1、肺动脉漂浮导管PAC优选肺动脉漂浮导管PACContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion What is Pulmonary Artery Catheter?v Full name:Swan-Ganz Catheterv Used it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clini
2、cal measures Clinical use of the PAC（Diagnosis）v Differentiation among causes of shock Cardiogenic Hypovolemic Distributive(sepsis)Obstructive(massive pulmonary embolism)v Differentiation of pulmonary edema Cardiogenic Noncardiogenic v Evaluation of pulmonary hypertensionv Diagnosis of left-to-right
3、 intracardiac shunt v Diagnosis of pericardial tamponade Clinical use of the PAC（Therapy）v Management of perioperative patient with unstable cardiac status v Management of complicated myocardial infarction v Management of severe preeclampsia v Guide to pharmacologic therapy Vasopressors；Inotropes；Va
4、sodilatorsv Guide to nonpharmacologic therapy Fluid management；Burns ；Renal failure；Sepsis；Heart failure；Decompensated cirrhosis v Ventilator management Assessment of best PEEP for DO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion出的血液
5、总量VO2170mL/min/m2仅有38的医生按照给出的PAC数据选择了正确的治 疗方案，但仍有多达35的医师选择了错误的治疗方案每搏量(SV)与 每搏量指数(SVI)EKG:sinus tachycardia.Vasopressors；ABG（Fi02 60%）:pH 7.应用未预计到的治疗 30%EKG:sinus tachycardia.Clinical use of the PAC（Therapy）Mechanical eventCases DiscussionPAWP600mL/min/m2Hemodynamic MonitoringLeft subclavian临床评价 VS 血
6、流动力学Cases DiscussionPAWP waveformDifferentiation of pulmonary edemaCases DiscussionCongenital heart defectsPAC insertionv After inserting the PAC as far as the 20cm mark，the balloon is inflated with air.v Inflation should be slow and controlled(1 mL/s)and should not surpass the recommended volume(1.
7、5 mL).v Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.v CRX：check the position of the PAC v PA diastolic pressure PAWP PAC on CRX（PA）Placement of the catheter Right Atrium20 cmNormal right atrial presssure is 0-6cmHg.Normal oxygen conte
8、nt 15%（ml/dL)Normal O2 saturation 75%Waveforms of CVP EKG-RAPEKG Mechanical event RAP80 100 milliseconds after P wave RA systolea wave RA diastole x descent After QRS Tricuspid valve closure c wave After peak of T wave RA filling/tricuspid valve closed v wave RA emptying at opening of tricuspid valv
9、e/onset of right ventricle diastole y descent Right Atrium Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75%Pulmonary artery waveform Normal PA pressure,systolic 15-30Normal PA pressure,diastolic 5-13O2 content 15%（ml/dL)O2 saturation 75%
10、EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolic PAS 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 artery systolicLVEDP:left ventricular end-diastolic pres
11、surePAEDP:pulmonary artery end-diastolic pressurePulmonary artery waveform PAWP waveformPAWP waveformEKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial(LA)systole a wave LA diastole x descent T-P interval LA filling/mitral valve closedv wave LA emptying at opening of mitral
12、 valve/onset of left ventricle diastoley descent PAWP waveformECG-CVP-PAWP How do u know u r in Zone 3？v Catheter should be below the left atrium on CRXv If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3v If PAD PAWP then you are likely not in Zone 3Inflation
13、should be slow and controlled(1 mL/s)and should not surpass the recommended volume(1.Assessment of best PEEP for DO2If PAD PAWP then you are likely not in Zone 3Cases DiscussionLeft atrial(LA)systoleSV定义：每次心跳所射出的血液量PAC参数整合：氧代谢Mechanical eventCases DiscussionPulmonary EmbolismCauses of PVR治疗计划需要重新修正
14、58%Cases Discussion2 PAC监测将改变治疗策略On day2，SBP dropped to 70 mmHg；IntroductionPAP MPAP PVRO2 content 15%（ml/dL)Rapid Flush Test（方波试验）Phlebostatic AxisPACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理并发症可能原因预防处理心律失常没有保护的导管尖在心内膜移动导管在右房或右室内形成多余环操作导管太多，时间太长前送导管时保持气囊充气，轻盈前送射胸片以最少的操作快速、轻柔插入导管必要时使用利多卡因，发生室颤立即除颤回撤导管消除多余环血栓/
15、栓塞导管周围纤维性管套形成形成血栓导管内血栓导管阻塞肺动脉分支使用肝素浸泡的导管使用带侧壁的套管滴注肝素肝素盐水持续冲洗，4-6 小时手工冲洗一次高危病人全身抗凝保持导管尖位于主肺动脉抗凝，可能时溶栓肺梗塞/肺动脉破裂导管尖向远端移位（尤其在头 24 小时）导管嵌顿时间过长导管血栓栓塞导管放好后即刻或 24 小时后拍胸片，消除右房或右室内导管环持续监测肺动脉波形短期嵌顿（30 秒，用 PAEDP 代替 PAWP使用肝素浸泡过的导管，用肝素液适当冲洗回撤导管尖至肺动脉加强护理必要时手术修复PACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理并发症可能原因预防处理感染插入导管、安装
16、设备、取血标本或交换导管时感染严格无菌操作所有三通均套上无菌帽在导管上使用无菌袖套使用前检查换能器顶盖，不反复使用一次性顶盖更换病人时消毒换能器除颤后更换换能器顶盖不要在换能器内使用 5%糖液或用之作冲洗液操作时间太长每 48 小时更换所有设备每天观察伤口并消毒减少导管放置时间每天在插管部位涂抹碘酊，加盖无菌敷料近早拔出导管（必要时 4 天更换一次）心脏填塞导管尖造成穿孔轻柔操作在气囊充气下送管预阻力决不能前送导管心包穿刺逆转肝素作用导管打圈或打结右房或右室扩大插管时间太长操作较多至导管变软使用小号（5F）导管在软化前轻送导管，用冰盐水冲洗导管或插入导引钢丝更换新导管气囊破裂过度充气用液体充盈
17、气囊回抽注射器主动放气监测 PAEDP 而不是 PAWP减少嵌顿次数按导管注明的数量充盈气囊使用空气或 CO2 充盈气囊通过撤走注射器让空气自动逸出气囊ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration Hemodynamic values of normal adultsHemodynamic MonitoringCO CI SV SVIRAP(CVP)PAP PAWPCardiac outputPressureSvO2 Cardiac Output（
18、CO）定义：在1min内从心室射 出的血液总量公式：CO=HR x SVCO=48 L/minCardiac Output Index（CI）CI CO/BSA 正常值:2.8 4.2 L/min/m2 CI更能体现患者的个体差异性每搏量每搏量(SV)与与 每搏量指数每搏量指数(SVI)SV定义：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/beatManagement of complicated myocardial infarctionNormal right atrial presssure is
19、0-6cmHg.O2 saturation 75%Parameter integrationPAC要回答的四个问题End-diastolic(PAEDP 8 12 mm Hg)SV/SVI增加的原因：代偿；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 integration
20、Prostacyclin（依前列醇）Transferred to the ICU：volume resuscitated,intubated and started on intravenous inotropes and vasopressors.基于PAC参数的失血性休克诊断PAC参数整合：后负荷Prominent RA pulsationsWhat Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTricuspid va
21、lvular diseasevLeft heart failureProminent RA pulsationsvProminent a wave:Tricuspid stenosisvCannon a wave:AV dissociation Ventricular tachycardiavProminent v wave:Tricuspid regurgitation or VSDWhat Increases RV Pressures?vRV failurevPulmonary hypertensionvPulmonary stenosisvPulmonary EmbolismvCardi
22、omyopathyvCardiac tamponadevCardiac constrictionWhat Elevates PA pressure?vVolume Overload(backflow)vPrimary lung diseasevPrimary pulmonary hypertensionvPulmonary EmbolismvLeft to right shuntvMitral Valve Disease用压力推测心室舒张末期容量的前提用压力推测心室舒张末期容量的前提 导管位置导管位置 无二尖瓣无二尖瓣 心室顺应性心室顺应性 正确正确 疾病疾病 正常正常 PAWP LAP LV
23、EDP LVEDV PreloadSVI正常值：30-65ml/m2/beatFluid challngeTricuspid valve closurePAP MPAP PVRHemodynamic MonitoringCO=48 L/minSVISV/BSA心肌收缩力下降：心功能不全（EF%）Rapid Flush Test（方波试验）Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.Case 5 Septic ShockS
24、hortest and straightest path to the heartPAWP LAP LVEDP LVEDV PreloadPAC Placement预测准确性：PAWP 30%；EKG:sinus tachycardia.Conditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus v Conditions in which PAWP25 mmHg)LVEDPSystemic and pulmonary vascular
25、resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理欧姆定理Systemic Vascular ResistancevCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityvCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tonePulmonary Va
26、scular ResistancevCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsvCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）SvO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControver
27、sy on PAC Parameter integrationCases DiscussionPAC was inserted.Pulmonary stenosis1984 Jul;12(7):549-53.PAC要回答的四个问题CO SVR RAP 50%Cases Discussion基于PAC参数的急性左心衰诊断Assessment of best PEEP for DO2基于PAC参数的急性左心衰诊断HypothermiaHemodynamic MonitoringLow CO statesPAC参数整合：氧代谢1 单纯根据临床评价难以准确预测血流动力学指标LA diastoleRA
28、systoleNitroprusside was titratedCRX:normal ；Pulmonary edemaIncreased blood viscosityESWL;urinary tract infectionsPAC为何不能改善预后？问问题题何何在在12345不恰当的适应症不恰当的适应症PAC相关的并发症相关的并发症数据的可靠性数据的可靠性不恰当的治疗不恰当的治疗数据解读的准确性数据解读的准确性Causes of SVR基于PAC参数的急性右心衰诊断Parameter integrationDO2600mL/min/m2PAC要回答的四个问题用压力推测心室舒张末期容量的前提F
29、emoral veinsTransferred to the 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 val
30、ve closureIntroductionCannon a wave:Nitroprusside was titratedAssessment of best PEEP for DO280 milliseconds after onset of QRSWe still need PAC？到底是谁的问题？v Iberti et al(JAMA 1990)美国和加拿大13家医院 496MD 47的受试者对PAC不能作出正确回答v Gnaegi A et al (CCM1997)134个ICU的535 MD 68的医生所具有的知识不能满足PAC使用Squara P et al(Chest 2002
31、)仅有38的医生按照给出的PAC数据选择了正确的治 疗方案，但仍有多达35的医师选择了错误的治疗方案临床评价 VS 血流动力学v 103例PACv 医生在置管前对血流动力学指标的范围及治疗方案进行预测v 预测准确性：PAWP 30%；CO SVR RAP 50%v 留置PAC后：治疗计划需要重新修正 58%应用未预计到的治疗 30%v 结论：1 单纯根据临床评价难以准确预测血流动力学指标 2 PAC监测将改变治疗策略Crit Care Med.1984 Jul;12(7):549-53.NoncardiogenicCannon a wave:PAC为何不能改善预后？Decompensated
32、cirrhosisWe still need PAC？Cannon a wave:O2 content 15%（ml/dL)心肌收缩力下降：心功能不全（EF%）正确 疾病 正常Normal PA pressure,diastolic 5-13IntroductionCases DiscussionParameter integrationSVI正常值：30-65ml/m2/beat80 milliseconds after onset of QRSWhat Increases RV Pressures?Left heart failureMechanical eventSVI正常值：30-65
33、ml/m2/beatNormal PA pressure,diastolic 5-13Systemic and pulmonary vascular resistanceBenefit or Harm？能否替代PAC？可以替代可以替代心输出量参数心输出量参数不可替代不可替代压力参数压力参数SCVO2近似替代近似替代SVO2Controversy on PAC1,Glu 16,scr 180What Increases RV Pressures?Decreased LV complianceFluid challngeCO=48 L/min80 milliseconds after onset
34、of QRSOn day2，SBP dropped to 70 mmHg；Conditions in which PAWP 10%PAC参数整合：后负荷v左室射血的阻抗及外左室射血的阻抗及外 周阻力周阻力v SAP MAP SVR后负荷后负荷v右室射血的阻抗及外右室射血的阻抗及外 周阻力周阻力v PAP MPAP PVRPAC参数整合：心脏收缩力v CO并不是心脏射血功能的可靠指标v 每搏输出量（SV）/每搏指数（SVI）v SV/SVI增加的原因：代偿；SVR下降v SV/SVI降低的原因：前负荷下降：出血 心肌收缩力下降：心功能不全（EF%）后负荷增加：SVR增加PAC参数整合：氧代谢Ox
35、ygen Delivery:What are the components?Oxygen DeliveryDO2Cardiac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%PAC目标指导性治疗 CI 4.5L/min/m2 DO2600mL/min/m2 VO2170mL/min/m2Shoemaker WC et al.Chest.1988 Dec;94(6):1176-86.PAC目标指导性治疗Crit Care Med.2002 Aug;30(8):1686
36、-92v CI 4.5L/min/m2v DO2600mL/min/m2v VO2170mL/min/m2v PAWP 10%PAEDP:pulmonary artery 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参数的常见危
37、重病的诊断RA diastoleGuide to nonpharmacologic therapyRV O2 saturation 75%IntroductionShortest and straightest path to the heartHow do u know u r in Zone 3？Parameter integrationEnd-diastolic(PAEDP 8 12 mm Hg)定义：在1min内从心室射SVI正常值：30-65ml/m2/beatstarted on mezlocillin and gentamicin.IntroductionPulmonary em
38、bolusProminent v wave:If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3治疗计划需要重新修正 58%After inserting the PAC as far as the 20cm mark，the balloon is inflated with air.Conditions in which PAWPLVEDPDistributive(sepsis)Cardiac tamponadeNormal O2 saturation 75%Loss
39、 of vasomotor toneO2 saturation 75%Cases DiscussionCauses of SVRDifferentiation among causes of shockShoemaker WC et al.右室射血的阻抗及外 周阻力1,Glu 16,scr 180Case 5 Septic Shockv 52/Fv ESWL;urinary tract infectionsv BP 100/45 HR 120 RR 40 T 39v WBC 13100,Na 138,K 5.1,Glu 16,scr 180 v CRX:normal ；EKG:sinus ta
40、chycardia.v Urine Cultures；started on mezlocillin and gentamicin.v On day2，SBP dropped to 70 mmHg；v ABG（Fi02 60%）:pH 7.38,PaO2 42,PaCO2 49 Sa02 75%.v CRX showed diffuse bilateral infiltrates.v Transferred to the ICU：volume resuscitated,intubated and started on intravenous inotropes and vasopressors.v PAC was inserted.v The patient remained oliguric,uremic and therefore hemodialysis was started.MV was maintained with high FiO2 and PEEP
