Dr.Feng肺動(dòng)脈漂浮導(dǎo)管PAC2020-12-081肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Dr.Feng肺動(dòng)脈漂浮導(dǎo)管PAC2020-12-081肺動(dòng)ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-082肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-083肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatisPulmonaryArteryClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-084肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（DiagnClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-085肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（TherapContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-086肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceStructureofPAC2020-12-087肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）StructureofPAC2020-12-087肺動(dòng)脈PAC2020-12-088肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC2020-12-088肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動(dòng)脈漂浮導(dǎo)管PAC（ComparisonamongPAcatheterinsertionsites2020-12-0810肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ComparisonamongPAcatheteriPACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0811肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PACinsertionRightinternaljPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0812肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PACinsertionAfterinsertingtPAConCRX（PA）2020-12-0813肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAConCRX（PA）2020-12-0813肺動(dòng)脈漂Placementofthecatheter

2020-12-0814肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Placementofthecatheter

2020RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-0815肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightAtrium>>20cm2020-12-081WaveformsofCVP

2020-12-0816肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WaveformsofCVP

2020-12-081EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-0817肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-RAPEKGMechanicaleventRightAtrium2020-12-0818肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightAtrium2020-12-0818肺動(dòng)脈漂浮導(dǎo)RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-0819肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightventricularwaveforPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-0820肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PulmonaryarterywaveforEKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-0821肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-PAPEKGMechanicaleventPulmonaryarterywaveform

2020-12-0822肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Pulmonaryarterywaveform

2020PAWPwaveform2020-12-0823肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0823肺動(dòng)脈PAWPwaveform2020-12-0824肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0824肺動(dòng)脈漂浮EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-0825肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-PAWPEKGMechanicaleventPAWPwaveform2020-12-0826肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0826肺動(dòng)脈漂浮ECG--CVP--PAWP2020-12-0827肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ECG--CVP--PAWP2020-12-0827HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-0828肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HowdouknowurinZone3？CRapidFlushTest（方波試驗(yàn)）2020-12-0829肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RapidFlushTest（方波試驗(yàn)）2020-12-PhlebostaticAxis2020-12-0830肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PhlebostaticAxis2020-12-08PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0831肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0831肺PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0832肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0832肺ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-0833肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceHemodynamicvaluesofnormaladults2020-12-0834肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HemodynamicvaluesofnormHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-0835肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HemodynamicMonitoringRAP(CVP)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(dòng)脈漂浮導(dǎo)管PAC（新課件）CardiacOutput（CO）CardiacOutputIndex（CI）

CI＝CO/BSA正常值:2.8–4.2L/min/m2CI更能體現(xiàn)患者的個(gè)體差異性2020-12-0837肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）CardiacOutputIndex（CI）CI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(dòng)脈漂浮導(dǎo)管PAC（新課件）每搏量(SV)與每搏量指數(shù)(SVI)SV定義：每次心跳WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-0839肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatElevatestheRightAtrialProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-0840肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ProminentRApulsationsPromineWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-0841肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatIncreasesRVPressures?RVWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-0842肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatElevatesPApressure?Volu用壓力推測(cè)心室舒張末期容量的前提

導(dǎo)管位置無(wú)二尖瓣心室順應(yīng)性正確疾病正常

PAWP~LAP~LVEDP~LVEDV~Preload2020-12-0843肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）用壓力推測(cè)心室舒張末期容量的前提2020-1PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-0844肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPandLVEDPmaybediscordaSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理2020-12-0845肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SystemicandpulmonaryvasculaSystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-0846肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SystemicVascularResistanceCaPulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-0847肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PulmonaryVascularResistanceCSvO22020-12-0848肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SvO22020-12-0848肺動(dòng)脈漂浮導(dǎo)管PAC（新課件ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0849肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlace2020-12-0850肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0850肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0851肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0851肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0852肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0852肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問(wèn)題何在12345不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)的并發(fā)癥數(shù)據(jù)的可靠性不恰當(dāng)?shù)闹委煍?shù)據(jù)解讀的準(zhǔn)確性2020-12-0853肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問(wèn)12345不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)WestillneedPAC？2020-12-0854肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WestillneedPAC？2020-12-085到底是誰(shuí)的問(wèn)題？Ibertietal(JAMA1990)美國(guó)和加拿大13家醫(yī)院496MD47％的受試者對(duì)PAC不能作出正確回答GnaegiAetal

(CCM1997)134個(gè)ICU的535MD68％的醫(yī)生所具有的知識(shí)不能滿(mǎn)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(dá)35％的醫(yī)師選擇了錯(cuò)誤的治療方案2020-12-0855肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）到底是誰(shuí)的問(wèn)題？Ibertietal(JAMA199臨床評(píng)價(jià)VS血流動(dòng)力學(xué)103例PAC醫(yī)生在置管前對(duì)血流動(dòng)力學(xué)指標(biāo)的范圍及治療方案進(jìn)行預(yù)測(cè)預(yù)測(cè)準(zhǔn)確性：PAWP30%；COSVRRAP50%留置PAC后：治療計(jì)劃需要重新修正58%

應(yīng)用未預(yù)計(jì)到的治療30%結(jié)論：

1單純根據(jù)臨床評(píng)價(jià)難以準(zhǔn)確預(yù)測(cè)血流動(dòng)力學(xué)指標(biāo)2PAC監(jiān)測(cè)將改變治療策略CritCareMed.1984Jul;12(7):549-53.2020-12-0856肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）臨床評(píng)價(jià)VS血流動(dòng)力學(xué)103例PACCritCareBenefitorHarm？2020-12-0857肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）BenefitorHarm？2020-12-0857肺動(dòng)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(dòng)脈漂浮導(dǎo)管PAC（新課件）能否替代PAC？心輸出量參數(shù)壓力參數(shù)SVO22020-12-ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0859肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlacePAC要回答的四個(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020-12-0860肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC要回答的四個(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluidchallnge

CVP2-5rulePAWP3-7rule△CO/

△CI/△SV>10%2020-12-0861肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP2020PAC參數(shù)整合：后負(fù)荷左室射血的阻抗及外周阻力SAPMAPSVR后負(fù)荷右室射血的阻抗及外周阻力PAPMPAPPVR2020-12-0862肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：后負(fù)荷左室射血的阻抗及外周阻力后負(fù)荷右室射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(biāo)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(fù)荷下降：出血心肌收縮力下降：心功能不全（EF%）后負(fù)荷增加：SVR增加2020-12-0863肺動(dòng)脈漂浮導(dǎo)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(biāo)2PAC參數(shù)整合：氧代謝2020-12-0864肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC參數(shù)整合：氧代謝2020-12-0864肺動(dòng)脈漂浮導(dǎo)管OxygenDelivery:

Whatarethecomponents?OxygenDeliveryDO2CardiacOutputHeartRateStrokeVolumeCaO2PaO2SaO2HbPreloadAfterloadContractilityCVPPCWPPVRSVREF%2020-12-0865肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）OxygenDelivery:

WhatarethePAC目標(biāo)指導(dǎo)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(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC目標(biāo)指導(dǎo)性治療ACI>4.5L/min/m2BPAC目標(biāo)指導(dǎo)性治療CritCareMed.2002Aug;30(8):1686-92CI>4.5L/min/m2DO2>600mL/min/m2VO2>170mL/min/m2PAWP<18mmHg2020-12-0867肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC目標(biāo)指導(dǎo)性治療CritCareMed.2002基于PAC參數(shù)的常見(jiàn)危重病的診斷2020-12-0868肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的常見(jiàn)危重病的診斷2020-12-0868肺動(dòng)基于PAC參數(shù)的急性右心衰診斷前負(fù)荷CVPPAWP正常后負(fù)荷MPAP正常或MAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO22020-12-0869肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的急性右心衰診斷前負(fù)荷CVPPAWP正常后負(fù)荷基于PAC參數(shù)的急性左心衰診斷前負(fù)荷CVPPAWP后負(fù)荷PVR/SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO22020-12-0870肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的急性左心衰診斷前負(fù)荷CVPPAWP后負(fù)荷PV基于PAC參數(shù)的感染性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2VO22020-12-0871肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的感染性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SV基于PAC參數(shù)的失血性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SVRMAP正?；蛐呐KHRSI氧代謝PaO2/FiO2DO2正?；騐O22020-12-0872肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的失血性休克診斷前負(fù)荷CVPPAWP后負(fù)荷SV基于PAC參數(shù)的急性肺栓塞診斷前負(fù)荷CVPPAWP后負(fù)荷MPAPMAP正常或心臟HRSI氧代謝PaO2/FiO2DO2VO22020-12-0873肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）基于PAC參數(shù)的急性肺栓塞診斷前負(fù)荷CVPPAWP后負(fù)荷MPPAC病例2020-12-0874肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC病例2020-12-0874肺動(dòng)脈漂浮導(dǎo)管PAC（新課Case1Fluidchallenge2020-12-0875肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case1Fluidchallenge2020-Case2Fluidchallenge2020-12-0876肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case2Fluidchallenge2020-Case2Diuretic2020-12-0877肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case2Diuretic2020-12-0877肺Case2Diuretic2020-12-0878肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case2Diuretic2020-12-0878肺動(dòng)Case3VasodilatorTherapy71/MAnteriorwallmyocardialinfarctionPE:BP132/82HR116R28.+2edemaofthelowerextremitiesLab:Na132Scr88ECG:anteriorleadS-TelevationsCRX:cardiomegalywithpulmonaryedemaThepatientwasadmittedtotheICUandPACwasplacedforoptimizationofcardiacstatusNitroprussidewastitrated2020-12-0879肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case3VasodilatorTherapy71/Case3VasodilatorTherapy2020-12-0880肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case3VasodilatorTherapy202Case4Cardiactonic2020-12-0881肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case4Cardiactonic2020-12-Case4Cardiactonic2020-12-0882肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case4Cardiactonic2020-12-08Case5SepticShock52/FESWL;urinarytractinfectionsBP100/45HR120RR40T39WBC13100,Na138,K5.1,Glu16,

scr180CRX:normal；EKG:sinustachycardia.UrineCultures；startedonmezlocillinandgentamicin.Onday2，SBPdroppedto70mmHg；ABG（Fi0260%）:pH7.38,PaO242,PaCO249Sa0275%.CRXshoweddiffusebilateralinfiltrates.TransferredtotheICU：volumeresuscitated,intubatedandstartedonintravenousinotropesandvasopressors.PACwasinserted.Thepatientremainedoliguric,uremicandthereforehemodialysiswasstarted.MVwasmaintainedwithhighFiO2andPEEP2020-12-0883肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case5SepticShock52/F2020-Case5SepticShock2020-12-0884肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Case5SepticShock2020-12-0Dr.Feng2020-12-0885肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Dr.Feng2020-12-0885肺動(dòng)脈漂浮導(dǎo)管PAC（謝謝感謝您的聆聽(tīng)

您的關(guān)注使我們更努力此課件下載后可自行編輯修改關(guān)注我每天分享干貨2020-12-0886肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）謝謝感謝您的聆聽(tīng)

您的關(guān)注使我們更努力此課件下載后可自行編輯Dr.Feng肺動(dòng)脈漂浮導(dǎo)管PAC2020-12-0887肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Dr.Feng肺動(dòng)脈漂浮導(dǎo)管PAC2020-12-081肺動(dòng)ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0888肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasures

2020-12-0889肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatisPulmonaryArteryClinicaluseofthePAC（Diagnosis）Differentiationamongcausesofshock

CardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)

DifferentiationofpulmonaryedemaCardiogenicNoncardiogenic

EvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponade2020-12-0890肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（DiagnClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapy

Vasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapy

Fluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagement

AssessmentofbestPEEPforDO22020-12-0891肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ClinicaluseofthePAC（TherapContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-0892肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceStructureofPAC2020-12-0893肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）StructureofPAC2020-12-087肺動(dòng)脈PAC2020-12-0894肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC2020-12-088肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-0895肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）首選：右頸內(nèi)靜脈2020-12-089肺動(dòng)脈漂浮導(dǎo)管PAC（ComparisonamongPAcatheterinsertionsites2020-12-0896肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ComparisonamongPAcatheteriPACinsertionRightinternaljugularvein

ShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishigh2020-12-0897肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PACinsertionRightinternaljPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.

CRX：checkthepositionofthePACPAdiastolicpressure~PAWP2020-12-0898肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PACinsertionAfterinsertingtPAConCRX（PA）2020-12-0899肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAConCRX（PA）2020-12-0813肺動(dòng)脈漂Placementofthecatheter

2020-12-08100肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Placementofthecatheter

2020RightAtrium>>20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%2020-12-08101肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightAtrium>>20cm2020-12-081WaveformsofCVP

2020-12-08102肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WaveformsofCVP

2020-12-081EKG-RAPEKG

MechanicaleventRAP80–100millisecondsafterPwaveRAsystole

a

waveRAdiastolex

descentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedv

waveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastole

y

descent2020-12-08103肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-RAPEKGMechanicaleventRightAtrium2020-12-08104肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightAtrium2020-12-0818肺動(dòng)脈漂浮導(dǎo)RightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%2020-12-08105肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RightventricularwaveforPulmonaryarterywaveform

NormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%2020-12-08106肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PulmonaryarterywaveforEKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculature

Systolic

PAS15–30mmHg80millisecondsafteronsetofQRS

IndirectindicatorofLVEDP

End-diastolic

(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressure2020-12-08107肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-PAPEKGMechanicaleventPulmonaryarterywaveform

2020-12-08108肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）Pulmonaryarterywaveform

2020PAWPwaveform2020-12-08109肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0823肺動(dòng)脈PAWPwaveform2020-12-08110肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0824肺動(dòng)脈漂浮EKG-PAWPEKG

MechanicaleventPAWPAlignedwiththeendoftheQRS

Leftatrial(LA)systolea

waveLAdiastolex

descentT-PintervalLAfilling/mitralvalveclosedv

waveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoley

descent2020-12-08111肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）EKG-PAWPEKGMechanicaleventPAWPwaveform2020-12-08112肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPwaveform2020-12-0826肺動(dòng)脈漂浮ECG--CVP--PAWP2020-12-08113肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ECG--CVP--PAWP2020-12-0827HowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPAD>PAWPthenyouarelikelynotinZone32020-12-08114肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HowdouknowurinZone3？CRapidFlushTest（方波試驗(yàn)）2020-12-08115肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）RapidFlushTest（方波試驗(yàn)）2020-12-PhlebostaticAxis2020-12-08116肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PhlebostaticAxis2020-12-08PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-08117肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0831肺PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-08118肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC并發(fā)癥、可能原因、預(yù)防及處理2020-12-0832肺ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

Parameterintegration2020-12-08119肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlaceHemodynamicvaluesofnormaladults2020-12-08120肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HemodynamicvaluesofnormHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO22020-12-08121肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）HemodynamicMonitoringRAP(CVP)CardiacOutput（CO）定義：在1min內(nèi)從心室射出的血液總量公式：CO=HRxSVCO=4~8L/min2020-12-08122肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）CardiacOutput（CO）CardiacOutputIndex（CI）

CI＝CO/BSA正常值:2.8–4.2L/min/m2CI更能體現(xiàn)患者的個(gè)體差異性2020-12-08123肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）CardiacOutputIndex（CI）CI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/beat2020-12-08124肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）每搏量(SV)與每搏量指數(shù)(SVI)SV定義：每次心跳WhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailure2020-12-08125肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatElevatestheRightAtrialProminentRApulsationsProminentawave:

TricuspidstenosisCannonawave:

AVdissociation

VentriculartachycardiaProminentvwave:

TricuspidregurgitationorVSD2020-12-08126肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ProminentRApulsationsPromineWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstriction2020-12-08127肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatIncreasesRVPressures?RVWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease2020-12-08128肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WhatElevatesPApressure?Volu用壓力推測(cè)心室舒張末期容量的前提

導(dǎo)管位置無(wú)二尖瓣心室順應(yīng)性正確疾病正常

PAWP~LAP~LVEDP~LVEDV~Preload2020-12-08129肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）用壓力推測(cè)心室舒張末期容量的前提2020-1PAWPandLVEDPmaybediscordantConditionsinwhichPAWP>LVEDPMitralstenosisMitralvalveregurgitationLeftatrialmyxomaPulmonaryembolus

ConditionsinwhichPAWP<LVEDPDecreasedLVcomplianceAorticvalveregurgitationHigh(>25mmHg)LVEDP2020-12-08130肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAWPandLVEDPmaybediscordaSystemicandpulmonaryvascularresistance80*(MPAP-LAP)/肺血流量80*(MAP-RAP)/COR=U/IPVRSVR歐姆定理2020-12-08131肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SystemicandpulmonaryvasculaSystemicVascularResistanceCausesofSVRVolumeinfusionsHypovolemiaLowCOstatesLVfailureHypothermiaVasopressorsIncreasedbloodviscosityCausesofSVRDiureticsSepsisVasodilatorsPeripheralvasodilationLossofvasomotortone2020-12-08132肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SystemicVascularResistanceCaPulmonaryVascularResistanceCausesofPVRHypoxiaPEEPPulmonaryedemaPulmonaryhypertensionARDSPulmonaryemboliValvularheartdiseaseCongenitalheartdefectsCausesofPVRVasodilatortherapyProstaglandinsCorrectionofhypoxiaProstacyclin（依前列醇）

2020-12-08133肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PulmonaryVascularResistanceCSvO22020-12-08134肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）SvO22020-12-0848肺動(dòng)脈漂浮導(dǎo)管PAC（新課件ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-08135肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlace2020-12-08136肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0850肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-08137肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0851肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-08138肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）2020-12-0852肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問(wèn)題何在12345不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)的并發(fā)癥數(shù)據(jù)的可靠性不恰當(dāng)?shù)闹委煍?shù)據(jù)解讀的準(zhǔn)確性2020-12-08139肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC為何不能改善預(yù)后？問(wèn)12345不恰當(dāng)?shù)倪m應(yīng)癥PAC相關(guān)WestillneedPAC？2020-12-08140肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）WestillneedPAC？2020-12-085到底是誰(shuí)的問(wèn)題？Ibertietal(JAMA1990)美國(guó)和加拿大13家醫(yī)院496MD47％的受試者對(duì)PAC不能作出正確回答GnaegiAetal

(CCM1997)134個(gè)ICU的535MD68％的醫(yī)生所具有的知識(shí)不能滿(mǎn)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(dá)35％的醫(yī)師選擇了錯(cuò)誤的治療方案2020-12-08141肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）到底是誰(shuí)的問(wèn)題？Ibertietal(JAMA199臨床評(píng)價(jià)VS血流動(dòng)力學(xué)103例PAC醫(yī)生在置管前對(duì)血流動(dòng)力學(xué)指標(biāo)的范圍及治療方案進(jìn)行預(yù)測(cè)預(yù)測(cè)準(zhǔn)確性：PAWP30%；COSVRRAP50%留置PAC后：治療計(jì)劃需要重新修正58%

應(yīng)用未預(yù)計(jì)到的治療30%結(jié)論：

1單純根據(jù)臨床評(píng)價(jià)難以準(zhǔn)確預(yù)測(cè)血流動(dòng)力學(xué)指標(biāo)2PAC監(jiān)測(cè)將改變治療策略CritCareMed.1984Jul;12(7):549-53.2020-12-08142肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）臨床評(píng)價(jià)VS血流動(dòng)力學(xué)103例PACCritCareBenefitorHarm？2020-12-08143肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）BenefitorHarm？2020-12-0857肺動(dòng)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SVO22020-12-08144肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）能否替代PAC？心輸出量參數(shù)壓力參數(shù)SVO22020-12-ContentsIntroductionPACPlacement

HemodynamicMonitoringControversyonPAC

ParameterintegrationCasesDiscussion2020-12-08145肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）ContentsIntroductionPACPlacePAC要回答的四個(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020-12-08146肺動(dòng)脈漂浮導(dǎo)管PAC（新課件）PAC要回答的四個(gè)問(wèn)題PAC前負(fù)荷后負(fù)荷心功能氧平衡2020PAC參數(shù)整合：前負(fù)荷CVP（RAP）/PAWP

Anygivenleveloffillingpressure:notreliable！StaticmarkersofcardiacpreloadfailtopredictvolumeresponsivenessFluid