肺動(dòng)脈漂浮導(dǎo)管-PAC課件

肺動(dòng)脈漂浮導(dǎo)管的應(yīng)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(yù)防及處理PAC并發(fā)癥、可能原因、預(yù)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(gè)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(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~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(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WestillneedPAC？到底是誰(shuí)的問(wèn)題？Ibertietal(JAMA1990)美國(guó)和加拿大13家醫(yī)院496MD47％的受試者對(duì)PAC不能作出正確回答GnaegiAetal

(CCM1997)134個(gè)ICU的535MD68％的醫(yī)生所具有的知識(shí)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(dá)35％的醫(yī)師選擇了錯(cuò)誤的治療方案臨床評(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：PAWP30%；COSVRRAP50%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)2PAC監(jiān)測(cè)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(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%PAC參數(shù)整合：后負(fù)荷左室射血的阻抗及外周阻力

SAPMAPSVR后負(fù)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(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PAC參數(shù)整合：氧代謝OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%PAC目標(biāo)指導(dǎo)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(biāo)指導(dǎo)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(jiàn)危重病的診斷基于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/FiO2DO2VO2基于PAC參數(shù)的急性左心衰診斷前負(fù)荷CVPPAWP后負(fù)荷PVR/SVRMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO2基于PAC參數(shù)的感染性休克診斷前負(fù)荷CVPPAWP后負(fù)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(fù)荷CVPPAWP后負(fù)荷SVRMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2正?；騐O2基于PAC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/FiO2DO2VO2PAC病例Case1FluidchallengeCase2FluidchallengeCase2DiureticCase2DiureticCase3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE:BP132/82HR116R28.+2edemaofthelowerextremitiesLab:Na132Scr88ECG:anteriorleadS-TelevationsC