肺动脉漂浮导管PAC(新课件)

Dr.Feng肺动脉漂浮导管PAC2020-12-081肺动脉漂浮导管PAC（新课件）Dr.Feng肺动脉漂浮导管PAC2020-12-081肺动ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-082肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-083肺动脉漂浮导管PAC（新课件）WhatisPulmonaryArteryClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-084肺动脉漂浮导管PAC（新课件）ClinicaluseofthePAC（DiagnClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-085肺动脉漂浮导管PAC（新课件）ClinicaluseofthePAC（TherapContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-086肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceStructureofPAC2020-12-087肺动脉漂浮导管PAC（新课件）StructureofPAC2020-12-087肺动脉PAC2020-12-088肺动脉漂浮导管PAC（新课件）PAC2020-12-088肺动脉漂浮导管PAC（新课件）首选：右颈内静脉2020-12-089肺动脉漂浮导管PAC（新课件）首选：右颈内静脉2020-12-089肺动脉漂浮导管PAC（ComparisonamongPAcatheterinsertionsites2020-12-0810肺动脉漂浮导管PAC（新课件）ComparisonamongPAcatheteriPACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0811肺动脉漂浮导管PAC（新课件）PACinsertionRightinternaljPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0812肺动脉漂浮导管PAC（新课件）PACinsertionAfterinsertingtPAConCRX（PA）2020-12-0813肺动脉漂浮导管PAC（新课件）PAConCRX（PA）2020-12-0813肺动脉漂Placementofthecatheter

2020-12-0814肺动脉漂浮导管PAC（新课件）Placementofthecatheter

2020RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-0815肺动脉漂浮导管PAC（新课件）RightAtrium>>20cm2020-12-081WaveformsofCVP

2020-12-0816肺动脉漂浮导管PAC（新课件）WaveformsofCVP

2020-12-081EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-0817肺动脉漂浮导管PAC（新课件）EKG-RAPEKGMechanicaleventRightAtrium2020-12-0818肺动脉漂浮导管PAC（新课件）RightAtrium2020-12-0818肺动脉漂浮导RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-0819肺动脉漂浮导管PAC（新课件）RightventricularwaveforPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-0820肺动脉漂浮导管PAC（新课件）PulmonaryarterywaveforEKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-0821肺动脉漂浮导管PAC（新课件）EKG-PAPEKGMechanicaleventPulmonaryarterywaveform

2020-12-0822肺动脉漂浮导管PAC（新课件）Pulmonaryarterywaveform

2020PAWPwaveform2020-12-0823肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0823肺动脉PAWPwaveform2020-12-0824肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0824肺动脉漂浮EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-0825肺动脉漂浮导管PAC（新课件）EKG-PAWPEKGMechanicaleventPAWPwaveform2020-12-0826肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0826肺动脉漂浮ECG--CVP--PAWP2020-12-0827肺动脉漂浮导管PAC（新课件）ECG--CVP--PAWP2020-12-0827HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-0828肺动脉漂浮导管PAC（新课件）HowdouknowurinZone3？CRapidFlushTest（方波试验）2020-12-0829肺动脉漂浮导管PAC（新课件）RapidFlushTest（方波试验）2020-12-PhlebostaticAxis2020-12-0830肺动脉漂浮导管PAC（新课件）PhlebostaticAxis2020-12-08PAC并发症、可能原因、预防及处理2020-12-0831肺动脉漂浮导管PAC（新课件）PAC并发症、可能原因、预防及处理2020-12-0831肺PAC并发症、可能原因、预防及处理2020-12-0832肺动脉漂浮导管PAC（新课件）PAC并发症、可能原因、预防及处理2020-12-0832肺ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-0833肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceHemodynamicvaluesofnormaladults2020-12-0834肺动脉漂浮导管PAC（新课件）HemodynamicvaluesofnormHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-0835肺动脉漂浮导管PAC（新课件）HemodynamicMonitoringRAP(CVP)CardiacOutput（CO）定义：在1min内从心室射出的血液总量公式：CO=HRxSVCO=4~8L/min2020-12-0836肺动脉漂浮导管PAC（新课件）CardiacOutput（CO）CardiacOutputIndex（CI）

CI＝CO/BSA正常值:2.8–4.2L/min/m2CI更能体现患者的个体差异性2020-12-0837肺动脉漂浮导管PAC（新课件）CardiacOutputIndex（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/HRSV正常值：50-110ml/beatSVI＝SV/BSASVI正常值：30-65ml/m2/beat2020-12-0838肺动脉漂浮导管PAC（新课件）每搏量(SV)与每搏量指数(SVI)SV定义：每次心跳WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-0839肺动脉漂浮导管PAC（新课件）WhatElevatestheRightAtrialProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-0840肺动脉漂浮导管PAC（新课件）ProminentRApulsationsPromineWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-0841肺动脉漂浮导管PAC（新课件）WhatIncreasesRVPressures?RVWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-0842肺动脉漂浮导管PAC（新课件）WhatElevatesPApressure?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~Preload2020-12-0843肺动脉漂浮导管PAC（新课件）用压力推测心室舒张末期容量的前提2020-1PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-0844肺动脉漂浮导管PAC（新课件）PAWPandLVEDPmaybediscordaSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理2020-12-0845肺动脉漂浮导管PAC（新课件）SystemicandpulmonaryvasculaSystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-0846肺动脉漂浮导管PAC（新课件）SystemicVascularResistanceCaPulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-0847肺动脉漂浮导管PAC（新课件）PulmonaryVascularResistanceCSvO22020-12-0848肺动脉漂浮导管PAC（新课件）SvO22020-12-0848肺动脉漂浮导管PAC（新课件ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0849肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlace2020-12-0850肺动脉漂浮导管PAC（新课件）2020-12-0850肺动脉漂浮导管PAC（新课件）2020-12-0851肺动脉漂浮导管PAC（新课件）2020-12-0851肺动脉漂浮导管PAC（新课件）2020-12-0852肺动脉漂浮导管PAC（新课件）2020-12-0852肺动脉漂浮导管PAC（新课件）PAC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2020-12-0853肺动脉漂浮导管PAC（新课件）PAC为何不能改善预后？问12345不恰当的适应症PAC相关WestillneedPAC？2020-12-0854肺动脉漂浮导管PAC（新课件）WestillneedPAC？2020-12-085到底是谁的问题？Ibertietal(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GnaegiAetal

(CCM1997)134个ICU的535MD68％的医生所具有的知识不能满足PAC使用SquaraP

etal(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2020-12-0855肺动脉漂浮导管PAC（新课件）到底是谁的问题？Ibertietal(JAMA199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：PAWP30%；COSVRRAP50%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2PAC监测将改变治疗策略CritCareMed.1984Jul;12(7):549-53.2020-12-0856肺动脉漂浮导管PAC（新课件）临床评价VS血流动力学103例PACCritCareBenefitorHarm？2020-12-0857肺动脉漂浮导管PAC（新课件）BenefitorHarm？2020-12-0857肺动能否替代PAC？可以替代心输出量参数不可替代压力参数SCVO2近似替代SVO22020-12-0858肺动脉漂浮导管PAC（新课件）能否替代PAC？心输出量参数压力参数SVO22020-12-ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0859肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlacePAC要回答的四个问题PAC前负荷后负荷心功能氧平衡2020-12-0860肺动脉漂浮导管PAC（新课件）PAC要回答的四个问题PAC前负荷后负荷心功能氧平衡2020PAC参数整合：前负荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%2020-12-0861肺动脉漂浮导管PAC（新课件）PAC参数整合：前负荷CVP（RAP）/PAWP2020PAC参数整合：后负荷左室射血的阻抗及外周阻力SAPMAPSVR后负荷右室射血的阻抗及外周阻力PAPMPAPPVR2020-12-0862肺动脉漂浮导管PAC（新课件）PAC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2020-12-0863肺动脉漂浮导管PAC（新课件）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2PAC参数整合：氧代谢2020-12-0864肺动脉漂浮导管PAC（新课件）PAC参数整合：氧代谢2020-12-0864肺动脉漂浮导管OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%2020-12-0865肺动脉漂浮导管PAC（新课件）OxygenDelivery:

WhatarethePAC目标指导性治疗ACI>4.5L/min/m2B

DO2>600mL/min/m2C

VO2>170mL/min/m2Shoemaker

WCetal.Chest.1988Dec;94(6):1176-86.2020-12-0866肺动脉漂浮导管PAC（新课件）PAC目标指导性治疗ACI>4.5L/min/m2BPAC目标指导性治疗CritCareMed.2002Aug;30(8):1686-92CI>4.5L/min/m2DO2>600mL/min/m2VO2>170mL/min/m2PAWP<18mmHg2020-12-0867肺动脉漂浮导管PAC（新课件）PAC目标指导性治疗CritCareMed.2002基于PAC参数的常见危重病的诊断2020-12-0868肺动脉漂浮导管PAC（新课件）基于PAC参数的常见危重病的诊断2020-12-0868肺动基于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/FiO2DO2VO22020-12-0869肺动脉漂浮导管PAC（新课件）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/SVRMAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO22020-12-0870肺动脉漂浮导管PAC（新课件）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SVRMAP正常或心脏HRSI氧代谢PaO2/FiO2DO2VO22020-12-0871肺动脉漂浮导管PAC（新课件）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SVRMAP正常或心脏HRSI氧代谢PaO2/FiO2DO2正常或VO22020-12-0872肺动脉漂浮导管PAC（新课件）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/FiO2DO2VO22020-12-0873肺动脉漂浮导管PAC（新课件）基于PAC参数的急性肺栓塞诊断前负荷CVPPAWP后负荷MPPAC病例2020-12-0874肺动脉漂浮导管PAC（新课件）PAC病例2020-12-0874肺动脉漂浮导管PAC（新课Case1Fluidchallenge2020-12-0875肺动脉漂浮导管PAC（新课件）Case1Fluidchallenge2020-Case2Fluidchallenge2020-12-0876肺动脉漂浮导管PAC（新课件）Case2Fluidchallenge2020-Case2Diuretic2020-12-0877肺动脉漂浮导管PAC（新课件）Case2Diuretic2020-12-0877肺Case2Diuretic2020-12-0878肺动脉漂浮导管PAC（新课件）Case2Diuretic2020-12-0878肺动Case3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE:BP132/82HR116R28.+2edemaofthelowerextremitiesLab:Na132Scr88ECG:anteriorleadS-TelevationsCRX:cardiomegalywithpulmonaryedemaThepatientwasadmittedtotheICUandPACwasplacedforoptimizationofcardiacstatusNitroprussidewastitrated2020-12-0879肺动脉漂浮导管PAC（新课件）Case3VasodilatorTherapy71/Case3VasodilatorTherapy2020-12-0880肺动脉漂浮导管PAC（新课件）Case3VasodilatorTherapy202Case4Cardiactonic2020-12-0881肺动脉漂浮导管PAC（新课件）Case4Cardiactonic2020-12-Case4Cardiactonic2020-12-0882肺动脉漂浮导管PAC（新课件）Case4Cardiactonic2020-12-08Case5SepticShock52/FESWL;urinarytractinfectionsBP100/45HR120RR40T39WBC13100,Na138,K5.1,Glu16,

scr180CRX:normal；EKG:sinustachycardia.UrineCultures；startedonmezlocillinandgentamicin.Onday2，SBPdroppedto70mmHg；ABG（Fi0260%）:pH7.38,PaO242,PaCO249Sa0275%.CRXshoweddiffusebilateralinfiltrates.TransferredtotheICU：volumeresuscitated,intubatedandstartedonintravenousinotropesandvasopressors.PACwasinserted.Thepatientremainedoliguric,uremicandthereforehemodialysiswasstarted.MVwasmaintainedwithhighFiO2andPEEP2020-12-0883肺动脉漂浮导管PAC（新课件）Case5SepticShock52/F2020-Case5SepticShock2020-12-0884肺动脉漂浮导管PAC（新课件）Case5SepticShock2020-12-0Dr.Feng2020-12-0885肺动脉漂浮导管PAC（新课件）Dr.Feng2020-12-0885肺动脉漂浮导管PAC（谢谢感谢您的聆听

您的关注使我们更努力此课件下载后可自行编辑修改关注我每天分享干货2020-12-0886肺动脉漂浮导管PAC（新课件）谢谢感谢您的聆听

您的关注使我们更努力此课件下载后可自行编辑Dr.Feng肺动脉漂浮导管PAC2020-12-0887肺动脉漂浮导管PAC（新课件）Dr.Feng肺动脉漂浮导管PAC2020-12-081肺动ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0888肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-0889肺动脉漂浮导管PAC（新课件）WhatisPulmonaryArteryClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-0890肺动脉漂浮导管PAC（新课件）ClinicaluseofthePAC（DiagnClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-0891肺动脉漂浮导管PAC（新课件）ClinicaluseofthePAC（TherapContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0892肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceStructureofPAC2020-12-0893肺动脉漂浮导管PAC（新课件）StructureofPAC2020-12-087肺动脉PAC2020-12-0894肺动脉漂浮导管PAC（新课件）PAC2020-12-088肺动脉漂浮导管PAC（新课件）首选：右颈内静脉2020-12-0895肺动脉漂浮导管PAC（新课件）首选：右颈内静脉2020-12-089肺动脉漂浮导管PAC（ComparisonamongPAcatheterinsertionsites2020-12-0896肺动脉漂浮导管PAC（新课件）ComparisonamongPAcatheteriPACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0897肺动脉漂浮导管PAC（新课件）PACinsertionRightinternaljPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0898肺动脉漂浮导管PAC（新课件）PACinsertionAfterinsertingtPAConCRX（PA）2020-12-0899肺动脉漂浮导管PAC（新课件）PAConCRX（PA）2020-12-0813肺动脉漂Placementofthecatheter

2020-12-08100肺动脉漂浮导管PAC（新课件）Placementofthecatheter

2020RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-08101肺动脉漂浮导管PAC（新课件）RightAtrium>>20cm2020-12-081WaveformsofCVP

2020-12-08102肺动脉漂浮导管PAC（新课件）WaveformsofCVP

2020-12-081EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-08103肺动脉漂浮导管PAC（新课件）EKG-RAPEKGMechanicaleventRightAtrium2020-12-08104肺动脉漂浮导管PAC（新课件）RightAtrium2020-12-0818肺动脉漂浮导RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-08105肺动脉漂浮导管PAC（新课件）RightventricularwaveforPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-08106肺动脉漂浮导管PAC（新课件）PulmonaryarterywaveforEKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-08107肺动脉漂浮导管PAC（新课件）EKG-PAPEKGMechanicaleventPulmonaryarterywaveform

2020-12-08108肺动脉漂浮导管PAC（新课件）Pulmonaryarterywaveform

2020PAWPwaveform2020-12-08109肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0823肺动脉PAWPwaveform2020-12-08110肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0824肺动脉漂浮EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-08111肺动脉漂浮导管PAC（新课件）EKG-PAWPEKGMechanicaleventPAWPwaveform2020-12-08112肺动脉漂浮导管PAC（新课件）PAWPwaveform2020-12-0826肺动脉漂浮ECG--CVP--PAWP2020-12-08113肺动脉漂浮导管PAC（新课件）ECG--CVP--PAWP2020-12-0827HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-08114肺动脉漂浮导管PAC（新课件）HowdouknowurinZone3？CRapidFlushTest（方波试验）2020-12-08115肺动脉漂浮导管PAC（新课件）RapidFlushTest（方波试验）2020-12-PhlebostaticAxis2020-12-08116肺动脉漂浮导管PAC（新课件）PhlebostaticAxis2020-12-08PAC并发症、可能原因、预防及处理2020-12-08117肺动脉漂浮导管PAC（新课件）PAC并发症、可能原因、预防及处理2020-12-0831肺PAC并发症、可能原因、预防及处理2020-12-08118肺动脉漂浮导管PAC（新课件）PAC并发症、可能原因、预防及处理2020-12-0832肺ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-08119肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlaceHemodynamicvaluesofnormaladults2020-12-08120肺动脉漂浮导管PAC（新课件）HemodynamicvaluesofnormHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-08121肺动脉漂浮导管PAC（新课件）HemodynamicMonitoringRAP(CVP)CardiacOutput（CO）定义：在1min内从心室射出的血液总量公式：CO=HRxSVCO=4~8L/min2020-12-08122肺动脉漂浮导管PAC（新课件）CardiacOutput（CO）CardiacOutputIndex（CI）

CI＝CO/BSA正常值:2.8–4.2L/min/m2CI更能体现患者的个体差异性2020-12-08123肺动脉漂浮导管PAC（新课件）CardiacOutputIndex（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/HRSV正常值：50-110ml/beatSVI＝SV/BSASVI正常值：30-65ml/m2/beat2020-12-08124肺动脉漂浮导管PAC（新课件）每搏量(SV)与每搏量指数(SVI)SV定义：每次心跳WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-08125肺动脉漂浮导管PAC（新课件）WhatElevatestheRightAtrialProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-08126肺动脉漂浮导管PAC（新课件）ProminentRApulsationsPromineWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-08127肺动脉漂浮导管PAC（新课件）WhatIncreasesRVPressures?RVWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-08128肺动脉漂浮导管PAC（新课件）WhatElevatesPApressure?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~Preload2020-12-08129肺动脉漂浮导管PAC（新课件）用压力推测心室舒张末期容量的前提2020-1PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-08130肺动脉漂浮导管PAC（新课件）PAWPandLVEDPmaybediscordaSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理2020-12-08131肺动脉漂浮导管PAC（新课件）SystemicandpulmonaryvasculaSystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-08132肺动脉漂浮导管PAC（新课件）SystemicVascularResistanceCaPulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-08133肺动脉漂浮导管PAC（新课件）PulmonaryVascularResistanceCSvO22020-12-08134肺动脉漂浮导管PAC（新课件）SvO22020-12-0848肺动脉漂浮导管PAC（新课件ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-08135肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlace2020-12-08136肺动脉漂浮导管PAC（新课件）2020-12-0850肺动脉漂浮导管PAC（新课件）2020-12-08137肺动脉漂浮导管PAC（新课件）2020-12-0851肺动脉漂浮导管PAC（新课件）2020-12-08138肺动脉漂浮导管PAC（新课件）2020-12-0852肺动脉漂浮导管PAC（新课件）PAC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2020-12-08139肺动脉漂浮导管PAC（新课件）PAC为何不能改善预后？问12345不恰当的适应症PAC相关WestillneedPAC？2020-12-08140肺动脉漂浮导管PAC（新课件）WestillneedPAC？2020-12-085到底是谁的问题？Ibertietal(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GnaegiAetal

(CCM1997)134个ICU的535MD68％的医生所具有的知识不能满足PAC使用SquaraP

etal(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2020-12-08141肺动脉漂浮导管PAC（新课件）到底是谁的问题？Ibertietal(JAMA199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：PAWP30%；COSVRRAP50%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2PAC监测将改变治疗策略CritCareMed.1984Jul;12(7):549-53.2020-12-08142肺动脉漂浮导管PAC（新课件）临床评价VS血流动力学103例PACCritCareBenefitorHarm？2020-12-08143肺动脉漂浮导管PAC（新课件）BenefitorHarm？2020-12-0857肺动能否替代PAC？可以替代心输出量参数不可替代压力参数SCVO2近似替代SVO22020-12-08144肺动脉漂浮导管PAC（新课件）能否替代PAC？心输出量参数压力参数SVO22020-12-ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-08145肺动脉漂浮导管PAC（新课件）ContentsIntroductionPACPlacePAC要回答的四个问题PAC前负荷后负荷心功能氧平衡2020-12-08146肺动脉漂浮导管PAC（新课件）PAC要回答的四个问题PAC前负荷后负荷心功能氧平衡2020PAC参数整合：前负荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluid