肺动脉漂浮导管-PAC

1、 肺动脉漂浮导管的应用 ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion2 What is Pulmonary Artery Catheter ?Full name: Swan-Ganz CatheterUsed it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clinical measure

2、s 3Clinical use of the PAC （Diagnosis） Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) Differentiation of pulmonary edema Cardiogenic Noncardiogenic Evaluation of pulmonary hypertensionDiagnosis of left-to-right intracardia

3、c shunt Diagnosis of pericardial tamponade 4Clinical use of the PAC（Therapy）Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarction Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors； Inotropes ； VasodilatorsGuide to

4、 nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO25ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion6Structure of PAC7

5、PAC8首选：右颈内静脉9Comparison among PA catheter insertion sites10PAC insertion Right internal jugular vein Shortest and straightest path to the heartLeft subclavian Does not require the PAC to pass and course at an acute angle to enter the SVC Femoral veins Distant sites Passing a PAC into the heart can b

6、e difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is high11PAC insertionAfter inserting the PAC as far as the 20cm mark，the balloon is inflated with air. Inflation should be slow and controlled (1 mL/s) and should not surpass the recommended v

7、olume (1.5 mL). Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC. CRX：check the position of the PAC PA diastolic pressure PAWP 12PAC on CRX（PA）13Placement of the catheter14Right Atrium20 cmNormal right atrial presssure is 0-6cmHg. Normal o

8、xygen content 15%（ml/dL)Normal O2 saturation 75%15Waveforms of CVP16EKG-RAPEKG Mechanical event 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 tri

9、cuspid valve/onset of right ventricle diastole ydescent 17Right Atrium18 Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75%19 Pulmonary artery waveformNormal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 15%（ml/dL

10、)O2 saturation 75%20EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolicPAS 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 ventri

11、cular end-diastolic pressurePAEDP: pulmonary artery end-diastolic pressure21Pulmonary artery waveform22 PAWP waveform23PAWP 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

12、LA emptying at opening of mitral valve/onset of left ventricle diastoleydescent 25PAWP waveform26ECG - CVP - PAWP27 How do u know u r in Zone 3？Catheter should be below the left atrium on CRXIf there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3If PAD PAWP then you

13、 are likely not in Zone 328Rapid Flush Test（方波试验）29 Phlebostatic Axis30PAC并发症、可能原因、预防及处理31PAC并发症、可能原因、预防及处理32ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration33 Hemodynamic values of normal adults34Hemodynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCard

14、iac outputPressureSvO235 Cardiac Output （CO）定义： 在1min内从心室射 出的血液总量公式：CO = HR x SVCO = 48 L/min36Cardiac 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37每搏量 (SV) 与 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

15、Atrial Pressure?RV infarctPulmonary hypertensionPulmonary stenosisLeft to right shuntTricuspid valvular diseaseLeft heart failure39Prominent RA pulsationsProminent a wave: Tricuspid stenosisCannon a wave: AV dissociation Ventricular tachycardiaProminent v wave: Tricuspid regurgitation or VSD40What I

16、ncreases RV Pressures?RV failurePulmonary hypertensionPulmonary stenosisPulmonary EmbolismCardiomyopathyCardiac tamponadeCardiac constriction41What Elevates PA pressure?Volume Overload (backflow)Primary lung diseasePrimary pulmonary hypertensionPulmonary EmbolismLeft to right shuntMitral Valve Disea

17、se42用压力推测心室舒张末期容量的前提 导管位置 无二尖瓣 心室顺应性 正确 疾病 正常 PAWP LAP LVEDP LVEDV Preload43PAWP and LVEDP may be discordantConditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus Conditions in which PAWP25 mmHg) LVEDP44Systemic and pulmonary vascular resistance

18、80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理45Systemic Vascular ResistanceCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tone46Pulmonary Vascular Resis

19、tanceCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）47SvO248ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC

20、Parameter integrationCases Discussion49505152PAC为何不能改善预后？问题何在12345不恰当的适应症PAC相关的并发症数据的可靠性不恰当的治疗数据解读的准确性53We still need PAC ？54到底是谁的问题？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) 仅有38的医生按照给出的PAC数据选

21、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103例PAC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预测准确性：PAWP 30%； CO SVR RAP 50%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%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 or Harm？57能否替代PAC？可以替代心输出量参数不可替代压力参数SCVO2近似替代SVO258ContentsIntrodu

22、ctionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion59PAC要回答的四个问题PAC前负荷后负荷心功能氧平衡60PAC参数整合：前负荷CVP（RAP） / PAWP Any given level of filling pressure: not reliable！ Static markers of cardiac preload fail to predict volume responsivenessFluid challnge CVP 2-5 r

23、ule PAWP 3-7 rule CO / CI / SV 10%61PAC参数整合：后负荷左室射血的阻抗及外 周阻力 SAP MAP SVR后负荷右室射血的阻抗及外 周阻力 PAP MPAP PVR62PAC参数整合：心脏收缩力CO并不是心脏射血功能的可靠指标每搏输出量（SV）/每搏指数（SVI）SV/SVI增加的原因：代偿；SVR下降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63PAC参数整合：氧代谢64Oxygen Delivery: What are the components?Oxygen DeliveryDO2Car

24、diac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%65PAC目标指导性治疗A CI 4.5L/min/m2B DO2600mL/min/m2C VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.66PAC目标指导性治疗Crit Care Med. 2002 Aug;30(8):1686-92CI 4.5L/min/m2DO2600mL/min/m2VO2170mL/min/m2PA

25、WP18mmHg67基于PAC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CVPPAWP正常后负荷MPAP正常或MAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO269基于PAC参数的急性左心衰诊断前负荷CVPPAWP后负荷PVR/SVR MAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO270基于PAC参数的感染性休克诊断前负荷CVPPAWP后负荷SVR MAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO271基于PAC参数的失血性休克诊断前负荷CVPPAWP后负荷SVR MAP正常或心脏HRSI氧代谢PaO2/FiO2DO2正常或VO272基于PA

26、C参数的急性肺栓塞诊断前负荷CVPPAWP后负荷MPAPMAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO273PAC病例74Case 1 Fluid challenge75Case 2 Fluid challenge76Case 2 Diuretic 77Case 2 Diuretic78Case3 Vasodilator Therapy71/MAnterior wall myocardial infarctionPE: BP 132/82 HR 116 R 28. +2 edema of the lower extremitiesLab: Na 132 Scr 88ECG: anterior l