肺动脉漂浮导管-PAC

肺动脉漂浮导管的应用ContentsIntroductionPACPlacementHemodynamicMonitoringControversyonPACParameterintegrationCasesDiscussionWhatisPulmonaryArteryCatheter?Fullname:Swan-GanzCatheterUsedittomonitorapatient’shemodynamicswhenwecantanswerthequestionusingnoninvasive/clinicalmeasuresClinicaluseofthePAC（Diagnosis）DifferentiationamongcausesofshockCardiogenicHypovolemicDistributive(sepsis)Obstructive(massivepulmonaryembolism)DifferentiationofpulmonaryedemaCardiogenicNoncardiogenicEvaluationofpulmonaryhypertensionDiagnosisofleft-to-rightintracardiacshuntDiagnosisofpericardialtamponadeClinicaluseofthePAC（Therapy）ManagementofperioperativepatientwithunstablecardiacstatusManagementofcomplicatedmyocardialinfarctionManagementofseverepreeclampsiaGuidetopharmacologictherapyVasopressors；Inotropes；VasodilatorsGuidetononpharmacologictherapyFluidmanagement；Burns；Renalfailure；Sepsis；Heartfailure；DecompensatedcirrhosisVentilatormanagementAssessmentofbestPEEPforDO2ContentsIntroductionPACPlacementHemodynamicMonitoringControversyonPACParameterintegrationCasesDiscussionStructureofPACPAC首选：右颈内静脉ComparisonamongPAcatheterinsertionsitesPACinsertionRightinternaljugularveinShortestandstraightestpathtotheheartLeftsubclavianDoesnotrequirethePACtopassandcourseatanacuteangletoentertheSVCFemoralveinsDistantsitesPassingaPACintotheheartcanbedifficultFluoroscopicassistancemaybenecessaryCompressibleandpreferableiftheriskofhemorrhageishighPACinsertionAfterinsertingthePACasfarasthe20cmmark，theballoonisinflatedwithair.Inflationshouldbeslowandcontrolled(1mL/s)andshouldnotsurpasstherecommendedvolume(1.5mL).AlwaysinflatetheballoonbeforeadvancingthePACandalwaysdeflatetheballoonbeforewithdrawingthePAC.CRX：checkthepositionofthePACPAdiastolicpressure~PAWPPAConCRX（PA）PlacementofthecatheterRightAtrium20cmNormalrightatrialpresssureis0-6cmHg.Normaloxygencontent15%（ml/dL)NormalO2saturation75%WaveformsofCVPEKG-RAPEKGMechanicaleventRAP80–100millisecondsafterPwaveRAsystoleawaveRAdiastolexdescentAfterQRSTricuspidvalveclosurecwaveAfterpeakofTwaveRAfilling/tricuspidvalveclosedvwaveRAemptyingatopeningoftricuspidvalve/onsetofrightventriclediastoleydescentRightAtriumRightventricularwaveformRVsystolic=17-30cmHgRVdiastolic=0-6cmHgRVO2content=15%（ml/dL)RVO2saturation75%PulmonaryarterywaveformNormalPApressure,systolic15-30NormalPApressure,diastolic5-13O2content15%（ml/dL)O2saturation75%EKG-PAPEKGMechanicaleventPAPTwaveRightventricleejectionofbloodintopulmonaryvasculatureSystolicPAS15–30mmHg80millisecondsafteronsetofQRSIndirectindicatorofLVEDPEnd-diastolic(PAEDP8–12mmHg)Mean(9–18mmHg)PAS:pulmonaryarterysystolicLVEDP:leftventricularend-diastolicpressurePAEDP:pulmonaryarteryend-diastolicpressurePulmonaryarterywaveformPAWPwaveformPAWPwaveformEKG-PAWPEKGMechanicaleventPAWPAlignedwiththeendoftheQRSLeftatrial(LA)systoleawaveLAdiastolexdescentT-PintervalLAfilling/mitralvalveclosedvwaveLAemptyingatopeningofmitralvalve/onsetofleftventriclediastoleydescentPAWPwaveformECG--CVP--PAWPHowdouknowurinZone3？CathetershouldbebelowtheleftatriumonCRXIfthereismarkedrespiratoryvairationinthePAWPtracingyouarelikelynotinZone3IfPADPAWPthenyouarelikelynotinZone3RapidFlushTest（方波试验）PhlebostaticAxisPAC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，4-6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PAC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充盈气囊通过撤走注射器让空气自动逸出气囊ContentsIntroductionPACPlacementHemodynamicMonitoringControversyonPACParameterintegrationHemodynamicvaluesofnormaladultsHemodynamicMonitoringCOCISVSVIRAP(CVP)PAPPAWPCardiacoutputPressureSvO2CardiacOutput（CO）•定义：在1min内从心室射出的血液总量•公式：CO=HRxSV•CO=4~8L/minCardiacOutputIndex（CI）•CI＝CO/BSA•正常值:2.8–4.2L/min/m2•CI更能体现患者的个体差异性每搏量(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/beatWhatElevatestheRightAtrialPressure?RVinfarctPulmonaryhypertensionPulmonarystenosisLefttorightshuntTricuspidvalvulardiseaseLeftheartfailureProminentRApulsationsProminentawave:TricuspidstenosisCannonawave:AVdissociationVentriculartachycardiaProminentvwave:TricuspidregurgitationorVSDWhatIncreasesRVPressures?RVfailurePulmonaryhypertensionPulmonarystenosisPulmonaryEmbolismCardiomyopathyCardiactamponadeCardiacconstrictionWhatElevatesPApressure?VolumeOverload(backflow)PrimarylungdiseasePrimarypulmonaryhypertensionPulmonaryEmbolismLefttorightshuntMitralValveDisease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