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1、 肺动脉漂浮导管的应用肺动脉漂浮导管的应用 ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion What is Pulmonary Artery Catheter ?v Full name: Swan-Ganz Catheterv Used it to monitor a patients hemodynamics when we cant answer the question using noninvasive/cli
2、nical measures Clinical use of the PAC Diagnosis v Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) v Differentiation of pulmonary edema Cardiogenic Noncardiogenic v Evaluation of pulmonary hypertensionv Diagnosis of left-to
3、-right intracardiac shunt v Diagnosis of pericardial tamponade Clinical use of the PACTherapyv Management of perioperative patient with unstable cardiac status v Management of complicated myocardial infarction v Management of severe preeclampsia v Guide to pharmacologic therapy Vasopressors； Inotrop
4、es ； Vasodilatorsv Guide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis v Ventilator management Assessment of best PEEP for DO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases
5、DiscussionStructure of PACPAC首选：右颈内静脉首选：右颈内静脉Comparison among PA catheter insertion sitesPAC insertion vRight internal jugular vein Shortest and straightest path to the heartvLeft subclavian Does not require the PAC to pass and course at an acute angle to enter the SVC vFemoral veins Distant sites P
6、assing a PAC into the heart can be difficult Fluoroscopic assistance may be necessary Compressible and preferable if the risk of hemorrhage is highPAC insertionv After inserting the PAC as far as the 20cm mark，the balloon is inflated with air.v Inflation should be slow and controlled (1 mL/s) and sh
7、ould not surpass the recommended volume (1.5 mL). v Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC. v CRX：check the position of the PAC v PA diastolic pressure PAWP PAC on CRXPAPlacement of the catheter Right Atrium20 cmNormal right atri
8、al presssure is 0-6cmHg. Normal oxygen content 15%ml/dL)Normal O2 saturation 75%Waveforms of CVP EKG-RAPEKG Mechanical event RAP80 100 milliseconds after P wave RA systolea wave RA diastole x descent After QRS Tricuspid valve closure c wave After peak of T wave RA filling/tricuspid valve closed v wa
9、ve RA emptying at opening of tricuspid valve/onset of right ventricle diastole y descent Right Atrium Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%ml/dL)RV O2 saturation 75% Pulmonary artery waveform Normal PA pressure, systolic 15-30Normal PA pressure, diastol
10、ic 5-13O2 content 15%ml/dL)O2 saturation 75%EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolic PAS 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
11、systolicLVEDP: left ventricular end-diastolic pressurePAEDP: pulmonary artery end-diastolic pressurePulmonary artery waveform PAWP waveformPAWP waveformEKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial (LA) systole a wave LA diastole x descent T-P interval LA filling/mitra
12、l valve closedv wave LA emptying at opening of mitral valve/onset of left ventricle diastoley descent PAWP waveformECG - CVP - PAWP How do u know u r in Zone 3？v Catheter should be below the left atrium on CRXv If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3
13、v If PAD PAWP then you are likely not in Zone 3Rapid Flush Test方波试验 Phlebostatic AxisPACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理并发症可能原因预防处理心律失常没有保护的导管尖在心内膜移动导管在右房或右室内形成多余环操作导管太多，时间太长前送导管时保持气囊充气，轻盈前送射胸片以最少的操作快速、轻柔插入导管必要时使用利多卡因，发生室颤立即除颤回撤导管消除多余环血栓/栓塞导管周围纤维性管套形成形成血栓导管内血栓导管阻塞肺动脉分支使用肝素浸泡的导管使用带侧壁的套管滴注肝素肝素盐水持续冲洗，4-
14、6 小时手工冲洗一次高危病人全身抗凝保持导管尖位于主肺动脉抗凝，可能时溶栓肺梗塞/肺动脉破裂导管尖向远端移位（尤其在头 24 小时）导管嵌顿时间过长导管血栓栓塞导管放好后即刻或 24 小时后拍胸片，消除右房或右室内导管环持续监测肺动脉波形短期嵌顿（ 30 秒 ，用 PAEDP 代替 PAWP使用肝素浸泡过的导管，用肝素液适当冲洗回撤导管尖至肺动脉加强护理必要时手术修复PACPAC并发症、可能原因、预防及处理并发症、可能原因、预防及处理并发症可能原因预防处理感染插入导管、安装设备、取血标本或交换导管时感染严格无菌操作所有三通均套上无菌帽在导管上使用无菌袖套使用前检查换能器顶盖，不反复使用一次性顶
15、盖更换病人时消毒换能器除颤后更换换能器顶盖不要在换能器内使用 5%糖液或用之作冲洗液操作时间太长每 48 小时更换所有设备每天观察伤口并消毒减少导管放置时间每天在插管部位涂抹碘酊，加盖无菌敷料近早拔出导管（必要时 4 天更换一次）心脏填塞导管尖造成穿孔轻柔操作在气囊充气下送管预阻力决不能前送导管心包穿刺逆转肝素作用导管打圈或打结右房或右室扩大插管时间太长操作较多至导管变软使用小号（5F）导管在软化前轻送导管，用冰盐水冲洗导管或插入导引钢丝更换新导管气囊破裂过度充气用液体充盈气囊回抽注射器主动放气监测 PAEDP 而不是 PAWP减少嵌顿次数按导管注明的数量充盈气囊使用空气或 CO2 充盈气囊通
16、过撤走注射器让空气自动逸出气囊ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration Hemodynamic values of normal adultsHemodynamic MonitoringCO CI SV SVIRAP(CVP) PAP PAWPCardiac outputPressureSvO2 Cardiac Output CO定义： 在1min内从心室射 出的血液总量公式：CO = HR x SVCO = 48 L/minCardiac O
17、utput Index CI CI CO / BSA 正常值: 2.8 4.2 L/min/m2 CI更能表达患者的个体差异性每搏量每搏量 (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/beatWhat Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTricuspid v
18、alvular diseasevLeft heart failureProminent RA pulsationsvProminent a wave: Tricuspid stenosisvCannon a wave: AV dissociation Ventricular tachycardiavProminent v wave: Tricuspid regurgitation or VSDWhat Increases RV Pressures?vRV failurevPulmonary hypertensionvPulmonary stenosisvPulmonary EmbolismvC
19、ardiomyopathyvCardiac tamponadevCardiac constrictionWhat Elevates PA pressure?vVolume Overload (backflow)vPrimary lung diseasevPrimary pulmonary hypertensionvPulmonary EmbolismvLeft to right shuntvMitral Valve Disease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 L
20、AP LVEDP LVEDV PreloadPAWP and LVEDP may be discordantv Conditions in which PAWPLVEDP Mitral stenosis Mitral valve regurgitation Left atrial myxoma Pulmonary embolus v Conditions in which PAWP25 mmHg) LVEDPSystemic and pulmonary vascular resistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR欧姆定理欧姆定理
21、Systemic Vascular ResistancevCauses of SVRVolume infusionsHypovolemiaLow CO statesLV failureHypothermiaVasopressorsIncreased blood viscosityvCauses of SVRDiureticsSepsisVasodilatorsPeripheral vasodilationLoss of vasomotor tonePulmonary Vascular ResistancevCauses of PVRHypoxiaPEEPPulmonary edemaPulmo
22、nary hypertensionARDSPulmonary emboliValvular heart diseaseCongenital heart defectsvCauses of PVRvVasodilator therapyvProstaglandinsvCorrection of hypoxiavProstacyclin依前列醇SvO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionPAC为何不能改善预后？问
23、问题题何何在在12345不恰当的适应症不恰当的适应症PAC相关的并发症相关的并发症数据的可靠性数据的可靠性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We still need PAC ？到底是谁的问题？v Iberti et al (JAMA 1990)v 美国和加拿大13家医院 496MDv 47的受试者对PAC不能作出正确答复v Gnaegi A et al (CCM1997)v 134个ICU的535 MDv 68的医生所具有的知识不能满足PAC使用v Squara P et al (Chest 2002)v 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
24、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v 103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：v 治疗方案需要重新修正 58%v 应用未预计到的治疗 30%v 结论：v 1 单纯根据临床评价难以准确预测血流动力学指标v 2 PAC监测将改变治疗策略Crit Care Med. 1984 Jul;12(7):549-53.Benefit or Harm？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SVO2C
25、ontentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases DiscussionPAC要答复的四个问题PAC参数整合：前负荷v CVPRAP / PAWPv Any given level of filling pressure: not reliable！v Static markers of cardiac preload fail to predict volume responsivenessv Fluid challngev CVP 2-5 r
26、ule PAWP 3-7 rulev CO / CI / SV 10%PAC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：心脏收缩力v CO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SVIv SV/SVI增加的原因：代偿；SVR下降v SV/SVI降低的原因：v 前负荷下降：出血v 心肌收缩力下降：心功能不全EF%v 后负荷增加：SVR增加PAC参数整合：氧代谢Oxygen Delivery: What are the com
27、ponents?Oxygen DeliveryDO2Cardiac OutputHeart RateStroke VolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%PAC目标指导性治疗2 DO2600mL/min/m2 VO2170mL/min/m2Shoemaker WC et al. Chest. 1988 Dec;94(6):1176-86.PAC目标指导性治疗Crit Care Med. 2002 Aug;30(8):1686-92v2v DO2600mL/min/m2v VO2170mL/min/m2v
28、PAWP18mmHg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参数的失血性休克诊断前负荷前负荷CVPPAWP后负荷后负
29、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/FiO2DO2VO2PAC病例病例Case 1 Fluid challengeCase 2 Fluid challengeCase 2 Diuretic Case 2 DiureticCase3 Vasodilator Therapyv 71/Mv Anterior wall myocardial infarctionv PE: BP 132/82 HR 116 R 28. +2 ed
30、ema of the lower extremitiesv Lab: Na 132 Scr 88v ECG: anterior lead S-T elevations v CRX: cardiomegaly with pulmonary edemav The patient was admitted to the ICU and PAC was placed for optimization of cardiac statusv Nitroprusside was titratedCase3 Vasodilator TherapyCase 4 Cardiac tonicCase 4 Cardi
31、ac tonicCase 5 Septic Shockv 52/Fv ESWL ; urinary tract infectionsv BP 100/45 HR 120 RR 40 T 39v WBC 13100, Na 138, K 5.1, Glu 16, scr 180 v CRX : normal ； EKG : sinus tachycardia.v Urine Cultures ； started on mezlocillin and gentamicin.v On day2，SBP dropped to 70 mmHg ；v ABG Fi02 60%: pH 7.38, PaO2
32、 42, PaCO2 49 Sa02 75%.v CRX showed diffuse bilateral infiltrates. v Transferred to the ICU：volume resuscitated, intubated and started on intravenous inotropes and vasopressors. v PAC was inserted.v The patient remained oliguric, uremic and therefore hemodialysis was started. MV was maintained with high FiO2 and PEEPCase 5 Septic Shock
