导管应用技巧与临床解读.ppt

Swan-Ganz,Catheterization Techniques,北京协和医院 加强医疗科 崔娜,1967年加州大学洛杉矶分院Dr. Swan 由 顺着洋流飘回港湾的帆船，联想到带气囊 的心脏导管可以随血流在心脏内向前漂移。 1970年Swan与Ganz合作研制了顶端带气囊的血流导向肺动脉漂浮导管(Balloon-tip flow-directed Catheter), 并应用于临床。,Swan HJC and Ganz W. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Eng J Med 1970; 283: 447,Swan-Ganz导管,Swan-Ganz,Swan-Ganz Catheter_CuiNa,2010-3-28,Swan-Ganz,CVP/Proximal Infusion Lumen Hub,PA/Distal Lumen Hub,Balloon Inflation valve,Thermistor Connector,Balloon,Thermistor,Backform,SVO2 Optical Connector,Thermocouple wire Connector,RA/Proximal Injection Lumen Hub,Thermocouple wire on the surface of the catheter,Bands,Swan-Ganz,PVC 聚氯乙烯材料,导管直径“French”,以不同颜色标示：,硬度“shore”,临床“触觉”及“扭结” 辐射透不过染料,X 光下可见,4F-红色/粉红； 5F-白色； 6F-蓝色； 7&8F-黄色,导管长度:成人一般为110cm ,儿科为60-75cm,Swan-Ganz,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,穿刺路径: 右颈内静脉最为常用,注意事项： 床旁备有除颤器和利多卡因、肾上腺素等急救药品 可靠静脉通路；,Sedinger穿刺法 将导管鞘套在静脉扩张器外，通过导丝送入，退出导丝及静脉扩张器后即可通过导管鞘插入Swan-Ganz导管。 (成人7号，小儿5号）,无菌操作,Swan-Ganz 置管,准备好穿刺针、导丝、扩张器、外套管、Swan-Ganz导管、压力传感器及冲洗装置等,PAC外套上保护鞘，将肺动脉腔及CVP腔用盐水冲注，与标定好的换能器相连，注1.5ml气体检查气囊是否匀称,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz Insertion,Swan-Ganz 置管,Swan-Ganz 置管,肺区的概念,3区,2区,1区,1区,2区,3区,Swan-Ganz 置管,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,实际测量的关键环节,“通畅”,Fast Flush Test (Square wave Test),Swan-Ganz 测量,“调零”,“衰减”,压力传感器隔膜前端液体平面 右心房水平,腋中线第四肋间隙,收缩压变低舒张压增高,Assumptions of TD CO Determinations,Forward Blood Flow Adequate Mixing of Blood and Injectate Steady pulmonary artery baseline temperature,Swan-Ganz 测量,Intermittent Bolus Thermodilution,Swan-Ganz 测量,Intermittent CO Measurements Technical Issues,Smooth steady injection Appropriate volume of injectate Timing of injectate Averaging strategy Appropriate computation constant,Swan-Ganz 测量,8 am CO/CI 6.0 / 3.0 4 pm CO/CI 3.6 / 1.8,Room injectatebag on monitor and warmer than measured injectate,1 degree C Room temp = 7.7% error 1 degree C Iced temp = 2.7 % error,Swan-Ganz 测量,What is the cause of the low CO?,Continuous Cardiac Output,Swan-Ganz 测量,CCO Modified Swan-Ganz Catheter,Swan-Ganz 测量,2010-3-28,Swan-Ganz Catheter CuiNa,Continuous Cardiac Output,Swan-Ganz 测量,2010-3-28,Swan-Ganz Catheter CuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,适应症,绝对禁忌症 相对禁忌症,血流动力学监测的目的,评价并维持机体的氧供需平衡，避免组织缺氧,协助诊断，确定高危人群 指导治疗，评估患者预后,Swan-Ganz 数据解读,Oxygen Exchange,Oxygen Delivery,Oxygen Utilization,Swan-Ganz 数据解读,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Oxygen Exchange,Swan-Ganz 数据解读,Preload,Definition: Volume of blood in the ventricle at the end of diastole.,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Contractility,Definition: The inotropic state of the myocardium The velocity and the extent of myocardial fiber shortening,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Afterload,Definition: Pressure or resistance ventricles must overcome to eject blood into the systemic and pulmonary circulations.,How to assess:,RV pulmonary vascular resistance,LV systemic vascular resistance,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Clinical Measurement of Afterload,Left Ventricular Afterload (Systemic vascular resistance, SVR),Right Ventricular Afterload(Pulmonary vascular resistance, PVR),Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Preload,Frank-Starling Curve,Assumption,= Volume = Pressure,？,？,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Compliance & Dynamics,The relationship between pressure and volume is known as COMPLIANCE,Pressure,Compliance is not a static state but is dynamic and always changing,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,RV & LV,Tricuspid Valve,Inferior Vena Cava,Joined in a Series by the Pulmonary Vasculature,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Right & Left Ventricle,彼此独立，相互依赖 共同目的，显著差异,RV Volumetric Parameters,Stroke volume End diastolic volume End systolic volume RV ejection fraction,Compensation,Interdependence,&,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,End Systolic Volume (ESV),Definition: the volume of blood remaining in the ventricle at the end of systole Normal RVESV: 50-100 ml Normal RVESVI: 30-60 ml/m2,Definition: the percentage of blood in the ventricle with each beat Normal RVEF: 40% - 60%,Ejection Fraction (EF),Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,End Diastolic Volume (EDV),Definition: the volume of blood in the ventricle at the end of diastole Normal RVEDV: 100-160 ml Normal RVEDVI: 60-100 ml/m2,EDV is derived from,SV = CO 1000 EDV = SV HR EF,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Continuous End Diastolic Volume,Swan-Ganz 数据解读,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,Swan-Ganz Catheter_CuiNa,20 vol % = 20 ml/dl,5 L/minute,1000 ml/min,250 ml/min,750 ml/min,SvO2 = 75%,Swan-Ganz 数据解读,2010-3-28,Resuscitation to normal vital signs may lead to occult hypoperfusion,Stroke 2004: What is “adequate resuscitation”,Provide therapeutic goal for resuscitation,Not feasible in early resuscitation We are too often late to resuscitate,SvO2 Monitoring requires PA catheter,ScvO2 easy to measure,Combine volume with flow surrogate,Swan-Ganz 数据解读,ScvO2 correlates with SvO2 in shock states,Superior vena cava, r = 0.86 Right atrium, r = 0.95,Feasible in the early settings,Trends more important.,More equal at lower saturations (50%).,Swan-Ganz 数据解读,How do we screen for high risk patients in the ICU?,A Screening Tool and Non-invasive Detection of Global Tissue Hypoxia,Swan-G