肺动脉漂浮导管PAC课件

1、肺动脉漂浮导管PAC肺动脉漂浮导管PAC优选肺动脉漂浮导管PAC优选肺动脉漂浮导管PACContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC Place What is Pulmonary Artery Catheter ?Full name: Swan-Ganz CatheterUsed it to monitor a patients hemodynamics when we

2、 cant answer the question using noninvasive/clinical measures What is Pulmonary Artery Clinical use of the PAC （Diagnosis） Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) Differentiation of pulmonary edema Cardiogenic Nonca

3、rdiogenic Evaluation of pulmonary hypertensionDiagnosis of left-to-right intracardiac shunt Diagnosis of pericardial tamponade Clinical use of the PAC （DiagnClinical use of the PAC（Therapy）Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarctio

4、n Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors； Inotropes ； VasodilatorsGuide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO2Clinical use of th

5、e PAC（TherapContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC PlaceStructure of PACStructure of PACPACPAC首选：右颈内静脉首选：右颈内静脉Vasodilator therapyPAC was inserted.SV = CO / HRCRX showed diffuse bilateral infiltrates.应用未预

6、计到的治疗 30%Aligned with the end of the QRSLeft atrial (LA) systoleLeft heart failureComparison among PA catheter insertion sitesHemodynamic values of normal adultsCase 1 Fluid challengeDistributive (sepsis)Congenital heart defectsPAWP and LVEDP may be discordantPAC was inserted.仅有38的医生按照给出的PAC数据选择了正确的

7、治 疗方案，但仍有多达35的医师选择了错误的治疗方案Comparison among PA catheter insertion sitesVasodilator therapyComparison PAC 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

8、 sites Passing a PAC into the heart can be difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is highPAC insertion Right internal jPAC insertionAfter inserting the PAC as far as the 20cm mark，the balloon is inflated with air. Inflation should be

9、slow and controlled (1 mL/s) and should not surpass the recommended volume (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 PAC insertionAfter inserting tPAC on CRX（PA

10、）PAC on CRX（PA）Placement of the catheterPlacement of the catheterRight Atrium20 cmNormal right atrial presssure is 0-6cmHg. Normal oxygen content 15%（ml/dL)Normal O2 saturation 75%Right Atrium20 cmHemodynamic MonitoringControversy on PACLA filling/mitral valve closedHemodynamic MonitoringConditions

11、in which PAWPLVEDP应用未预计到的治疗 30%Used it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clinical measuresHemodynamic MonitoringGnaegi A et al (CCM1997)Ventilator managementCongenital heart defectsHypothermiaHeart failure ；started on mezlocillin and gentamicin.VO2

12、170mL/min/m2IntroductionCI CO / BSA公式：CO = HR x SV预测准确性：PAWP 30%；Waveforms of CVPHemodynamic MonitoringWaveformEKG-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

13、 closed vwave RA emptying at opening of tricuspid valve/onset of right ventricle diastole ydescent EKG-RAPEKG Mechanical event Right AtriumRight Atrium Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%（ml/dL)RV O2 saturation 75% Right ventricular wavefor Pulmonary

14、artery waveformNormal PA pressure, systolic 15-30Normal PA pressure, diastolic 5-13O2 content 15%（ml/dL)O2 saturation 75% Pulmonary artery waveforEKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolicPAS 15 30 mm Hg80 milliseconds after onset of QRS

15、 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 pressureEKG-PAPEKG Mechanical event Pulmonary artery waveformPulmonary artery waveform PAWP waveform PAWP wa

16、veformAlways inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.Crit Care Med.Cardiac Output Index （CI）Case 5 Septic ShockO2 saturation 75%Left heart failureAligned with the end of the QRSFluid challnge2 PAC监测将改变治疗策略Vasodilators预测准确性：PAWP 30%；Aorti

17、c valve regurgitationCases Discussion前负荷下降：出血Case 2 DiureticO2 saturation 75%CI CO / BSASV = CO / HR68的医生所具有的知识不能满足PAC使用Controversy on PACWhat Elevates PA pressure?PAWP waveformAlways inflate the balloon befEKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial (LA) systole awa

18、ve LA diastole xdescent T-P interval LA filling/mitral valve closedvwave LA emptying at opening of mitral valve/onset of left ventricle diastoleydescent EKG-PAWPEKG Mechanical eventPAWP waveformPAWP waveformECG - CVP - PAWPECG - CVP - PAWP How do u know u r in Zone 3？Catheter should be below the lef

19、t atrium on CRXIf there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3If PAD PAWP then you are likely not in Zone 3 How do u know u r in Zone 3？CRapid Flush Test（方波试验）Rapid Flush Test（方波试验） Phlebostatic Axis Phlebostatic AxisPAC并发症、可能原因、预防及处理PAC并发症、可能原因、预防及处理PAC并发症、

20、可能原因、预防及处理PAC并发症、可能原因、预防及处理ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationContentsIntroductionPAC Place Hemodynamic values of normal adults Hemodynamic values of normHemodynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCardiac outputPressureSvO2Hemodyna

21、mic MonitoringRAP(CVP) 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/min Cardiac Output （CO）Cardiac 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Cardiac Output Index （CI） CI 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

22、值：30-65ml/m2/beat每搏量 (SV) 与 每搏量指数(SVI)SV定义：每次心跳What Elevates the Right Atrial Pressure?RV infarctPulmonary hypertensionPulmonary stenosisLeft to right shuntTricuspid valvular diseaseLeft heart failureWhat Elevates the Right AtrialProminent RA pulsationsProminent a wave: Tricuspid stenosisCannon a wa

23、ve: AV dissociation Ventricular tachycardiaProminent v wave: Tricuspid regurgitation or VSDProminent RA pulsationsPromineWhat Increases RV Pressures?RV failurePulmonary hypertensionPulmonary stenosisPulmonary EmbolismCardiomyopathyCardiac tamponadeCardiac constrictionWhat Increases RV Pressures?RVWh

24、at Elevates PA pressure?Volume Overload (backflow)Primary lung diseasePrimary pulmonary hypertensionPulmonary EmbolismLeft to right shuntMitral Valve DiseaseWhat Elevates PA pressure?Volu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 Preload用压力推测心室舒张末期容量的前提 PAC并发症、可能原因、预防及处理Compariso

25、n among PA catheter insertion sitesLeft atrial myxoma80*(MAP-RAP)/COVolume infusionsPulmonary stenosisControversy on PACHemodynamic Monitoring基于PAC参数的急性右心衰诊断Assessment of best PEEP for DO2Prominent RA pulsations每搏量 (SV) 与 每搏量指数(SVI)Correction of hypoxiaPulmonary emboliSystemic Vascular ResistancePro

26、staglandinsStatic markers of cardiac preload fail to predict volume responsivenessProminent a wave:Case 1 Fluid challengeGnaegi A et al (CCM1997)PAWP and LVEDP may be discordantConditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus Conditions in

27、 which PAWP25 mmHg) LVEDPPAC并发症、可能原因、预防及处理PAWP and LVEDSystemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理Systemic and pulmonary vasculaSystemic Vascular ResistanceCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased b

28、lood viscosityCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor toneSystemic Vascular ResistanceCaPulmonary Vascular ResistanceCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsCauses of PVRVa

29、sodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）Pulmonary Vascular ResistanceCSvO2SvO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC Place肺动脉漂浮导管PAC课件肺动脉漂浮导管PAC课件肺动脉漂浮导管PAC课件PAC为何不能改善预后？问题何

30、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PAC为何不能改善预后？问12345不恰当的适应症PAC相关We still need PAC ？We still need PAC ？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数据选择了正确的治 疗方案，但仍有多

31、达35的医师选择了错误的治疗方案到底是谁的问题？Iberti et al (JAMA 199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.临床评价 VS 血流动力学103例PACCrit CareSV/SVI增加的原因：代偿；每搏量 (SV) 与 每搏量指数(SV

32、I)VasodilatorsFull name: Swan-Ganz Catheter基于PAC参数的常见危重病的诊断Case 1 Fluid challengeAlways inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.Controversy on PACRA systole应用未预计到的治疗 30%Tricuspid valvular disease每搏输出量（SV）/每搏指数（SVI）Diagnosis of left-to-ri

33、ght intracardiac shuntClinical use of the PAC（Therapy）CardiomyopathyConditions in which PAWPLVEDPInotropes ；VasodilatorsPAC on CRX（PA）1 单纯根据临床评价难以准确预测血流动力学指标ESWL ; urinary tract infectionsBenefit or Harm？SV/SVI增加的原因：代偿；Benefit or Harm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SVO2能否替代PAC？心输出量参数压力参数SVO2Conte

34、ntsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPAC PlacePAC要回答的四个问题PAC前负荷后负荷心功能氧平衡PAC要回答的四个问题PAC前负荷后负荷心功能氧平衡PAC参数整合：前负荷CVP（RAP） / PAWP Any given level of filling pressure: not reliable！ Static markers of cardiac preload

35、fail to predict volume responsivenessFluid challnge CVP 2-5 rule PAWP 3-7 rule CO / CI / SV 10%PAC参数整合：前负荷CVP（RAP） / PAWPPAC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 PVRPAC参数整合：后负荷左室射血的阻抗及外 周阻力后负荷右室射PAC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

36、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：心脏收缩力CO并不是心脏射血功能的可靠指标PAC参数整合：氧代谢PAC参数整合：氧代谢Oxygen Delivery: What are the components?Oxygen DeliveryDO2Cardiac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%Oxygen Delivery: What are thePAC目标指导性治疗A CI 4.5L/min/m2B D

37、O2600mL/min/m2C VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.PAC目标指导性治疗A CI 4.5L/min/m2B PAC目标指导性治疗Crit Care Med. 2002 Aug;30(8):1686-92CI 4.5L/min/m2DO2600mL/min/m2VO2170mL/min/m2PAWP 10%Prominent RA pulsationsDiagnosis of pericardial tamponadePhlebostatic AxisInflation should b

38、e slow and controlled (1 mL/s) and should not surpass the recommended volume (1.基于PAC参数的常见危重病的诊断Causes of SVR基于PAC参数的常见危重病的诊断基于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/FiO2DO2VO2基于PAC参数的急性右心衰诊断前负荷CVPPAWP正常后负荷基于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/FiO2DO2VO2基于PAC参数的急性左心衰诊断前负荷CVPPAWP后负荷PV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/FiO2DO2VO2基于PAC参数的感染性休克诊断前负荷CVPPAWP后负荷SV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VO2基于PAC参数的失血性休克诊断前负荷CVPPAWP后负荷SV基于PAC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/FiO