肺動脈漂浮導管-PAC課件

肺動脈漂浮導管的應用

ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussionWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

ClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO2ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussionStructureofPACPACComparisonamongPAcatheterinsertionsitesPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWPPlacementofthecatheter

RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%WaveformsofCVP

EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descentRightAtriumPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressurePAWPwaveformPAWPwaveformPAWPwaveformECG--CVP--PAWPHowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone3PhlebostaticAxisPAC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ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationHemodynamicvaluesofnormaladultsHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO2CardiacOutput（CO）定義：在1min內(nèi)從心室射出的血液總量公式：CO=HRxSVCO=4~8

L/minCardiacOutputIndex（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/beatWhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailureProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSDWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstrictionWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease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~PreloadPAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDPSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理SystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortonePulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

SvO2ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussionPAC為何不能改善預后？問題何在12345不恰當?shù)倪m應癥PAC相關的并發(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SquaraP

etal(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：PAWP30%；COSVRRAP50%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2PAC監(jiān)測將改變治療策略CritCareMed.1984Jul;12(7):549-53.BenefitorHarm？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SVO2ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussionPAC要回答的四個問題PAC前負荷后負荷心功能氧平衡PAC參數(shù)整合：前負荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△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

PAPMPAPPVRPAC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?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%PAC目標指導性治療ACI>4.5L/min/m2B

DO2>600mL/min/m2C

VO2>170mL/min/m2Shoemaker

WCetal.Chest.1988Dec;94(6):1176-86.PAC目標指導性治療CritCareMed.2002Aug;30(8):1686-92CI>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)的急性右心衰診斷前負荷CVPPAWP正常后負荷MPAP正常或MAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2基于PAC參數(shù)的急性左心衰診斷前負荷CVPPAWP后負荷PVR/SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2基于PAC參數(shù)的感染性休克診斷前負荷CVPPAWP后負荷SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2基于PAC參數(shù)的失血性休克診斷前負荷CVPPAWP后負荷SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2正常或VO2基于PAC參數(shù)的急性肺栓塞診斷前負荷CVPPAWP后負荷MPAPMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2PAC病例Case1FluidchallengeCase2FluidchallengeCase2DiureticCase2DiureticCase3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE:BP132/82HR116R28.+2edemaofthelowerextremitiesLab:Na132Scr88ECG:anteriorleadS-TelevationsC