肺动脉漂浮导管PAC演示文稿

肺动脉漂浮导管PAC演示文稿当前1页，总共84页。ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion当前2页，总共84页。WhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

当前3页，总共84页。ClinicaluseofthePAC（Diagnosis）DifferentiationamongcausesofshockCardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)DifferentiationofpulmonaryedemaCardiogenicNoncardiogenicEvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade当前4页，总共84页。ClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapyFluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagementAssessmentofbestPEEPforDO2当前5页，总共84页。ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion当前6页，总共84页。StructureofPAC当前7页，总共84页。PAC当前8页，总共84页。首选：右颈内静脉当前9页，总共84页。ComparisonamongPAcatheterinsertionsites当前10页，总共84页。PACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh当前11页，总共84页。PACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP当前12页，总共84页。PAConCRX（PA）当前13页，总共84页。Placementofthecatheter

当前14页，总共84页。RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%当前15页，总共84页。WaveformsofCVP

当前16页，总共84页。EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent当前17页，总共84页。RightAtrium当前18页，总共84页。RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%当前19页，总共84页。Pulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%当前20页，总共84页。EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure当前21页，总共84页。Pulmonaryarterywaveform

当前22页，总共84页。PAWPwaveform当前23页，总共84页。PAWPwaveform当前24页，总共84页。EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent当前25页，总共84页。PAWPwaveform当前26页，总共84页。ECG--CVP--PAWP当前27页，总共84页。HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone3当前28页，总共84页。RapidFlushTest（方波试验）当前29页，总共84页。

PhlebostaticAxis当前30页，总共84页。PAC并发症、可能原因、预防及处理当前31页，总共84页。PAC并发症、可能原因、预防及处理当前32页，总共84页。ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration当前33页，总共84页。Hemodynamicvaluesofnormaladults当前34页，总共84页。HemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO2当前35页，总共84页。CardiacOutput（CO）定义：在1min内从心室射出的血液总量公式：CO=HRxSVCO=4~8L/min当前36页，总共84页。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当前37页，总共84页。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当前38页，总共84页。WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure当前39页，总共84页。ProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD当前40页，总共84页。WhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction当前41页，总共84页。WhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease当前42页，总共84页。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当前43页，总共84页。PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP当前44页，总共84页。Systemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理当前45页，总共84页。SystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone当前46页，总共84页。PulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

当前47页，总共84页。SvO2当前48页，总共84页。ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion当前49页，总共84页。当前50页，总共84页。当前51页，总共84页。当前52页，总共84页。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当前53页，总共84页。WestillneedPAC？当前54页，总共84页。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当前55页，总共84页。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.当前56页，总共84页。BenefitorHarm？当前57页，总共84页。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SVO2当前58页，总共84页。ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion当前59页，总共84页。PAC要回答的四个问题PAC前负荷后负荷心功能氧平衡当前60页，总共84页。PAC参数整合：前负荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%当前61页，总共84页。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当前62页，总共84页。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增加当前63页，总共84页。PAC参数整合：氧代谢当前64页，总共84页。OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%当前65页，总共84页。PAC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.当前66页，总共84页。PAC目标指导性治疗CritCareMed.2002Aug;30(8):1686-92CI>4.5L/min/m2DO2>600mL/min/m2VO2>170mL/min/m2PAWP<18mmHg当前67页，总共84页。基于PAC参数的常见危重病的诊断当前68页，总共84页。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/FiO2DO2VO2当前69页，总共84页。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/FiO2DO2VO2当前70页，总共84页。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/FiO2DO2VO2当前71页，总共84页。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VO2当前72页，总共84页。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/FiO2DO2VO2当前73页，总共84页。PAC病例当前74页，总共84页。Case1Fluidchallenge当前75页，总共84页。Case2Fluidchallenge当前76页，总共84页。Case2Diuretic当前77页，总共84页。Case2Diuretic当前78页，总共84页。Case3Vasodilator