肺动脉漂浮导管_PAC

肺动脉漂浮导管的应用 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion WhatisPulmonaryArteryCatheter Fullname Swan GanzCatheterUsedittomonitorapatient shemodynamicswhenwecantanswerthequestionusingnoninvasive clinicalmeasures ClinicaluseofthePAC Diagnosis DifferentiationamongcausesofshockCardiogenicHypovolemicDistributive sepsis Obstructive massivepulmonaryembolism DifferentiationofpulmonaryedemaCardiogenicNoncardiogenicEvaluationofpulmonaryhypertensionDiagnosisofleft to rightintracardiacshuntDiagnosisofpericardialtamponade ClinicaluseofthePAC Therapy ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapyVasopressors Inotropes VasodilatorsGuidetononpharmacologictherapyFluidmanagement Burns Renalfailure Sepsis Heartfailure DecompensatedcirrhosisVentilatormanagementAssessmentofbestPEEPforDO2 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion StructureofPAC PAC 首选 右颈内静脉 ComparisonamongPAcatheterinsertionsites PACinsertion RightinternaljugularveinShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh PACinsertion AfterinsertingthePACasfarasthe20cmmark theballoonisinflatedwithair Inflationshouldbeslowandcontrolled 1mL s andshouldnotsurpasstherecommendedvolume 1 5mL AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC CRX checkthepositionofthePACPAdiastolicpressure PAWP PAConCRX PA Placementofthecatheter RightAtrium 20cmNormalrightatrialpresssureis0 6cmHg Normaloxygencontent15 ml dL NormalO2saturation75 WaveformsofCVP EKG RAP RightAtrium Rightventricularwaveform RVsystolic 17 30cmHgRVdiastolic 0 6cmHgRVO2content 15 ml dL RVO2saturation75 Pulmonaryarterywaveform NormalPApressure systolic15 30NormalPApressure diastolic5 13O2content15 ml dL O2saturation75 EKG PAP Pulmonaryarterywaveform PAWPwaveform PAWPwaveform EKG PAWP PAWPwaveform ECG CVP PAWP HowdouknowurinZone3 CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD PAWPthenyouarelikelynotinZone3 RapidFlushTest 方波试验 PhlebostaticAxis PAC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 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration Hemodynamicvaluesofnormaladults HemodynamicMonitoring COCISVSVI RAP CVP PAPPAWP Cardiacoutput Pressure SvO2 CardiacOutput CO 定义 在1min内从心室射出的血液总量公式 CO HRxSVCO 4 8L min 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 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 beat WhatElevatestheRightAtrialPressure RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure ProminentRApulsations Prominentawave TricuspidstenosisCannonawave AVdissociationVentriculartachycardiaProminentvwave TricuspidregurgitationorVSD WhatIncreasesRVPressures RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction WhatElevatesPApressure VolumeOverload backflow PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease 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 PAWPandLVEDPmaybediscordant ConditionsinwhichPAWP LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolusConditionsinwhichPAWP25mmHg LVEDP Systemicandpulmonaryvascularresistance 80 MPAP LAP 肺血流量 80 MAP RAP CO R U I PVR SVR 欧姆定理 SystemicVascularResistance Causesof SVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosity Causesof SVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone PulmonaryVascularResistance Causesof PVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefects Causesof PVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin 依前列醇 SvO2 Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion PAC为何不能改善预后 问题何在 1 2 3 4 5 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 WestillneedPAC 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SquaraPetal 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 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 BenefitorHarm 能否替代PAC Contents Introduction PACPlacement HemodynamicMonitoring ControversyonPAC Parameterintegration CasesDiscussion PAC要回答的四个问题 PAC参数整合 前负荷 CVP RAP PAWPAnygivenleveloffillingpressure notreliable StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallngeCVP2 5rulePAWP3 7rule CO CI SV 10 PAC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PAPMPAPPVR 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 PAC参数整合 氧代谢 OxygenDelivery Whatarethecomponents OxygenDeliveryDO2 CardiacOutput HeartRate StrokeVolume CaO2 PaO2 SaO2 Hb Preload Afterload Contractility CVPPCWP PVRSVR EF PAC目标指导性治疗 CI 4 5L min m2 DO2 600mL min m2 VO2 170mL min m2 ShoemakerWCetal Chest 1988Dec 94 6 1176 86 PAC目标指导性治疗 CritCareMed 2002Aug 30 8 1686 92 CI 4 5L min m2DO2 600mL min m2VO2 170mL min m2PAWP 18mmHg 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 基于PAC参数的急性左心衰诊断 基于PAC参数的感染性休克诊断 基于PAC参数的失血性休克诊断 基于PAC参数的急性肺栓塞诊断 PAC病例 Case1Fluidchallenge Case2Fluidchallenge Case2Diuretic Case2Diuretic Case3VasodilatorTherapy 71 MAnteriorwallmyocardialinfarctionPE BP132 82HR116R28 2edemaofthelowerextremitiesLab Na132Scr88ECG anteriorleadS TelevationsCRX cardiomegalywithpulmonaryedemaThepatientwa