWP PVRSVR EF PAC目標指導(dǎo)性治療 CI 4 5L min m2 DO2 600mL min m2 VO2 170mL min m2 ShoemakerWCetal Chest 1988Dec 94 6 1176 86 PAC目標指導(dǎo)性治療 CritCareMed 2002Aug 30 8 1686 92 CI 4 5L min m2DO2 600mL min m2VO2 170mL min m2PAWP 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 基于PAC參數(shù)的急性左心衰診斷 基于PAC參數(shù)的感染性休克診斷 基于PAC參數(shù)的失血性休克診斷 基于PAC參數(shù)的急性肺栓塞診斷 PAC病例 Case1Fluidchallenge Case2Fluidchallenge Case2Diuretic Case2Diuretic Case3VasodilatorTherapy 71 MAnteriorwallmyocardialinfarctionPE BP132 82HR116R28 2edemaofthelowerextremitiesLab Na132Scr88ECG anteriorleadS TelevationsCRX cardiomegalywithpulmonaryedemaThepatientwa