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1、 肺动脉漂浮导管的应用肺动脉漂浮导管的应用肺动脉漂浮导管的应用肺动脉漂浮导管的应用 ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionWhatisPulmonaryArteryCatheter?vFullname:Swan-GanzCathetervUsedittomonitorapatientshemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasuresClin
2、icaluseofthePAC（Diagnosis）vDifferentiationamongcausesofshockCardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)vDifferentiationofpulmonaryedemaCardiogenicNoncardiogenicvEvaluationofpulmonaryhypertensionvDiagnosisofleft-to-rightintracardiacshuntvDiagnosisofpericardialtampo
3、nadeClinicaluseofthePAC（Therapy）vManagementofperioperativepatientwithunstablecardiacstatusvManagementofcomplicatedmyocardialinfarctionvManagementofseverepreeclampsiavGuidetopharmacologictherapyVasopressors；Inotropes；VasodilatorsvGuidetononpharmacologictherapyFluidmanagement；Burns；Renalfailure；Sepsis
4、；Heartfailure；DecompensatedcirrhosisvVentilatormanagementAssessmentofbestPEEPforDO2ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionStructureofPACPAC首选：右颈内静脉首选：右颈内静脉ComparisonamongPAcatheterinsertionsitesPACinsertionvRight internal jugular vein Shor
5、test and straightest path to the heartvLeft subclavian Does not require the PAC to pass and course at an acute angle to enter the SVC vFemoral veins Distant sites Passing a PAC into the heart can be difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrh
6、age is highPACinsertionvAfter 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 (1.5 mL). vAlways inflate the balloon before advancing the PAC and always deflate the balloon befo
7、re withdrawing the PAC.vCRX：check the position of the PAC vPA diastolic pressure PAWP PAConCRX（PA）PlacementofthecatheterRightAtrium20 cmNormal right atrial presssure is 0-6cmHg. Normal oxygen content 15%（ml/dL)Normal O2 saturation 75%WaveformsofCVPEKG-RAPEKG MechanicaleventRAP80100millisecondsafterP
8、waveRAsystoleawaveRAdiastolexdescentAfterQRSTricuspidvalveclosurec waveAfterpeakofTwaveRAfilling/tricuspidvalveclosedvwaveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastoleydescentRightAtriumRightventricularwaveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2
9、 saturation 75%PulmonaryarterywaveformNormal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 15%（ml/dL)O2 saturation 75%EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculatureSystolicPAS1530mmHg80millisecondsafteronsetofQRSIndirectindicatorofLVE
10、DPEnd-diastolic(PAEDP812mmHg)Mean(918mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressurePulmonaryarterywaveformPAWPwaveformPAWPwaveformEKG-PAWPEKG MechanicaleventPAWPAlignedwiththeendoftheQRSLeftatrial(LA)systole awaveLAdiastolexdescen
11、tT-PintervalLAfilling/mitralvalveclosedvwaveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoleydescentPAWPwaveformECG-CVP-PAWPHowdouknowurinZone3？vCathetershouldbebelowtheleftatriumonCRXvIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3vIfPADPAWPthenyouarelikelynot
12、inZone3RapidFlushTest（方波试验）PhlebostaticAxisPACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理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ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationHemodynamicvaluesofnormaladultsHemodynamicMonitoringCO CI SV SVIRAP(CVP) PAP PAWPCardiac outputPressureSv
13、O2 Cardiac Output （CO）定义：在1min内从心室射出的血液总量公式：CO=HRxSVCO=48L/minCardiacOutputIndex（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/HRSV正常值：50-110ml/beatSVISV/BSASVI正常值：30-65ml/m2/beatWhatElevatestheRightAtrialPressure?vRVinfarctvPulmonaryhypertensi
14、onvPulmonarystenosisvLefttorightshuntvTricuspidvalvulardiseasevLeftheartfailureProminentRApulsationsvProminent a wave: Tricuspid stenosisvCannon a wave: AV dissociation Ventricular tachycardiavProminent v wave: Tricuspid regurgitation or VSDWhatIncreasesRVPressures?vRVfailurevPulmonaryhypertensionvP
15、ulmonarystenosisvPulmonaryEmbolismvCardiomyopathyvCardiactamponadevCardiacconstrictionWhatElevatesPApressure?vVolumeOverload(backflow)vPrimarylungdiseasevPrimarypulmonaryhypertensionvPulmonaryEmbolismvLefttorightshuntvMitralValveDisease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
16、正确 疾病疾病 正常正常 PAWPLAPLVEDPLVEDVPreloadPAWPandLVEDPmaybediscordantvConditionsinwhichPAWPLVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolusvConditionsinwhichPAWP25mmHg)LVEDPSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理欧姆定理SystemicVascula
17、rResistancevCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityvCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortonePulmonaryVascularResistancevCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliV
18、alvularheartdiseaseCongenitalheartdefectsvCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）SvO2ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionPAC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不恰当的适应症不恰当的适应症PACPAC相关的并发症相关的并发症相关的
19、并发症相关的并发症数据的可靠性数据的可靠性数据的可靠性数据的可靠性不恰当的治疗不恰当的治疗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数据解读的准确性数据解读的准确性WestillneedPAC？到底是谁的问题？vIbertietal(JAMA1990)美国和加拿大13家医院496MD47的受试者对PAC不能作出正确回答vGnaegiAetal(CCM1997)134个ICU的535MD68的医生所具有的知识不能满足PAC使用SquaraPetal(Chest2002)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
20、力学v103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：PAWP30%；COSVRRAP50%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2PAC监测将改变治疗策略Crit Care Med. 1984 Jul;12(7):549-53.BenefitorHarm？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SVO2ContentsPAC Placement Hemodynamic MonitoringControver
21、sy on PAC Parameter integrationCases DiscussionPAC要回答的四个问题PACPAC前负荷后负荷后负荷后负荷后负荷心功能心功能心功能心功能氧平衡氧平衡PAC参数整合：前负荷vCVP（RAP）/PAWPAnygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessvFluidchallngeCVP2-5rulePAWP3-7ruleCO/CI/SV10%PAC参数整合：后负荷v左室射血的阻抗及外左室射血的阻
22、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vCO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）vSV/SVI增加的原因：代偿；SVR下降vSV/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OxygenDelivery:Whatarethecomponents?Oxygen DeliveryDO2Cardiac OutputHeart RateStroke VolumeCaO2PaO2
23、SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%PAC目标指导性治疗AA CI 4.5L/min/m2BB DO2600mL/min/m2C C 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):1686-92vCI4.5L/min/m2vDO2600mL/min/m2vVO2170mL/min/m2vPAWP18mmHg基于基于PAC参数的常见危重病的诊断参数的常见危重病的诊断基于
24、PAC参数的急性右心衰诊断前负荷前负荷CVPPAWP正常后负荷后负荷MPAP正常或MAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO2基于PAC参数的急性左心衰诊断前负荷前负荷CVPPAWP后负荷后负荷PVR/SVRMAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO2基于PAC参数的感染性休克诊断前负荷前负荷CVPPAWP后负荷后负荷SVRMAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO2基于PAC参数的失血性休克诊断前负荷前负荷CVPPAWP后负荷后负荷SVRMAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2正常或VO2基
25、于PAC参数的急性肺栓塞诊断前负荷前负荷CVPPAWP后负荷后负荷MPAPMAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO2PAC病例病例Case1FluidchallengeCase2FluidchallengeCase2DiureticCase2DiureticCase3VasodilatorTherapyv71/MvAnteriorwallmyocardialinfarctionvPE:BP132/82HR116R28.+2edemaofthelowerextremitiesvLab:Na132Scr88vECG:anteriorleadS-TelevationsvC
26、RX:cardiomegalywithpulmonaryedemavThepatientwasadmittedtotheICUandPACwasplacedforoptimizationofcardiacstatusvNitroprussidewastitratedCase3VasodilatorTherapyCase4CardiactonicCase4CardiactonicCase5SepticShockv52/FvESWL;urinarytractinfectionsvBP100/45HR120RR40T39vWBC13100,Na138,K5.1,Glu16,scr180vCRX:no
27、rmal；EKG:sinustachycardia.vUrineCultures；startedonmezlocillinandgentamicin.vOnday2，SBPdroppedto70mmHg；vABG（Fi0260%）:pH7.38,PaO242,PaCO249Sa0275%.vCRXshoweddiffusebilateralinfiltrates.vTransferredtotheICU：volumeresuscitated,intubatedandstartedonintravenousinotropesandvasopressors.vPACwasinserted.vThepatientremainedoliguric,uremicandthereforehemodialysiswasstarted.MVwasmaintainedwithhighFiO2andPEEPCase5SepticShock
