肺动脉漂浮导管_PAC

心脏填塞
导管尖造成穿孔
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 过度充气
在软化前轻送导管，用冰盐水 更换新导管 冲洗导管或插入导引钢丝
气囊破裂
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
PAC insertion
Right internal jugular vein
Shortest and straightest path to the heart
Left subclavian
Does not require the PAC to pass and course at an acute angle to enter the SVC
PAS: pulmonary artery systolic LVEDP: left ventricular end-diastolic pressure PAEDP: pulmonary artery end-diastolic pressure
Pulmonary artery waveform
• CI ＝ CO / BSA
• 正常值: 2.8 – 4.2 L/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)
Cardiac output
Pressure
SvO2
CO CI SV SVI
RAP(CVP) PAP PAWP
Cardiac Output （CO）
•定义： 在1min内从心室射 出的血液总量 •公式：CO = HR x SV •CO = 4~8 L/min
Cardiac Output Index （CI）
Differentiation among causes of shock Cardiogenic Hypovolemic Distributive (sepsis) Obstructive (massive pulmonary embolism) Differentiation of pulmonary edema Cardiogenic Noncardiogenic Evaluation of pulmonary hypertension Diagnosis of left-to-right intracardiac shunt Diagnosis of pericardial tamponade
LA filling/mitral valve closed
v wave
LA emptying at opening of mitral y descent valve/onset of left ventricle diastole
PAWP wavWP
肺动脉漂浮导管的应用
Contents
Introduction
PAC Placement Hemodynamic Monitoring Controversy on PAC Parameter integration Cases Discussion
What is Pulmonary Artery Catheter ?
PAC insertion
After inserting the PAC as far as the 20cm mark，the balloon is inflated with air. Inflation should be slow and controlled (1 mL/s) and should not surpass the recommended volume (1.5 mL). Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC. CRX：check the position of the PAC PA diastolic pressure ~ PAWP
How do u know u r in Zone 3？
Catheter should be below the left atrium on CRX If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3 If PAD> PAWP then you are likely not in Zone 3
用液体充盈气囊 回抽注射器主动放气
Contents
Introduction
PAC Placement
Hemodynamic Monitoring
Controversy on PAC Parameter integration
Hemodynamic values of normal adults
Hemodynamic Monitoring
Waveforms of CVP
EKG-RAP
EKG Mechanical event RAP
a wave x descent c wave v wave
80 – 100 milliseconds RA systole after P wave RA diastole After QRS After peak of T wave Tricuspid valve closure RA filling/tricuspid valve closed RA emptying at opening of tricuspid valve/onset of right ventricle diastole
Normal PA pressure, systolic 15-30 Normal PA pressure, diastolic 5-13 O2 content 15%（ml/dL) O2 saturation 75%
EKG-PAP
EKG Mechanical event
Right ventricle ejection of blood into pulmonary vasculature
Full name: Swan-Ganz Catheter
Used it to monitor a patient’s hemodynamics when we cant answer the question using noninvasive/clinical measures
Clinical use of the PAC （Diagnosis）
y descent
Right Atrium
Right ventricular waveform
RV systolic=17-30cmHg RV diastolic=0-6cmHg RV O2 content=15%（ml/dL) RV O2 saturation 75%
Pulmonary artery waveform
PAP
T wave
Systolic PAS 15 –30 mm Hg End-diastolic (PAEDP 8 – 12 mm Hg) Mean (9 – 18 mm Hg)
80 milliseconds Indirect indicator of after onset of LVEDP QRS
Contents
Introduction
PAC Placement
Hemodynamic Monitoring Controversy on PAC Parameter integration Cases Discussion
Structure of PAC
PAC
首选：右颈内静脉
Comparison among PA catheter insertion sites
Rapid Flush Test（方波试验）
Phlebostatic Axis
PAC并发症、可能原因、预防及处理
并发症 心律失常 可能原因 预防 处理 没有保护的导管尖在心内膜 前送导管时保持气囊充气，轻盈 必 要 时 使 用 利 多 卡 移动 前送 因，发生室颤立即 除颤 导管在右房或右室内形成多 射胸片 回撤导管消除多余 余环 环 操作导管太多，时间太长 血栓/栓塞 以最少的操作快速、轻柔插入导 管
Clinical use of the PAC（Therapy）
Management of perioperative patient with unstable cardiac status Management of complicated myocardial infarction Management of severe preeclampsia Guide to pharmacologic therapy Vasopressors； Inotropes ； Vasodilators Guide to nonpharmacologic therapy Fluid management ；Burns ； Renal failure ； Sepsis ； Heart failure ；Decompensated cirrhosis Ventilator management Assessment of best PEEP for DO2
导管周围纤维性管套形成形 使用肝素浸泡的导管 抗凝，可能时溶栓 成血栓 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 导管内血栓 冲洗一次 高危病人全身抗凝 导管阻塞肺动脉分支 保持导管尖位于主肺动脉 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