肺動脈漂浮導管PAC演示文稿

肺動脈漂浮導管PAC演示文稿當前第1頁\共有84頁\編于星期六\9點優(yōu)選肺動脈漂浮導管PAC當前第2頁\共有84頁\編于星期六\9點ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion當前第3頁\共有84頁\編于星期六\9點WhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

當前第4頁\共有84頁\編于星期六\9點ClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade當前第5頁\共有84頁\編于星期六\9點ClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO2當前第6頁\共有84頁\編于星期六\9點ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion當前第7頁\共有84頁\編于星期六\9點StructureofPAC當前第8頁\共有84頁\編于星期六\9點PAC當前第9頁\共有84頁\編于星期六\9點首選：右頸內靜脈當前第10頁\共有84頁\編于星期六\9點ComparisonamongPAcatheterinsertionsites當前第11頁\共有84頁\編于星期六\9點PACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh當前第12頁\共有84頁\編于星期六\9點PACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP當前第13頁\共有84頁\編于星期六\9點PAConCRX（PA）當前第14頁\共有84頁\編于星期六\9點Placementofthecatheter

當前第15頁\共有84頁\編于星期六\9點RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%當前第16頁\共有84頁\編于星期六\9點WaveformsofCVP

當前第17頁\共有84頁\編于星期六\9點EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent當前第18頁\共有84頁\編于星期六\9點RightAtrium當前第19頁\共有84頁\編于星期六\9點RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%當前第20頁\共有84頁\編于星期六\9點Pulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%當前第21頁\共有84頁\編于星期六\9點EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure當前第22頁\共有84頁\編于星期六\9點Pulmonaryarterywaveform

當前第23頁\共有84頁\編于星期六\9點PAWPwaveform當前第24頁\共有84頁\編于星期六\9點PAWPwaveform當前第25頁\共有84頁\編于星期六\9點EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent當前第26頁\共有84頁\編于星期六\9點PAWPwaveform當前第27頁\共有84頁\編于星期六\9點ECG--CVP--PAWP當前第28頁\共有84頁\編于星期六\9點HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone3當前第29頁\共有84頁\編于星期六\9點RapidFlushTest（方波試驗）當前第30頁\共有84頁\編于星期六\9點

PhlebostaticAxis當前第31頁\共有84頁\編于星期六\9點PAC并發(fā)癥、可能原因、預防及處理當前第32頁\共有84頁\編于星期六\9點PAC并發(fā)癥、可能原因、預防及處理當前第33頁\共有84頁\編于星期六\9點ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration當前第34頁\共有84頁\編于星期六\9點Hemodynamicvaluesofnormaladults當前第35頁\共有84頁\編于星期六\9點HemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO2當前第36頁\共有84頁\編于星期六\9點CardiacOutput（CO）定義：在1min內從心室射出的血液總量公式：CO=HRxSVCO=4~8L/min當前第37頁\共有84頁\編于星期六\9點CardiacOutputIndex（CI）

CI＝CO/BSA正常值:2.8–4.2L/min/m2CI更能體現(xiàn)患者的個體差異性當前第38頁\共有84頁\編于星期六\9點每搏量(SV)

與每搏量指數(shù)(SVI)SV定義：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當前第39頁\共有84頁\編于星期六\9點WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure當前第40頁\共有84頁\編于星期六\9點ProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD當前第41頁\共有84頁\編于星期六\9點WhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction當前第42頁\共有84頁\編于星期六\9點WhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease當前第43頁\共有84頁\編于星期六\9點用壓力推測心室舒張末期容量的前提

導管位置無二尖瓣心室順應性正確疾病正常

PAWP~LAP~LVEDP~LVEDV~Preload當前第44頁\共有84頁\編于星期六\9點PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP當前第45頁\共有84頁\編于星期六\9點Systemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理當前第46頁\共有84頁\編于星期六\9點SystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone當前第47頁\共有84頁\編于星期六\9點PulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

當前第48頁\共有84頁\編于星期六\9點SvO2當前第49頁\共有84頁\編于星期六\9點ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion當前第50頁\共有84頁\編于星期六\9點當前第51頁\共有84頁\編于星期六\9點當前第52頁\共有84頁\編于星期六\9點當前第53頁\共有84頁\編于星期六\9點PAC為何不能改善預后？問題何在12345不恰當?shù)倪m應癥PAC相關的并發(fā)癥數(shù)據(jù)的可靠性不恰當?shù)闹委煍?shù)據(jù)解讀的準確性當前第54頁\共有84頁\編于星期六\9點WestillneedPAC？當前第55頁\共有84頁\編于星期六\9點到底是誰的問題？Ibertietal(JAMA1990)美國和加拿大13家醫(yī)院496MD47％的受試者對PAC不能作出正確回答GnaegiAetal

(CCM1997)134個ICU的535MD68％的醫(yī)生所具有的知識不能滿足PAC使用SquaraP

etal(Chest2002)僅有38％的醫(yī)生按照給出的PAC數(shù)據(jù)選擇了正確的治療方案，但仍有多達35％的醫(yī)師選擇了錯誤的治療方案當前第56頁\共有84頁\編于星期六\9點臨床評價VS血流動力學103例PAC醫(yī)生在置管前對血流動力學指標的范圍及治療方案進行預測預測準確性：PAWP30%；COSVRRAP50%留置PAC后：治療計劃需要重新修正58%

應用未預計到的治療30%結論：

1單純根據(jù)臨床評價難以準確預測血流動力學指標2PAC監(jiān)測將改變治療策略CritCareMed.1984Jul;12(7):549-53.當前第57頁\共有84頁\編于星期六\9點BenefitorHarm？當前第58頁\共有84頁\編于星期六\9點能否替代PAC？可以替代心輸出量參數(shù)不可替代壓力參數(shù)SCVO2近似替代SVO2當前第59頁\共有84頁\編于星期六\9點ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion當前第60頁\共有84頁\編于星期六\9點PAC要回答的四個問題PAC前負荷后負荷心功能氧平衡當前第61頁\共有84頁\編于星期六\9點PAC參數(shù)整合：前負荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%當前第62頁\共有84頁\編于星期六\9點PAC參數(shù)整合：后負荷左室射血的阻抗及外周阻力SAPMAPSVR后負荷右室射血的阻抗及外周阻力PAPMPAPPVR當前第63頁\共有84頁\編于星期六\9點PAC參數(shù)整合：心臟收縮力CO并不是心臟射血功能的可靠指標每搏輸出量（SV）/每搏指數(shù)（SVI）SV/SVI增加的原因：代償；SVR下降SV/SVI降低的原因：前負荷下降：出血心肌收縮力下降：心功能不全（EF%）后負荷增加：SVR增加當前第64頁\共有84頁\編于星期六\9點PAC參數(shù)整合：氧代謝當前第65頁\共有84頁\編于星期六\9點OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%當前第66頁\共有84頁\編于星期六\9點PAC目標指導性治療ACI>4.5L/min/m2B

DO2>600mL/min/m2C

VO2>170mL/min/m2Shoemaker

WCetal.Chest.1988Dec;94(6):1176-86.當前第67頁\共有84頁\編于星期六\9點PAC目標指導性治療CritCareMed.2002Aug;30(8):1686-92CI>4.5L/min/m2DO2>600mL/min/m2VO2>170mL/min/m2PAWP<18mmHg當前第68頁\共有84頁\編于星期六\9點基于PAC參數(shù)的常見危重病的診斷當前第69頁\共有84頁\編于星期六\9點基于PAC參數(shù)的急性右心衰診斷前負荷CVPPAWP正常后負荷MPAP正?；騇AP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO2當前第70頁\共有84頁\編于星期六\9點基于PAC參數(shù)的急性左心衰診斷前負荷CVPPAWP后負荷PVR/SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2當前第71頁\共有84頁\編于星期六\9點基于PAC參數(shù)的感染性休克診斷前負荷CVPPAWP后負荷SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO2當前第72頁\共有84頁\編于星期六\9點基于PAC參數(shù)的失血性休克診斷前負荷CVPPAWP后負荷SVRMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2正?；騐O2當前第73頁\共有84頁\編于星期六\9點基于PAC參數(shù)的急性肺栓塞診斷前負荷CVPPAWP后負荷MPAPMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO2當前第74頁\共有84頁\編于星期六\9點PAC病例當前第75頁\共有84頁\編于星期六\9點Case1Fluidchallenge當前第76頁\共有84頁\編于星期六\9點Case2Fluidchallenge當前第77頁\共有84頁\編于星期六\9點Case2Diuretic當前第78頁\共有84頁\編于