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1、会计学1SwanGanz导管应用导管应用(yngyng)技巧与临技巧与临床解读幻灯床解读幻灯第一页，共48页。n n19671967年加州大学洛杉矶分院年加州大学洛杉矶分院Dr. Swan Dr. Swan 由由n n 顺着洋流飘回港湾的帆船，联想到带气囊顺着洋流飘回港湾的帆船，联想到带气囊n n 的心脏的心脏(xnzng)(xnzng)导管可以随血流在心脏导管可以随血流在心脏(xnzng)(xnzng)内向前漂移。内向前漂移。n n19701970年年SwanSwan与与GanzGanz合作研制了顶端带气囊的血流导向肺动脉漂浮合作研制了顶端带气囊的血流导向肺动脉漂浮导管导管(Balloon-
2、tip flow-directed Catheter), (Balloon-tip flow-directed Catheter), 并应用于临床。并应用于临床。Swan HJC and Ganz W. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Eng J Med 1970; 283: 447Swan-Ganz导管导管(dogun)Swan-GanzSwan-Ganz Catheter_CuiNa2010-3-28第1页/共48页第二页，共48页。Ther
3、mistor ConnectorBalloonThermocouple wire ConnectorBalloon Inflation valveRA/Proximal Injection Lumen HubPA/Distal Lumen HubBalloonBandsBalloon Inflation valveThermistor BackformBandsThermocouple wire ConnectorRA/Proximal Injection Lumen HubSVO2 Optical ConnectorPA/Distal Lumen HubBalloon Inflation v
4、alveBalloonSwan-Ganz第2页/共48页第三页，共48页。CVP/Proximal Infusion Lumen HubPA/Distal Lumen HubBalloon Inflation valveThermistor ConnectorBalloonThermistor BackformSVO2 Optical ConnectorThermocouple wire ConnectorRA/Proximal Injection Lumen HubThermocouple wire on the surface of the catheter BandsSwan-Ganz第
5、3页/共48页第四页，共48页。n nPVC 聚氯乙烯(j l y x)材料 导管直径导管直径“French”,“French”,以不同以不同(b tn)(b tn)颜色颜色标示：标示： v硬度硬度“shore”,“shore”,临床临床“触觉触觉(chju)”(chju)”及及“扭结扭结” ” v辐射透不过染料辐射透不过染料,X ,X 光下可见光下可见 v4F-红色红色/ /粉红；粉红；v5F-白色；白色；v6F-蓝色；蓝色；v7&8F-黄色黄色 导管长度导管长度: :成人一般为成人一般为110cm ,儿科为儿科为60-75cm Swan-Ganz第4页/共48页第五页，共48页。临床临床(
6、ln chun)(ln chun)应用技巧应用技巧Swan-Ganzv置管置管监测数据解读监测数据解读(ji d)(ji d)2010-3-28Swan-Ganz Catheter CuiNav测量测量(cling(cling) )v左心与右心左心与右心v氧供与氧耗氧供与氧耗第5页/共48页第六页，共48页。n n穿刺路径(ljng): 右颈内静脉最为常用注意事项：注意事项： 床旁备有除颤器和利多卡因、肾上腺素等急救药品床旁备有除颤器和利多卡因、肾上腺素等急救药品 可靠静脉可靠静脉(jngmi)(jngmi)通路；通路； Sedinger穿刺法穿刺法 将将导导管管鞘鞘套套在在静静脉脉扩扩张张器
7、器外外，通通过过导导丝丝送送入入，退退出出导导丝丝及及静静脉脉扩扩张张器器后后即即可可通通过过导导管管鞘鞘插插入入(ch r)Swan-Ganz导管。导管。 (成人成人7号，小儿号，小儿5号）号）无菌操作无菌操作无菌操作无菌操作Swan-Ganz 置管置管 第6页/共48页第七页，共48页。准备准备(zhnbi)(zhnbi)好穿刺针、导丝、扩张器、外套管、好穿刺针、导丝、扩张器、外套管、Swan-GanzSwan-Ganz导管、压力传感器及冲洗装置等导管、压力传感器及冲洗装置等PAC外套上保护鞘，将肺动脉腔及外套上保护鞘，将肺动脉腔及 CVP腔用盐水冲注，与标定好的换能器相连，注腔用盐水冲注
8、，与标定好的换能器相连，注 1.5ml气体气体(qt)检查气囊是否匀称检查气囊是否匀称Swan-Ganz 置管置管 第7页/共48页第八页，共48页。Swan-Ganz 置管置管 第8页/共48页第九页，共48页。Swan-Ganz 置管置管 第9页/共48页第十页，共48页。Swan-Ganz 置管置管 第10页/共48页第十一页，共48页。Swan-Ganz 置管置管 第11页/共48页第十二页，共48页。Swan-Ganz Insertion Swan-Ganz 置管置管 第12页/共48页第十三页，共48页。Swan-Ganz 置管置管 第13页/共48页第十四页，共48页。肺区的概念
9、肺区的概念(ginin)(ginin)3区2区1区1区2区3区Swan-Ganz 置管置管 第14页/共48页第十五页，共48页。临床临床(ln chun)(ln chun)应用技巧应用技巧Swan-Ganzv置管置管监测数据解读监测数据解读(ji d)(ji d)2010-3-28Swan-Ganz Catheter CuiNav测量测量(cling(cling) )v左心与右心左心与右心v氧供与氧耗氧供与氧耗第15页/共48页第十六页，共48页。实际实际(shj)(shj)测量的关键测量的关键环节环节v“通畅通畅(tngchng)”Fast Flush Test (Square wave
10、Test)Swan-Ganz 测量测量(cling) v“调零调零”v“衰减衰减”压力传感器隔膜前端液体平面压力传感器隔膜前端液体平面 右心房水平右心房水平, ,腋中线第四肋间隙腋中线第四肋间隙收缩压变低收缩压变低舒张压增高舒张压增高第16页/共48页第十七页，共48页。Assumptions of TD CO DeterminationsvForward Blood FlowvAdequate Mixing of Blood and InjectatevSteady pulmonary artery baseline temperatureSwan-Ganz 测量测量(cling) 第17页
11、/共48页第十八页，共48页。Intermittent Bolus Thermodilution Swan-Ganz 测量测量(cling) 第18页/共48页第十九页，共48页。Intermittent CO Measurements Technical IssuesvSmooth steady injectionvAppropriate volume of injectatevTiming of injectatevAveraging strategyvAppropriate computation constantSwan-Ganz 测量测量(cling) 第19页/共48页第二十页，共
12、48页。8 am CO/CI 6.0 / 3.04 pm CO/CI 3.6 / 1.8 Room injectate.bag on monitor and warmer than measured injectate1 degree C Room temp = 7.7% error1 degree C Iced temp = 2.7 % errorSwan-Ganz 测量测量(cling) What is the cause of the low CO? 第20页/共48页第二十一页，共48页。Continuous Cardiac Output Swan-Ganz 测量测量(cling) 第
13、21页/共48页第二十二页，共48页。CCO Modified Swan-Ganz Catheter Swan-Ganz 测量测量(cling) 2010-3-28Swan-Ganz Catheter CuiNa第22页/共48页第二十三页，共48页。Continuous Cardiac Output Swan-Ganz 测量测量(cling) 2010-3-28Swan-Ganz Catheter CuiNa第23页/共48页第二十四页，共48页。临床应用临床应用(yngyng)(yngyng)技巧技巧Swan-Ganzv置管置管监测数据解读监测数据解读(ji d)(ji d)2010-3-
14、28Swan-Ganz Catheter CuiNav测量测量(cling(cling) )v左心与右心左心与右心v氧供与氧耗氧供与氧耗第24页/共48页第二十五页，共48页。适应症适应症绝对绝对(judu)(judu)禁禁忌症忌症相对禁忌症相对禁忌症血流动力学监测血流动力学监测(jin c)(jin c)的目的的目的评价并维持机体的氧供需平衡，避免组织评价并维持机体的氧供需平衡，避免组织(zzh)(zzh)缺氧缺氧协助诊断，确定高危人群协助诊断，确定高危人群指导治疗，评估患者预后指导治疗，评估患者预后Swan-Ganz 数据解读数据解读 第25页/共48页第二十六页，共48页。vOxygen
15、 ExchangevOxygen DeliveryvOxygen UtilizationSwan-Ganz 数据数据(shj)解读解读 第26页/共48页第二十七页，共48页。参数略语计算方法参考正常值中心静脉压CVP直接测量6-12mmHg肺动脉嵌顿压PAWP直接测量6-12mmHg平均肺动脉压MAP直接测量11-16mmHg心输出量CO直接测量5-6L/min心排指数CICO/BSA2.8-3.6L/min/m2每搏输出量SVCO/HR60-90ml/beat每搏输出量指数SVISV/BSA30-50 ml/beat/m2体循环阻力指数SVRI79.92(MAP-CVP)/CI1760-2
16、600dynesec/cm5m2肺循环阻力指数PVRI79.92(MPAP-PAWP)/CI45-225 dynesec/cm5m2右心室做功指数RVSWI SVI(MPAP-CVP)0.01434-8g/m/ m2左心室做功指数LVSWISVI(MAP-PAWP)0.01444-68 g/m/ m2氧输送DO2CICaO210520-720ml/min/ m2氧耗量VO2CI(CaO2-CvO2) 10100-180 ml/min/ m2氧摄取率O2ext(CaO2-CvO2)/CaO222-30%CVP直接测量6-12mmHgPAWP直接测量6-12mmHgMAP直接测量11-16mmHg
17、CO直接测量5-6L/minCICO/BSA2.8-3.6L/min/m2SVCO/HR60-90ml/beatSVISV/BSA30-50 ml/beat/m2SVRI79.92(MAP-CVP)/CI1760-2600dynesec/cm5m2PVRI79.92(MPAP-PAWP)/CI45-225 dynesec/cm5m2RVSWI SVI(MPAP-CVP)0.01434-8g/m/ m2LVSWISVI(MAP-PAWP)0.01444-68 g/m/ m2SVRI79.92(MAP-CVP)/CI1760-2600dynesec/cm5m2PVRI79.92(MPAP-PAWP
18、)/CI45-225 dynesec/cm5m2Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第27页/共48页第二十八页，共48页。Oxygen ExchangeOxygen DeliverySwan-Ganz 数据数据(shj)解读解读 第28页/共48页第二十九页，共48页。Preload PreloadPreloadRV PreloadRV PreloadCVP/RACVP/RANormal: 2-6mmHgNormal: 2-6mmHgLV PreloadLV PreloadPADPADNormal: 8-15mmH
19、gNormal: 8-15mmHgPAWP/LAPPAWP/LAPNormal: 6-12mmHgNormal: 6-12mmHgDefinition:Definition: Volume of blood in the ventricle at the Volume of blood in the ventricle at the end of diastole. end of diastole.Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第29页/共48页第三十页，共48页。Contractility Definitio
20、n:Definition:vvThe inotropic state of the myocardium The inotropic state of the myocardium vvThe velocity and the extent of myocardialThe velocity and the extent of myocardial fiber shortening fiber shorteningContractilityContractilityRV STROKE WORK INDEXRV STROKE WORK INDEXRVSWI=SVI (MPAP-RAP) RVSW
21、I=SVI (MPAP-RAP) 0.01360.0136Normal: 5-10gm m/mNormal: 5-10gm m/m2 2/beat/beatSTROKE VOLUMESTROKE VOLUMESTROKE VOL. INDEXSTROKE VOL. INDEXLV STROKE WORK INDEXLV STROKE WORK INDEXLVSWI=SVI (MAP-PAWP) LVSWI=SVI (MAP-PAWP) 0.01360.0136Normal: 45-65gm m/mNormal: 45-65gm m/m2 2/beat /beat Swan-Ganz 数据数据(
22、shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第30页/共48页第三十一页，共48页。Afterload Definition:Definition: Pressure or resistance ventricles must Pressure or resistance ventricles must overcome to eject blood into the systemic overcome to eject blood into the systemic and pulmonary circulations. and pulmonary c
23、irculations.How to assess:How to assess:vvRV pulmonary vascular resistanceRV pulmonary vascular resistancevvLV systemic vascular resistanceLV systemic vascular resistanceSwan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第31页/共48页第三十二页，共48页。Clinical Measurement of Afterload Left Ventricular Af
24、terload (Systemic vascular resistance, SVR)vSVR= MAP- RAP 80vNormal: 800-1200 dynes/sec/cm-5CORight Ventricular Afterload(Pulmonary vascular resistance, PVR)vPVR= MPAP- PAWP 80vNormal: 250 dynes/sec/cm-5COSwan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第32页/共48页第三十三页，共48页。PreloadFrank-Starl
25、ing CurveFrank-Starling CurveAssumptionAssumption= Volume = Pressure？Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第33页/共48页第三十四页，共48页。 Compliance & DynamicsvvThe relationship between The relationship between pressure and volume is pressure and volume is known as known as COMPLIANCEPressu
26、revvCompliance is not a static Compliance is not a static state but is dynamic and always changing state but is dynamic and always changingSwan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第34页/共48页第三十五页，共48页。临床临床(ln chun)(ln chun)应用技巧应用技巧Swan-Ganzv置管置管监测数据解读监测数据解读(ji d)(ji d)2010-3-28Swan-Ga
27、nz Catheter CuiNav测量测量(cling(cling) )v左心与右心左心与右心v氧供与氧耗氧供与氧耗第35页/共48页第三十六页，共48页。 RV & LV Tricuspid ValveTricuspid ValveInferior Vena CavaInferior Vena CavaJoined in a Series by the Pulmonary Vasculature Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第36页/共48页第三十七页，共48页。Right & Left Ventricl
28、ev彼此独立，相互依赖彼此独立，相互依赖v共同目的共同目的(md)(md)，显著，显著差异差异RV Volumetric ParametersvStroke volumevEnd diastolic volumevEnd systolic volumevRV ejection fractionCompensationInterdependence&Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第37页/共48页第三十八页，共48页。End Systolic Volume (ESV)vDefinition: the volume
29、 of blood remaining in the ventricle at the end of systolevNormal RVESV: 50-100 mlvNormal RVESVI: 30-60 ml/m2vDefinition: the percentage of blood in the ventricle with each beatvNormal RVEF: 40% - 60%Ejection Fraction (EF)Swan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第38页/共48页第三十九页，共48页。E
30、nd Diastolic Volume (EDV)vDefinition: the volume of blood in the ventricle at the end of diastolevNormal RVEDV: 100-160 mlvNormal RVEDVI: 60-100 ml/m2EDV is derived fromvSV = CO 1000 EDV = SV HR EFSwan-Ganz 数据数据(shj)解读解读 2010-3-28Swan-Ganz Catheter CuiNa第39页/共48页第四十页，共48页。Continuous End Diastolic Vo
31、lume Swan-Ganz 数据数据(shj)解读解读 第40页/共48页第四十一页，共48页。临床临床(ln chun)(ln chun)应用技巧应用技巧Swan-Ganzv置管置管监测数据解读监测数据解读(ji d)(ji d)2010-3-28Swan-Ganz Catheter CuiNav测量测量(cling(cling) )v左心与右心左心与右心v氧供与氧耗氧供与氧耗第41页/共48页第四十二页，共48页。Swan-Ganz Catheter_CuiNa20vol%=20ml/dl5L/minute1000ml/min250ml/min750ml/minSvO2=75%SvO2=
32、75%Swan-Ganz 数据数据(shj)解读解读 2010-3-28第42页/共48页第四十三页，共48页。Resuscitation to normal vital signs may lead to occult hypoperfusionvStroke 2004: What is “adequate resuscitation”Provide therapeutic goal for resuscitationvNot feasible in early resuscitationvWe are too often late to resuscitateSvO2 Monitoring
33、 requires PA catheterScvO2 easy to measurevCombine volume with flow surrogateSwan-Ganz 数据数据(shj)解读解读 第43页/共48页第四十四页，共48页。ScvO2 correlates with SvO2 in shock statesvSuperior vena cava, r = 0.86vRight atrium, r = 0.95Feasible in the early settingsTrends more important.More equal at lower saturations (
34、50%).ScvOScvO2 2SvOSvO2 2hypotensionhemorrhagehypoxiaScvO2SvO2Swan-Ganz 数据数据(shj)解读解读 第44页/共48页第四十五页，共48页。Swan-Ganz Catheter_CuiNaHow do we screen for high risk patients in the ICU?A Screening Tool and A Screening Tool and Non-invasive Detection of Global Tissue HypoxiaNon-invasive Detection of Glob
35、al Tissue HypoxiaSwan-Ganz 数据数据(shj)解读解读 2010-3-28第45页/共48页第四十六页，共48页。CurrentOpinioninCriticalCareCurrentOpinioninCriticalCare2009,15:249253Swan-Ganz 数据数据(shj)解读解读 “This study discusses and problems associated with its inappropriate delays in applying interventions, and inappro-use including inaccur
36、acy of measurements and data interpr- etation, inappropriately applied therapeutic interventions, priate patient selection”.第46页/共48页第四十七页，共48页。内容(nirng)总结会计学。1967年加州大学洛杉矶分院Dr. Swan 由。硬度“shore”,临床“触觉”及“扭结”。准备(zhnbi)好穿刺针、导丝、扩张器、外套管、Swan-Ganz导管、压力传感器及冲洗装置等。第20页/共48页。Swan-Ganz 数据解读。1760-2600dynesec/cm5m2。45-225 dynesec/cm5m2。CICaO210。CI(CaO2-CvO2) 10。第46页/共48页第四十八页，共48页。
