肺动脉漂浮导管课件

肺动脉漂浮导管PAC肺动脉漂浮导管PAC1优选肺动脉漂浮导管PAC优选肺动脉漂浮导管PAC2ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPACPlace3 What is Pulmonary Artery Catheter?vFull name:Swan-Ganz CathetervUsed it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clinical measures WhatisPulmonaryArtery4Clinical 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 left-to-right intracardiac shunt vDiagnosis of pericardial tamponade ClinicaluseofthePAC（Diagn5Clinical 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；Inotropes；VasodilatorsvGuide to nonpharmacologic therapy Fluid management；Burns ；Renal failure；Sepsis；Heart failure；Decompensated cirrhosis vVentilator management Assessment of best PEEP for DO2ClinicaluseofthePAC（Therap6ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPACPlace7Structure of PACStructureofPAC8PACPAC9首选：右颈内静脉首选：右颈内静脉首选：右颈内静脉10VasodilatortherapyPACwasinserted.SV=CO/HRCRXshoweddiffusebilateralinfiltrates.应用未预计到的治疗30%AlignedwiththeendoftheQRSLeftatrial(LA)systoleLeftheartfailureComparisonamongPAcatheterinsertionsitesHemodynamicvaluesofnormaladultsCase1FluidchallengeDistributive(sepsis)CongenitalheartdefectsPAWPandLVEDPmaybediscordantPACwasinserted.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Comparison among PA catheter insertion sitesVasodilatortherapyComparison11PAC insertion vRightinternaljugularveinShortestandstraightestpathtotheheartvLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCvFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishighPACinsertionRightinternalj12PAC insertionvAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.vInflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).vAlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.vCRX：checkthepositionofthePACvPAdiastolicpressurePAWPPACinsertionAfterinsertingt13PAC on CRX（PA）PAConCRX（PA）14Placement of the catheterPlacementofthecatheter15Right Atrium20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%RightAtrium20cm16HemodynamicMonitoringControversyonPACLAfilling/mitralvalveclosedHemodynamicMonitoringConditionsinwhichPAWPLVEDP应用未预计到的治疗30%Usedittomonitorapatientshemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasuresHemodynamicMonitoringGnaegiAetal(CCM1997)VentilatormanagementCongenitalheartdefectsHypothermiaHeartfailure；startedonmezlocillinandgentamicin.VO2170mL/min/m2IntroductionCICO/BSA公式：CO=HRxSV预测准确性：PAWP30%；Waveforms of CVPHemodynamicMonitoringWaveform17EKG-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 tricuspid valve/onset of right ventricle diastole ydescent EKG-RAPEKGMechanicalevent18Right AtriumRightAtrium19 Right ventricular waveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%Rightventricularwavefor20 Pulmonary artery waveformNormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%Pulmonaryarterywavefor21EKG-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 ventricular end-diastolic pressurePAEDP:pulmonary artery end-diastolic pressureEKG-PAPEKGMechanicalevent22Pulmonary artery waveformPulmonaryarterywaveform23 PAWP waveformPAWPwaveform24AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.CritCareMed.CardiacOutputIndex（CI）Case5SepticShockO2saturation75%LeftheartfailureAlignedwiththeendoftheQRSFluidchallnge2PAC监测将改变治疗策略Vasodilators预测准确性：PAWP30%；AorticvalveregurgitationCasesDiscussion前负荷下降：出血Case2DiureticO2saturation75%CICO/BSASV=CO/HR68的医生所具有的知识不能满足PAC使用ControversyonPACWhatElevatesPApressure?PAWP waveformAlwaysinflatetheballoonbef25EKG-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 EKG-PAWPEKGMechanicalevent26PAWP waveformPAWPwaveform27ECG-CVP-PAWPECG-CVP-PAWP28 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 3HowdouknowurinZone3？C29Rapid Flush Test（方波试验）RapidFlushTest（方波试验）30 Phlebostatic AxisPhlebostaticAxis31PACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理PAC并发症、可能原因、预防及处理32PACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理PAC并发症、可能原因、预防及处理33ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationContentsIntroductionPACPlace34 Hemodynamic values of normal adultsHemodynamicvaluesofnorm35Hemodynamic MonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiac outputPressureSvO2HemodynamicMonitoringRAP(CVP)36CardiacOutput（CO）定义：在1min内从心室射 出的血液总量公式：CO=HR x SVCO=48 L/minCardiacOutput（CO）37Cardiac 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CardiacOutputIndex（CI）CI38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/beat每搏量(SV)与每搏量指数(SVI)SV定义：每次心跳39What Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTricuspid valvular diseasevLeft heart failureWhatElevatestheRightAtrial40Prominent RA pulsationsvProminent a wave:TricuspidstenosisvCannon a wave:AVdissociationVentriculartachycardiavProminent v wave:TricuspidregurgitationorVSDProminentRApulsationsPromine41What Increases RV Pressures?vRV failurevPulmonary hypertensionvPulmonary stenosisvPulmonary EmbolismvCardiomyopathyvCardiac tamponadevCardiac constrictionWhatIncreasesRVPressures?RV42What Elevates PA pressure?vVolume Overload(backflow)vPrimary lung diseasevPrimary pulmonary hypertensionvPulmonary EmbolismvLeft to right shuntvMitral Valve DiseaseWhatElevatesPApressure?Volu43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 PAWP LAP LVEDP LVEDV Preload用压力推测心室舒张末期容量的前提44PAC并发症、可能原因、预防及处理ComparisonamongPAcatheterinsertionsitesLeftatrialmyxoma80*(MAP-RAP)/COVolumeinfusionsPulmonarystenosisControversyonPACHemodynamicMonitoring基于PAC参数的急性右心衰诊断AssessmentofbestPEEPforDO2ProminentRApulsations每搏量(SV)与每搏量指数(SVI)CorrectionofhypoxiaPulmonaryemboliSystemicVascularResistanceProstaglandinsStaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessProminentawave:Case1FluidchallengeGnaegiAetal(CCM1997)PAWP and LVEDP may be discordantvConditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus vConditions in which PAWP25 mmHg)LVEDPPAC并发症、可能原因、预防及处理PAWPandLVED45Systemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理欧姆定理Systemicandpulmonaryvascula46Systemic Vascular ResistancevCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityvCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor toneSystemicVascularResistanceCa47Pulmonary Vascular ResistancevCauses of PVRHypoxiaPEEPPulmonary edemaPulmonary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsvCauses of PVRVasodilator therapyProstaglandinsCorrection of hypoxiaProstacyclin（依前列醇）PulmonaryVascularResistanceC48SvO2SvO249ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPACPlace50肺动脉漂浮导管课件51肺动脉漂浮导管课件52肺动脉漂浮导管课件53PAC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PAC为何不能改善预后？问12345不恰当的适应症PAC相关54We still need PAC？WestillneedPAC？55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到底是谁的问题？Ibertietal(JAMA19956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.临床评价VS血流动力学103例PACCritCare57SV/SVI增加的原因：代偿；每搏量(SV)与每搏量指数(SVI)VasodilatorsFullname:Swan-GanzCatheter基于PAC参数的常见危重病的诊断Case1FluidchallengeAlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.ControversyonPACRAsystole应用未预计到的治疗30%Tricuspidvalvulardisease每搏输出量（SV）/每搏指数（SVI）Diagnosisofleft-to-rightintracardiacshuntClinicaluseofthePAC（Therapy）CardiomyopathyConditionsinwhichPAWPLVEDPInotropes；VasodilatorsPAConCRX（PA）1单纯根据临床评价难以准确预测血流动力学指标ESWL;urinarytractinfectionsBenefit or Harm？SV/SVI增加的原因：代偿；BenefitorHarm58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SVO2能否替代PAC？心输出量参数压力参数SVO259ContentsPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionContentsIntroductionPACPlace60PAC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要回答的四个问题PAC前负荷后负荷心功能氧平衡61PAC参数整合：前负荷vCVP（RAP）/PAWP Any given level of filling pressure: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%PAC参数整合：前负荷CVP（RAP）/PAWP62PAC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：后负荷左室射血的阻抗及外周阻力后负荷右室射63PAC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：心脏收缩力CO并不是心脏射血功能的可靠指标64PAC参数整合：氧代谢PAC参数整合：氧代谢65Oxygen Delivery:What are the components?Oxygen DeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%OxygenDelivery:Whatarethe66PAC目标指导性治疗AACI4.5L/min/m2BBDO2600mL/min/m2C C VO2170mL/min/m2ShoemakerWCetal.Chest.1988Dec;94(6):1176-86.PAC目标指导性治疗ACI4.5L/min/m2B67PAC目标指导性治疗Crit Care Med.2002 Aug;30(8):1686-92vCI 4.5L/min/m2vDO2600mL/min/m2vVO2170mL/min/m2vPAWP10%ProminentRApulsationsDiagnosisofpericardialtamponadePhlebostaticAxisInflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.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CausesofSVR基于PAC参数的常见危重病的诊断69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/FiO2DO2VO2基于PAC参数的急性右心衰诊断前负荷CVPPAWP正常后负荷70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/SVR 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CVPPAWP后负荷PV71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/FiO2DO2VO2基于PAC参数的感染性休克诊断前负荷CVPPAWP后负荷SV72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VO2基于PAC参数的失血性休克诊断前负荷CVPPAWP后负荷SV73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/FiO2DO2VO2基于PAC参数的急性肺栓塞诊断前负荷CVPPAWP后负荷MP74PAC病例病例PAC病例75Case 1 Fluid challengeCase1Fluidchallenge76Case 2 Fluid challengeCase2Fluidchallenge77Case 2 Diuretic Case2Diuretic78Case 2 DiureticCase2Diuretic79Case3 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 admitted to the ICU and PAC was placed for optimization of cardiac statusvNitroprusside was titratedCase3VasodilatorTherapy71/80Case3 Vasodilator TherapyCase3VasodilatorTherapy81Case 4 Cardiac tonicCase4Cardiactonic82Case 4 Cardiac tonicCase4Cardiactonic83Case 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 vCRX: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 PEEPCase5SepticShock52/F84