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1、Swan-Ganz,Catheterization Techniques,北京协和医院 加强医疗科 崔娜,1967年加州大学洛杉矶分院Dr. Swan 由 顺着洋流飘回港湾的帆船，联想到带气囊 的心脏导管可以随血流在心脏内向前漂移。 1970年Swan与Ganz合作研制了顶端带气囊的血流导向肺动脉漂浮导管(Balloon-tip flow-directed Catheter), 并应用于临床。,Swan HJC and Ganz W. Catheterization of the heart in man with use of a flow-directed balloon-tipped c
2、atheter. N Eng J Med 1970; 283: 447,Swan-Ganz导管,Swan-Ganz,Swan-Ganz Catheter_CuiNa,2010-3-28,Swan-Ganz,CVP/Proximal Infusion Lumen Hub,PA/Distal Lumen Hub,Balloon Inflation valve,Thermistor Connector,Balloon,Thermistor,Backform,SVO2 Optical Connector,Thermocouple wire Connector,RA/Proximal Injection
3、 Lumen Hub,Thermocouple wire on the surface of the catheter,Bands,Swan-Ganz,PVC 聚氯乙烯材料,导管直径“French”,以不同颜色标示：,硬度“shore”,临床“触觉”及“扭结” 辐射透不过染料,X 光下可见,4F-红色/粉红； 5F-白色； 6F-蓝色； 7&8F-黄色,导管长度:成人一般为110cm ,儿科为60-75cm,Swan-Ganz,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,穿刺路径: 右
4、颈内静脉最为常用,注意事项： 床旁备有除颤器和利多卡因、肾上腺素等急救药品 可靠静脉通路；,Sedinger穿刺法 将导管鞘套在静脉扩张器外，通过导丝送入，退出导丝及静脉扩张器后即可通过导管鞘插入Swan-Ganz导管。 (成人7号，小儿5号）,无菌操作,Swan-Ganz 置管,准备好穿刺针、导丝、扩张器、外套管、Swan-Ganz导管、压力传感器及冲洗装置等,PAC外套上保护鞘，将肺动脉腔及CVP腔用盐水冲注，与标定好的换能器相连，注1.5ml气体检查气囊是否匀称,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置管,Swan-Ganz 置
5、管,Swan-Ganz Insertion,Swan-Ganz 置管,Swan-Ganz 置管,肺区的概念,3区,2区,1区,1区,2区,3区,Swan-Ganz 置管,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,实际测量的关键环节,“通畅”,Fast Flush Test (Square wave Test),Swan-Ganz 测量,“调零”,“衰减”,压力传感器隔膜前端液体平面 右心房水平,腋中线第四肋间隙,收缩压变低舒张压增高,Assumptions of TD CO Dete
6、rminations,Forward Blood Flow Adequate Mixing of Blood and Injectate Steady pulmonary artery baseline temperature,Swan-Ganz 测量,Intermittent Bolus Thermodilution,Swan-Ganz 测量,Intermittent CO Measurements Technical Issues,Smooth steady injection Appropriate volume of injectate Timing of injectate Aver
7、aging strategy Appropriate computation constant,Swan-Ganz 测量,8 am CO/CI 6.0 / 3.0 4 pm CO/CI 3.6 / 1.8,Room injectatebag on monitor and warmer than measured injectate,1 degree C Room temp = 7.7% error 1 degree C Iced temp = 2.7 % error,Swan-Ganz 测量,What is the cause of the low CO?,Continuous Cardiac
8、 Output,Swan-Ganz 测量,CCO Modified Swan-Ganz Catheter,Swan-Ganz 测量,2010-3-28,Swan-Ganz Catheter CuiNa,Continuous Cardiac Output,Swan-Ganz 测量,2010-3-28,Swan-Ganz Catheter CuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,适应症,绝对禁忌症 相对禁忌症,血流动力学监测的目的,评价并维持机体的氧供需平衡，避免组织缺氧,
9、协助诊断，确定高危人群 指导治疗，评估患者预后,Swan-Ganz 数据解读,Oxygen Exchange,Oxygen Delivery,Oxygen Utilization,Swan-Ganz 数据解读,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Oxygen Exchange,Swan-Ganz 数据解读,Preload,Definition: Volume of blood in the ventricle at the end of diastole.,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Ca
10、theter CuiNa,Contractility,Definition: The inotropic state of the myocardium The velocity and the extent of myocardial fiber shortening,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Afterload,Definition: Pressure or resistance ventricles must overcome to eject blood into the systemic and pulmona
11、ry circulations.,How to assess:,RV pulmonary vascular resistance,LV systemic vascular resistance,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Clinical Measurement of Afterload,Left Ventricular Afterload (Systemic vascular resistance, SVR),Right Ventricular Afterload(Pulmonary vascular resistanc
12、e, PVR),Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Preload,Frank-Starling Curve,Assumption,= Volume = Pressure,？,？,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Compliance & Dynamics,The relationship between pressure and volume is known as COMPLIANCE,Pressure,Compliance is not a static st
13、ate but is dynamic and always changing,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,测量,左心与右心,氧供与氧耗,RV & LV,Tricuspid Valve,Inferior Vena Cava,Joined in a Series by the Pulmonary Vasculature,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter
14、 CuiNa,Right & Left Ventricle,彼此独立，相互依赖 共同目的，显著差异,RV Volumetric Parameters,Stroke volume End diastolic volume End systolic volume RV ejection fraction,Compensation,Interdependence,&,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,End Systolic Volume (ESV),Definition: the volume of blood remaining
15、in the ventricle at the end of systole Normal RVESV: 50-100 ml Normal RVESVI: 30-60 ml/m2,Definition: the percentage of blood in the ventricle with each beat Normal RVEF: 40% - 60%,Ejection Fraction (EF),Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,End Diastolic Volume (EDV),Definition: the vol
16、ume of blood in the ventricle at the end of diastole Normal RVEDV: 100-160 ml Normal RVEDVI: 60-100 ml/m2,EDV is derived from,SV = CO 1000 EDV = SV HR EF,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Continuous End Diastolic Volume,Swan-Ganz 数据解读,临床应用技巧,Swan-Ganz,置管,监测数据解读,2010-3-28,Swan-Ganz Ca
17、theter CuiNa,测量,左心与右心,氧供与氧耗,Swan-Ganz Catheter_CuiNa,20 vol % = 20 ml/dl,5 L/minute,1000 ml/min,250 ml/min,750 ml/min,SvO2 = 75%,Swan-Ganz 数据解读,2010-3-28,Resuscitation to normal vital signs may lead to occult hypoperfusion,Stroke 2004: What is “adequate resuscitation”,Provide therapeutic goal for re
18、suscitation,Not feasible in early resuscitation We are too often late to resuscitate,SvO2 Monitoring requires PA catheter,ScvO2 easy to measure,Combine volume with flow surrogate,Swan-Ganz 数据解读,ScvO2 correlates with SvO2 in shock states,Superior vena cava, r = 0.86 Right atrium, r = 0.95,Feasible in
19、 the early settings,Trends more important.,More equal at lower saturations (50%).,Swan-Ganz 数据解读,How do we screen for high risk patients in the ICU?,A Screening Tool and Non-invasive Detection of Global Tissue Hypoxia,Swan-Ganz 数据解读,2010-3-28,Swan-Ganz 数据解读,“This study discusses and problems associated with its,inappropriate delays in applying interventions, and inappro-,use including inaccuracy of measurements and data interpr-,etation, inappropriately applied therapeutic interventions,priate patient selection”.,