肺动脉漂浮导管PAC培训课程课件.ppt
- 【下载声明】
1. 本站全部试题类文档,若标题没写含答案,则无答案;标题注明含答案的文档,主观题也可能无答案。请谨慎下单,一旦售出,不予退换。
2. 本站全部PPT文档均不含视频和音频,PPT中出现的音频或视频标识(或文字)仅表示流程,实际无音频或视频文件。请谨慎下单,一旦售出,不予退换。
3. 本页资料《肺动脉漂浮导管PAC培训课程课件.ppt》由用户(晟晟文业)主动上传,其收益全归该用户。163文库仅提供信息存储空间,仅对该用户上传内容的表现方式做保护处理,对上传内容本身不做任何修改或编辑。 若此文所含内容侵犯了您的版权或隐私,请立即通知163文库(点击联系客服),我们立即给予删除!
4. 请根据预览情况,自愿下载本文。本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
5. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007及以上版本和PDF阅读器,压缩文件请下载最新的WinRAR软件解压。
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- 肺动脉 漂浮 导管 PAC 培训 课程 课件
- 资源描述:
-
1、肺动脉漂浮导管PAC优选肺动脉漂浮导管PACContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion What is Pulmonary Artery Catheter?v Full name:Swan-Ganz Catheterv Used it to monitor a patients hemodynamics when we cant answer the question using noninvasive/clini
2、cal measures Clinical use of the PAC(Diagnosis)v Differentiation among causes of shock Cardiogenic Hypovolemic Distributive(sepsis)Obstructive(massive pulmonary embolism)v Differentiation of pulmonary edema Cardiogenic Noncardiogenic v Evaluation of pulmonary hypertensionv Diagnosis of left-to-right
3、 intracardiac shunt v Diagnosis of pericardial tamponade Clinical use of the PAC(Therapy)v Management of perioperative patient with unstable cardiac status v Management of complicated myocardial infarction v Management of severe preeclampsia v Guide to pharmacologic therapy Vasopressors;Inotropes;Va
4、sodilatorsv Guide to nonpharmacologic therapy Fluid management;Burns ;Renal failure;Sepsis;Heart failure;Decompensated cirrhosis v Ventilator management Assessment of best PEEP for DO2ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integrationCases Discussion出的血液
5、总量VO2170mL/min/m2仅有38的医生按照给出的PAC数据选择了正确的治 疗方案,但仍有多达35的医师选择了错误的治疗方案每搏量(SV)与 每搏量指数(SVI)EKG:sinus tachycardia.Vasopressors;ABG(Fi02 60%):pH 7.应用未预计到的治疗 30%EKG:sinus tachycardia.Clinical use of the PAC(Therapy)Mechanical eventCases DiscussionPAWP600mL/min/m2Hemodynamic MonitoringLeft subclavian临床评价 VS 血
6、流动力学Cases DiscussionPAWP waveformDifferentiation of pulmonary edemaCases DiscussionCongenital heart defectsPAC insertionv After inserting the PAC as far as the 20cm mark,the balloon is inflated with air.v Inflation should be slow and controlled(1 mL/s)and should not surpass the recommended volume(1.
7、5 mL).v Always inflate the balloon before advancing the PAC and always deflate the balloon before withdrawing the PAC.v CRX:check the position of the PAC v PA diastolic pressure PAWP PAC on CRX(PA)Placement of the catheter Right Atrium20 cmNormal right atrial presssure is 0-6cmHg.Normal oxygen conte
8、nt 15%(ml/dL)Normal O2 saturation 75%Waveforms of CVP EKG-RAPEKG Mechanical event RAP80 100 milliseconds after P wave RA systolea wave RA diastole x descent After QRS Tricuspid valve closure c wave After peak of T wave RA filling/tricuspid valve closed v wave RA emptying at opening of tricuspid valv
9、e/onset of right ventricle diastole y descent Right Atrium Right ventricular waveformRV systolic=17-30cmHgRV diastolic=0-6cmHgRV O2 content=15%(ml/dL)RV O2 saturation 75%Pulmonary artery waveform Normal PA pressure,systolic 15-30Normal PA pressure,diastolic 5-13O2 content 15%(ml/dL)O2 saturation 75%
10、EKG-PAPEKG Mechanical event PAPT waveRight ventricle ejection of blood into pulmonary vasculatureSystolic PAS 15 30 mm Hg80 milliseconds after onset of QRS Indirect indicator of LVEDPEnd-diastolic(PAEDP 8 12 mm Hg)Mean(9 18 mm Hg)PAS:pulmonary artery systolicLVEDP:left ventricular end-diastolic pres
11、surePAEDP:pulmonary artery end-diastolic pressurePulmonary artery waveform PAWP waveformPAWP waveformEKG-PAWPEKG Mechanical event PAWPAligned with the end of the QRS Left atrial(LA)systole a wave LA diastole x descent T-P interval LA filling/mitral valve closedv wave LA emptying at opening of mitral
12、 valve/onset of left ventricle diastoley descent PAWP waveformECG-CVP-PAWP How do u know u r in Zone 3?v Catheter should be below the left atrium on CRXv If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3v If PAD PAWP then you are likely not in Zone 3Inflation
13、should be slow and controlled(1 mL/s)and should not surpass the recommended volume(1.Assessment of best PEEP for DO2If PAD PAWP then you are likely not in Zone 3Cases DiscussionLeft atrial(LA)systoleSV定义:每次心跳所射出的血液量PAC参数整合:氧代谢Mechanical eventCases DiscussionPulmonary EmbolismCauses of PVR治疗计划需要重新修正
14、58%Cases Discussion2 PAC监测将改变治疗策略On day2,SBP dropped to 70 mmHg;IntroductionPAP MPAP PVRO2 content 15%(ml/dL)Rapid Flush Test(方波试验)Phlebostatic AxisPACPAC并发症、可能原因、预防及处理并发症、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/
15、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PACPAC并发症、可能原因、预防及处理并发症、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
16、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
17、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ContentsIntroductionPAC Placement Hemodynamic MonitoringControversy on PAC Parameter integration Hemodynamic values of normal adultsHemodynamic MonitoringCO CI SV SVIRAP(CVP)PAP PAWPCardiac outputPressureSvO2 Cardiac Output(
18、CO)定义:在1min内从心室射 出的血液总量公式:CO=HR x SVCO=48 L/minCardiac Output Index(CI)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每搏量(SV)与与 每搏量指数每搏量指数(SVI)SV定义:每次心跳所射出的血液量SV=CO/HR SV正常值:50-110ml/beatSVISV/BSA SVI正常值:30-65ml/m2/beatManagement of complicated myocardial infarctionNormal right atrial presssure is
19、0-6cmHg.O2 saturation 75%Parameter integrationPAC要回答的四个问题End-diastolic(PAEDP 8 12 mm Hg)SV/SVI增加的原因:代偿;1984 Jul;12(7):549-53.Diagnosis of pericardial tamponadePAC insertionTransferred to the ICU:volume resuscitated,intubated and started on intravenous inotropes and vasopressors.Parameter integration
20、Prostacyclin(依前列醇)Transferred to the ICU:volume resuscitated,intubated and started on intravenous inotropes and vasopressors.基于PAC参数的失血性休克诊断PAC参数整合:后负荷Prominent RA pulsationsWhat Elevates the Right Atrial Pressure?vRV infarctvPulmonary hypertensionvPulmonary stenosisvLeft to right shuntvTricuspid va
展开阅读全文