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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 Discussion2 What is Pulmonary Artery Catheter ?vFull name: Swan-Ganz CathetervUsed it to monitor a patients hemodynamics when we cant answer the question using noninvas
2、ive/clinical measures 3Clinical use of the PAC （Diagnosis） vDifferentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) vDifferentiation of pulmonary edema Cardiogenic Noncardiogenic vEvaluation of pulmonary hypertensionvDiagnosis of l
3、eft-to-right intracardiac shunt vDiagnosis of pericardial tamponade 4Clinical use of the PAC（Therapy）vManagement of perioperative patient with unstable cardiac status vManagement of complicated myocardial infarction vManagement of severe preeclampsia vGuide to pharmacologic therapy Vasopressors； Ino
4、tropes ； VasodilatorsvGuide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis vVentilator management Assessment of best PEEP for DO25ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussio
5、n6Structure of PAC7PAC8首选：右颈内静脉首选：右颈内静脉9Comparison among PA catheter insertion sites10PAC insertion vRightinternaljugularveinShortestandstraightestpathtotheheartvLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCvFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficult
6、FluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh11PAC insertionvAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.vInflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).vAlwaysinflatetheballoonbeforeadvancingt
7、hePACandalwaysdeflatetheballoonbeforewithdrawingthePAC. vCRX：checkthepositionofthePACvPAdiastolicpressurePAWP12PAC on CRX（PA）13Placement of the catheter14Right Atrium20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%15Waveforms of CVP16EKG-RAPEKG Mechanical ev
8、ent RAP80 100 milliseconds after P wave RA systoleawave RA diastole xdescent After QRS Tricuspid valve closure c wave After peak of T wave RA filling/tricuspid valve closed vwave RA emptying at opening of tricuspid valve/onset of right ventricle diastole ydescent 17Right Atrium18 Right ventricular w
9、aveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%19 Pulmonary artery waveformNormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%20EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vascu
10、latureSystolicPAS 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 pressurePAEDP: pulmonary artery end-diastolic pressure21Pulmonary artery waveform22 PAWP wa
11、veform23PAWP waveform24EKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial (LA) systole awave LA diastole xdescent T-P interval LA filling/mitral valve closedvwave LA emptying at opening of mitral valve/onset of left ventricle diastoleydescent 25PAWP waveform26ECG - CVP - PA
12、WP27 How do u know u r in Zone 3？vCatheter should be below the left atrium on CRXvIf there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3vIf PAD PAWP then you are likely not in Zone 328Rapid Flush Test（方波试验）29 Phlebostatic Axis30PACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理31P
13、ACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理32ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration33 Hemodynamic values of normal adults34Hemodynamic MonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiac outputPressureSvO235CardiacOutput（CO）定义： 在1min内从心室射 出的血液总量公式：CO = HR x SVCO = 48 L/min3
14、6Cardiac Output Index （CI） CICO/BSA正常值:2.84.2L/min/m2CI更能体现患者的个体差异性37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/beat38What Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTri
15、cuspid valvular diseasevLeft heart failure39Prominent RA pulsationsvProminent a wave:TricuspidstenosisvCannon a wave:AVdissociationVentriculartachycardiavProminent v wave:TricuspidregurgitationorVSD40What Increases RV Pressures?vRV failurevPulmonary hypertensionvPulmonary stenosisvPulmonary Embolism
16、vCardiomyopathyvCardiac tamponadevCardiac constriction41What Elevates PA pressure?vVolume Overload (backflow)vPrimary lung diseasevPrimary pulmonary hypertensionvPulmonary EmbolismvLeft to right shuntvMitral Valve Disease42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
17、PAWP LAP LVEDP LVEDV Preload43PAWP and LVEDP may be discordantvConditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus vConditions in which PAWP25 mmHg) LVEDP44Systemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR
18、欧姆定理欧姆定理45Systemic Vascular ResistancevCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityvCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tone46Pulmonary Vascular ResistancevCauses of PVRHypoxiaPEEPPulmonar
19、y edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsvCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）47SvO248ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion49505152PAC
20、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53We still need PAC ？54到底是谁的问题？vIberti 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vGnaegi A et al (CCM1997) 134个ICU的535 MD 68的医生所
21、具有的知识不能满足PAC使用Squara P et al (Chest 2002) 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55临床评价 VS 血流动力学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：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):549-53.56Benefit o
22、r Harm？57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SVO258ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion59PAC要回答的四个问题PACPAC前负荷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氧平衡氧平衡60PAC参数整合：前负荷vCVP（RAP） / PAWP Any given level of filling pressure:
23、not reliable！ Static markers of cardiac preload fail to predict volume responsivenessvFluid challnge CVP 2-5 rule PAWP 3-7 rule CO / CI / SV 10%61PAC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 周阻周阻力力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 周阻周阻力力v PAP MPAP PVR62PAC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/SV
24、I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63PAC参数整合：氧代谢64Oxygen Delivery: What are the components?Oxygen DeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%65PAC目标指导性治疗AACI4.5L/min/m2BBDO2600mL/min/m2C C VO2170mL/min/m2Sh
25、oemakerWCetal.Chest.1988Dec;94(6):1176-86.66PAC目标指导性治疗Crit Care Med. 2002 Aug;30(8):1686-92vCI 4.5L/min/m2vDO2600mL/min/m2vVO2170mL/min/m2vPAWP18mmHg67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68基于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/FiO2DO2VO269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/
26、SVR MAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO270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SVR MAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2VO271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SVR MAP正常或心脏心脏HRSI氧代谢氧代谢PaO2/FiO2DO2正常或VO272基于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/FiO2DO2VO273PAC病例病例74Case 1 Fluid challenge
27、75Case 2 Fluid challenge76Case 2 Diuretic 77Case 2 Diuretic78Case3 Vasodilator Therapyv71/MvAnterior wall myocardial infarctionvPE: BP 132/82 HR 116 R 28. +2 edema of the lower extremitiesvLab: Na 132 Scr 88vECG: anterior lead S-T elevations vCRX: cardiomegaly with pulmonary edemavThe patient was ad
28、mitted to the ICU and PAC was placed for optimization of cardiac statusvNitroprusside was titrated79Case3 Vasodilator Therapy80Case 4 Cardiac tonic81Case 4 Cardiac tonic82Case 5 Septic Shockv52/FvESWL ; urinary tract infectionsvBP 100/45 HR 120 RR 40 T 39vWBC 13100, Na 138, K 5.1, Glu 16, scr 180 vC
29、RX : normal ； EKG : sinus tachycardia.vUrine Cultures ； started on mezlocillin and gentamicin.vOn day2，SBP dropped to 70 mmHg ；vABG （Fi02 60%）: pH 7.38, PaO2 42, PaCO2 49 Sa02 75%.vCRX showed diffuse bilateral infiltrates. vTransferred to the ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors. vPAC was inserted.vThe patient remained oliguric, uremic and therefore hemodialysis was started. MV was maintained with high FiO2 and PEEP83Case 5 Septic Shock84
