Dr.Feng肺動脈漂浮導管PAC2020-12-081肺動脈漂浮導管PAC（新課件）ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-082肺動脈漂浮導管PAC（新課件）WhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-083肺動脈漂浮導管PAC（新課件）ClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-084肺動脈漂浮導管PAC（新課件）ClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-085肺動脈漂浮導管PAC（新課件）ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-086肺動脈漂浮導管PAC（新課件）StructureofPAC2020-12-087肺動脈漂浮導管PAC（新課件）PAC2020-12-088肺動脈漂浮導管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動脈漂浮導管PAC（新課件）ComparisonamongPAcatheterinsertionsites2020-12-0810肺動脈漂浮導管PAC（新課件）PACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0811肺動脈漂浮導管PAC（新課件）PACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0812肺動脈漂浮導管PAC（新課件）PAConCRX（PA）2020-12-0813肺動脈漂浮導管PAC（新課件）Placementofthecatheter

2020-12-0814肺動脈漂浮導管PAC（新課件）RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-0815肺動脈漂浮導管PAC（新課件）WaveformsofCVP

2020-12-0816肺動脈漂浮導管PAC（新課件）EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-0817肺動脈漂浮導管PAC（新課件）RightAtrium2020-12-0818肺動脈漂浮導管PAC（新課件）RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-0819肺動脈漂浮導管PAC（新課件）Pulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-0820肺動脈漂浮導管PAC（新課件）EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-0821肺動脈漂浮導管PAC（新課件）Pulmonaryarterywaveform

2020-12-0822肺動脈漂浮導管PAC（新課件）PAWPwaveform2020-12-0823肺動脈漂浮導管PAC（新課件）PAWPwaveform2020-12-0824肺動脈漂浮導管PAC（新課件）EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-0825肺動脈漂浮導管PAC（新課件）PAWPwaveform2020-12-0826肺動脈漂浮導管PAC（新課件）ECG--CVP--PAWP2020-12-0827肺動脈漂浮導管PAC（新課件）HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-0828肺動脈漂浮導管PAC（新課件）RapidFlushTest（方波試驗）2020-12-0829肺動脈漂浮導管PAC（新課件）PhlebostaticAxis2020-12-0830肺動脈漂浮導管PAC（新課件）PAC并發(fā)癥、可能原因、預防及處理2020-12-0831肺動脈漂浮導管PAC（新課件）PAC并發(fā)癥、可能原因、預防及處理2020-12-0832肺動脈漂浮導管PAC（新課件）ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-0833肺動脈漂浮導管PAC（新課件）Hemodynamicvaluesofnormaladults2020-12-0834肺動脈漂浮導管PAC（新課件）HemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-0835肺動脈漂浮導管PAC（新課件）CardiacOutput（CO）定義：在1min內(nèi)從心室射出的血液總量公式：CO=HRxSVCO=4~8L/min2020-12-0836肺動脈漂浮導管PAC（新課件）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2020-12-0837肺動脈漂浮導管PAC（新課件）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/beat2020-12-0838肺動脈漂浮導管PAC（新課件）WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-0839肺動脈漂浮導管PAC（新課件）ProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-0840肺動脈漂浮導管PAC（新課件）WhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-0841肺動脈漂浮導管PAC（新課件）WhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-0842肺動脈漂浮導管PAC（新課件）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~Preload2020-12-0843肺動脈漂浮導管PAC（新課件）PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-0844肺動脈漂浮導管PAC（新課件）Systemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理2020-12-0845肺動脈漂浮導管PAC（新課件）SystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-0846肺動脈漂浮導管PAC（新課件）PulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-0847肺動脈漂浮導管PAC（新課件）SvO22020-12-0848肺動脈漂浮導管PAC（新課件）ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0849肺動脈漂浮導管PAC（新課件）2020-12-0850肺動脈漂浮導管PAC（新課件）2020-12-0851肺動脈漂浮導管PAC（新課件）2020-12-0852肺動脈漂浮導管PAC（新課件）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2020-12-0853肺動脈漂浮導管PAC（新課件）WestillneedPAC？2020-12-0854肺動脈漂浮導管PAC（新課件）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2020-12-0855肺動脈漂浮導管PAC（新課件）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):549-53.2020-12-0856肺動脈漂浮導管PAC（新課件）BenefitorHarm？2020-12-0857肺動脈漂浮導管PAC（新課件）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SVO22020-12-0858肺動脈漂浮導管PAC（新課件）ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0859肺動脈漂浮導管PAC（新課件）PAC要回答的四個問題PAC前負荷后負荷心功能氧平衡2020-12-0860肺動脈漂浮導管PAC（新課件）PAC參數(shù)整合：前負荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%2020-12-0861肺動脈漂浮導管PAC（新課件）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PAPMPAPPVR2020-12-0862肺動脈漂浮導管PAC（新課件）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2020-12-0863肺動脈漂浮導管PAC（新課件）PAC參數(shù)整合：氧代謝2020-12-0864肺動脈漂浮導管PAC（新課件）OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%2020-12-0865肺動脈漂浮導管PAC（新課件）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):1176-86.2020-12-0866肺動脈漂浮導管PAC（新課件）PAC目標指導性治療CritCareMed.2002Aug;30(8):1686-92CI>4.5L/min/m2DO2>600mL/min/m2VO2>170mL/min/m2PAWP<18mmHg2020-12-0867肺動脈漂浮導管PAC（新課件）基于PAC參數(shù)的常見危重病的診斷2020-12-0868肺動脈漂浮導管PAC（新課件）基于PAC參數(shù)的急性右心衰診斷前負荷CVPPAWP正常后負荷MPAP正常或MAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO22020-12-0869肺動脈漂浮導管PAC（新課件）基于PAC參數(shù)的急性左心衰診斷前負荷CVPPAWP后負荷PVR/SVRMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO22020-12-0870肺動脈漂浮導管PAC（新課件）基于PAC參數(shù)的感染性休克診斷前負荷CVPPAWP后負荷SVRMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO22020-12-0871肺動脈漂浮導管PAC（新課件）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正常或VO22020-12-0872肺動脈漂浮導管PAC（新課件）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/FiO2DO2VO22020-12-0873肺動脈漂浮導管PAC（新課件）PAC病例2020-12-0874肺動脈漂浮導管PAC（新課件）Case1Fluidchallenge2020-12-0875肺動脈漂浮導管PAC（新課件）Case2Fluidchallenge2020-12-0876肺動脈漂浮導管PAC（新課件）Case2Diuretic2020-12-0877肺動脈漂浮導管PAC（新課件）Case2Diuretic2020-12-0878肺動脈漂浮導管PAC（新課件）Case3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE:BP132/82HR11