导管应用技巧与临床解读.ppt

Swan-Ganz,CatheterizationTechniques,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-tipflow-directedCatheter),并应用于临床。,SwanHJCandGanzW.Catheterizationoftheheartinmanwithuseofaflow-directedballoon-tippedcatheter.NEngJMed1970;283:447,Swan-Ganz导管,Swan-Ganz,Swan-GanzCatheter_CuiNa,2019-3-28,Swan-Ganz,CVP/ProximalInfusionLumenHub,PA/DistalLumenHub,BalloonInflationvalve,ThermistorConnector,Balloon,Thermistor,Backform,SVO2OpticalConnector,ThermocouplewireConnector,RA/ProximalInjectionLumenHub,Thermocouplewireonthesurfaceofthecatheter,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,2019-3-28,Swan-GanzCatheterCuiNa,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-GanzInsertion,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,2019-3-28,Swan-GanzCatheterCuiNa,测量,左心与右心,氧供与氧耗,实际测量的关键环节,“通畅”,FastFlushTest(SquarewaveTest),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,AssumptionsofTDCODeterminations,ForwardBloodFlowAdequateMixingofBloodandInjectateSteadypulmonaryarterybaselinetemperature,Swan-Ganz测量,IntermittentBolusThermodilution,Swan-Ganz测量,IntermittentCOMeasurementsTechnicalIssues,SmoothsteadyinjectionAppropriatevolumeofinjectateTimingofinjectateAveragingstrategyAppropriatecomputationconstant,Swan-Ganz测量,8amCO/CI6.0/3.04pmCO/CI3.6/1.8,Roominjectate.bagonmonitorandwarmerthanmeasuredinjectate,1degreeCRoomtemp=7.7%error1degreeCIcedtemp=2.7%error,Swan-Ganz测量,WhatisthecauseofthelowCO?,ContinuousCardiacOutput,Swan-Ganz测量,CCOModifiedSwan-GanzCatheter,Swan-Ganz测量,2019-3-28,Swan-GanzCatheterCuiNa,ContinuousCardiacOutput,Swan-Ganz测量,2019-3-28,Swan-GanzCatheterCuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2019-3-28,Swan-GanzCatheterCuiNa,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,OxygenExchange,OxygenDelivery,OxygenUtilization,Swan-Ganz数据解读,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,OxygenExchange,Swan-Ganz数据解读,Preload,Definition:Volumeofbloodintheventricleattheendofdiastole.,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,Contractility,Definition:TheinotropicstateofthemyocardiumThevelocityandtheextentofmyocardialfibershortening,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,Afterload,Definition:Pressureorresistanceventriclesmustovercometoejectbloodintothesystemicandpulmonarycirculations.,Howtoassess:,RVpulmonaryvascularresistance,LVsystemicvascularresistance,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,ClinicalMeasurementofAfterload,LeftVentricularAfterload(Systemicvascularresistance,SVR),RightVentricularAfterload(Pulmonaryvascularresistance,PVR),Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,Preload,Frank-StarlingCurve,Assumption,=Volume=Pressure,？,？,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,Compliance&Dynamics,TherelationshipbetweenpressureandvolumeisknownasCOMPLIANCE,Pressure,Complianceisnotastaticstatebutisdynamicandalwayschanging,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2019-3-28,Swan-GanzCatheterCuiNa,测量,左心与右心,氧供与氧耗,RV&LV,TricuspidValve,InferiorVenaCava,JoinedinaSeriesbythePulmonaryVasculature,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,Right&LeftVentricle,彼此独立，相互依赖共同目的，显著差异,RVVolumetricParameters,StrokevolumeEnddiastolicvolumeEndsystolicvolumeRVejectionfraction,Compensation,Interdependence,&,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,EndSystolicVolume(ESV),Definition:thevolumeofbloodremainingintheventricleattheendofsystoleNormalRVESV:50-100mlNormalRVESVI:30-60ml/m2,Definition:thepercentageofbloodintheventriclewitheachbeatNormalRVEF:40%-60%,EjectionFraction(EF),Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,EndDiastolicVolume(EDV),Definition:thevolumeofbloodintheventricleattheendofdiastoleNormalRVEDV:100-160mlNormalRVEDVI:60-100ml/m2,EDVisderivedfrom,Swan-Ganz数据解读,2019-3-28,Swan-GanzCatheterCuiNa,ContinuousEndDiastolicVolume,Swan-Ganz数据解读,临床应用技巧,Swan-Ganz,置管,监测数据解读,2019-3-28,Swan-GanzCatheterCuiNa,测量,左心与右心,氧供与氧耗,Swan-GanzCatheter_CuiNa,20vol%=20ml/dl,5L/minute,1000ml/min,250ml/min,750ml/min,SvO2=75%,Swan-Ganz数据解读,2019-3-28,Resuscitationtonormalvitalsignsmayleadtoocculthypoperfusion,Stroke2019:Whatis“adequateresuscitation”,Providetherapeuticgoalforresuscitation,NotfeasibleinearlyresuscitationWearetoooftenlatetoresuscitate,SvO2MonitoringrequiresPAcatheter,ScvO2easytomeasure,Combinevolumewithflowsurrogate,Swan-Ganz数据解读,ScvO2correlateswithSvO2inshockstates,Superiorvenacava,r=0.86Rightatrium,r=0.95,Feasibleintheearlysettings,Trendsmoreimportant.,Moreequalatlowersaturations(50%).,Swan-Ganz数据解读,HowdowescreenforhighriskpatientsintheICU?,AScreeningToolandNon-invasiveDetectionofGlobalTissueHypoxia,Swan-Ga