肺動脈漂浮導(dǎo)管PAC(新課件)

Dr.Feng肺動脈漂浮導(dǎo)管PAC2020-12-081肺動脈漂浮導(dǎo)管PAC（新課件）Dr.Feng肺動脈漂浮導(dǎo)管PAC2020-12-081肺動ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-082肺動脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-083肺動脈漂浮導(dǎo)管PAC（新課件）WhatisPulmonaryArteryClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-084肺動脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（DiagnClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-085肺動脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（TherapContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-086肺動脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceStructureofPAC2020-12-087肺動脈漂浮導(dǎo)管PAC（新課件）StructureofPAC2020-12-087肺動脈PAC2020-12-088肺動脈漂浮導(dǎo)管PAC（新課件）PAC2020-12-088肺動脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動脈漂浮導(dǎo)管PAC（ComparisonamongPAcatheterinsertionsites2020-12-0810肺動脈漂浮導(dǎo)管PAC（新課件）ComparisonamongPAcatheteriPACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0811肺動脈漂浮導(dǎo)管PAC（新課件）PACinsertionRightinternaljPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0812肺動脈漂浮導(dǎo)管PAC（新課件）PACinsertionAfterinsertingtPAConCRX（PA）2020-12-0813肺動脈漂浮導(dǎo)管PAC（新課件）PAConCRX（PA）2020-12-0813肺動脈漂Placementofthecatheter

2020-12-0814肺動脈漂浮導(dǎo)管PAC（新課件）Placementofthecatheter

2020RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-0815肺動脈漂浮導(dǎo)管PAC（新課件）RightAtrium>>20cm2020-12-081WaveformsofCVP

2020-12-0816肺動脈漂浮導(dǎo)管PAC（新課件）WaveformsofCVP

2020-12-081EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-0817肺動脈漂浮導(dǎo)管PAC（新課件）EKG-RAPEKGMechanicaleventRightAtrium2020-12-0818肺動脈漂浮導(dǎo)管PAC（新課件）RightAtrium2020-12-0818肺動脈漂浮導(dǎo)RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-0819肺動脈漂浮導(dǎo)管PAC（新課件）RightventricularwaveforPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-0820肺動脈漂浮導(dǎo)管PAC（新課件）PulmonaryarterywaveforEKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-0821肺動脈漂浮導(dǎo)管PAC（新課件）EKG-PAPEKGMechanicaleventPulmonaryarterywaveform

2020-12-0822肺動脈漂浮導(dǎo)管PAC（新課件）Pulmonaryarterywaveform

2020PAWPwaveform2020-12-0823肺動脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0823肺動脈PAWPwaveform2020-12-0824肺動脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0824肺動脈漂浮EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-0825肺動脈漂浮導(dǎo)管PAC（新課件）EKG-PAWPEKGMechanicaleventPAWPwaveform2020-12-0826肺動脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0826肺動脈漂浮ECG--CVP--PAWP2020-12-0827肺動脈漂浮導(dǎo)管PAC（新課件）ECG--CVP--PAWP2020-12-0827HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-0828肺動脈漂浮導(dǎo)管PAC（新課件）HowdouknowurinZone3？CRapidFlushTest（方波試驗）2020-12-0829肺動脈漂浮導(dǎo)管PAC（新課件）RapidFlushTest（方波試驗）2020-12-PhlebostaticAxis2020-12-0830肺動脈漂浮導(dǎo)管PAC（新課件）PhlebostaticAxis2020-12-08PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0831肺動脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0831肺PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0832肺動脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0832肺ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-0833肺動脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceHemodynamicvaluesofnormaladults2020-12-0834肺動脈漂浮導(dǎo)管PAC（新課件）HemodynamicvaluesofnormHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-0835肺動脈漂浮導(dǎo)管PAC（新課件）HemodynamicMonitoringRAP(CVP)CardiacOutput（CO）定義：在1min內(nèi)從心室射出的血液總量公式：CO=HRxSVCO=4~8L/min2020-12-0836肺動脈漂浮導(dǎo)管PAC（新課件）CardiacOutput（CO）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2020-12-0837肺動脈漂浮導(dǎo)管PAC（新課件）CardiacOutputIndex（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/HRSV正常值：50-110ml/beatSVI＝SV/BSASVI正常值：30-65ml/m2/beat2020-12-0838肺動脈漂浮導(dǎo)管PAC（新課件）每搏量(SV)與每搏量指數(shù)(SVI)SV定義：每次心跳WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-0839肺動脈漂浮導(dǎo)管PAC（新課件）WhatElevatestheRightAtrialProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-0840肺動脈漂浮導(dǎo)管PAC（新課件）ProminentRApulsationsPromineWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-0841肺動脈漂浮導(dǎo)管PAC（新課件）WhatIncreasesRVPressures?RVWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-0842肺動脈漂浮導(dǎo)管PAC（新課件）WhatElevatesPApressure?Volu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~Preload2020-12-0843肺動脈漂浮導(dǎo)管PAC（新課件）用壓力推測心室舒張末期容量的前提2020-1PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-0844肺動脈漂浮導(dǎo)管PAC（新課件）PAWPandLVEDPmaybediscordaSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理2020-12-0845肺動脈漂浮導(dǎo)管PAC（新課件）SystemicandpulmonaryvasculaSystemicVascularResistanceCausesof

SVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesof

SVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-0846肺動脈漂浮導(dǎo)管PAC（新課件）SystemicVascularResistanceCaPulmonaryVascularResistanceCausesof

PVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesof

PVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-0847肺動脈漂浮導(dǎo)管PAC（新課件）PulmonaryVascularResistanceCSvO22020-12-0848肺動脈漂浮導(dǎo)管PAC（新課件）SvO22020-12-0848肺動脈漂浮導(dǎo)管PAC（新課件ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0849肺動脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlace2020-12-0850肺動脈漂浮導(dǎo)管PAC（新課件）2020-12-0850肺動脈漂浮導(dǎo)管PAC（新課件）2020-12-0851肺動脈漂浮導(dǎo)管PAC（新課件）2020-12-0851肺動脈漂浮導(dǎo)管PAC（新課件）2020-12-0852肺動脈漂浮導(dǎo)管PAC（新課件）2020-12-0852肺動脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問題何在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2020-12-0853肺動脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問12345不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)WestillneedPAC？2020-12-0854肺動脈漂浮導(dǎo)管PAC（新課件）WestillneedPAC？2020-12-085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(dá)35％的醫(yī)師選擇了錯誤的治療方案2020-12-0855肺動脈漂浮導(dǎo)管PAC（新課件）到底是誰的問題？Ibertietal(JAMA199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(biāo)的范圍及治療方案進(jìn)行預(yù)測預(yù)測準(zhǔn)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(zhǔn)確預(yù)測血流動力學(xué)指標(biāo)2PAC監(jiān)測將改變治療策略CritCareMed.1984Jul;12(7):549-53.2020-12-0856肺動脈漂浮導(dǎo)管PAC（新課件）臨床評價VS血流動力學(xué)103例PACCritCareBenefitorHarm？2020-12-0857肺動脈漂浮導(dǎo)管PAC（新課件）BenefitorHarm？2020-12-0857肺動能否替代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SVO22020-12-0858肺動脈漂浮導(dǎo)管PAC（新課件）能否替代PAC？心輸出量參數(shù)壓力參數(shù)SVO22020-12-ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0859肺動脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlacePAC要回答的四個問題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020-12-0860肺動脈漂浮導(dǎo)管PAC（新課件）PAC要回答的四個問題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%2020-12-0861肺動脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP2020PAC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PAPMPAPPVR2020-12-0862肺動脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：后負(fù)荷左室射血的阻抗及外周阻力后負(fù)荷右室射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(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2020-12-0863肺動脈漂浮導(dǎo)管PAC（新課件）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(biāo)2PAC參數(shù)整合：氧代謝2020-12-0864肺動脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：氧代謝2020-12-0864肺動脈漂浮導(dǎo)管OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%2020-12-0865肺動脈漂浮導(dǎo)管PAC（新課件）OxygenDelivery:

WhatarethePAC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):1176-86.2020-12-0866肺動脈漂浮導(dǎo)管PAC（新課件）PAC目標(biāo)指導(dǎo)性治療ACI>4.5L/min/m2BPAC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<18mmHg2020-12-0867肺動脈漂浮導(dǎo)管PAC（新課件）PAC目標(biāo)指導(dǎo)性治療CritCareMed.2002基于PAC參數(shù)的常見危重病的診斷2020-12-0868肺動脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的常見危重病的診斷2020-12-0868肺動基于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/FiO2DO2VO22020-12-0869肺動脈漂浮導(dǎo)管PAC（新課件）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/FiO2DO2VO22020-12-0870肺動脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的急性左心衰診斷前負(fù)荷CVPPAWP后負(fù)荷PV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/FiO2DO2VO22020-12-0871肺動脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的感染性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SV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?；蛐呐KHRSI氧代謝PaO2/FiO2DO2正?；騐O22020-12-0872肺動脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的失血性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SV基于PAC參數(shù)的急性肺栓塞診斷前負(fù)荷CVPPAWP后負(fù)荷MPAPMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO22020-12-0873肺動脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的急性肺栓塞診斷前負(fù)荷CVPPAWP后負(fù)荷MPPAC病例2020-12-0874肺動脈漂浮導(dǎo)管PAC（新課件）PAC病例2020-12-0874肺動脈漂浮導(dǎo)管PAC（新課Case1Fluidchallenge2020-12-0875肺動脈漂浮導(dǎo)管PAC（新課件）Case1Fluidchallenge2020-Case2Fluidchallenge2020-12-0876肺動脈漂浮導(dǎo)管PAC（新課件）Case2Fluidchallenge2020-Case2Diuretic2020-12-0877肺動脈漂浮導(dǎo)管PAC（新課件）Case2Diuretic2020-12-0877肺Case2Diuretic2020-12-0878肺動脈漂浮導(dǎo)管PAC（新課件）Case2Diuretic2020-12-0878肺動Case3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE