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血流动力学监测 Hemodynamic Monitoring

血流动力学监测 Hemodynamic Monitoring. 杨 毅 东南大学附属中大医院 ICU 东南大学急诊与危重病医学研究所. 定义 Definition. 循环系统 Circulation System 流体力学 Hydrodynamics 流量、阻力、压力 Flow ， Resistance ， Pressure 广义 Broad Definition 狭义 Narrow Definition. 历史 History. 1962 年 Wilson 床边中心静脉压监测 Bedside CVP monitoring

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血流动力学监测 Hemodynamic Monitoring

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  1. 血流动力学监测Hemodynamic Monitoring 杨 毅 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所

  2. 定义 Definition • 循环系统 Circulation System • 流体力学 Hydrodynamics • 流量、阻力、压力 Flow ，Resistance，Pressure • 广义 Broad Definition • 狭义Narrow Definition

  3. 历史 History • 1962年Wilson • 床边中心静脉压监测 Bedside CVP monitoring • 床旁有创血流动力学监测开端 Bedside invasive hemodynamic monitoring • 中心静脉压：估测右室舒张末压 CVP：estimate RVEDP • 左室舒张末期容积/压力? Left ventricular end-diastolic volume Left ventricular end-diastolic pressure

  4. 1970年 William Ganz (left) And H.J.C Swan (right)

  5. 评 价Evaluation • 心脏收缩性 cardiac contractility (CO,SV) • 心脏前负荷 cardiac preload (RVEDP/CVP，LVEDP/PAWP) • 心脏后负荷 cardiac afterload (PAP/PVR，BP/SVR) • 心脏搏功 cardiac stroke work (LVSW, RVSW)

  6. 心输出量测定－热稀释法measure CO－Thermodilution

  7. 血流动力学监测适应证与禁忌证Indications And Contraindications Of Hemodynamic Monitoring 适应证 Indications • 任何原因引起的 Any causes which lead to • 血流动力学不稳定 Hemodynamic Instability • 氧合功能改变 Indices of oxygenation • 或存在可能引起这些改变的危险因素 Risk factors

  8. 诊断应用 Diagnosis • 肺水肿的鉴别诊断 Estimate of pulmonary edema • 休克的鉴别诊断 Estimate of shock • 肺动脉高压 Pulmonary artery hypertension • 心包填塞 Pericardial tamponade • 急性二尖瓣关闭不全 Acute mitral incompetence • 右室梗塞 Right ventricular infarction; RVI

  9. 指导治疗 Treatment • 指导液体量的管理 Assessment of volume status • 调节肺水肿时的液体平衡 Fluid administration of pulmonary edema • 降低充血性心衰患者的前负荷 Cut down the preload of CHF • 维持少尿型肾衰患者液体平衡 Fluid administration of ARF • 指导休克治疗 Shock treatment • 指导血容量的调整和液体复苏 Fluid resuscitation • 调节正性肌力药和血管扩张药的剂量 Adjust the dosage of angiotonics and angiotenic • 监测组织的氧代谢 Monitoring oxygen metabolism • 机械通气时调节容量和正性肌力药 Volume administration and angiotonics during mechanical ventilation

  10. 禁忌证 Contraindications 无绝对禁忌证，下列情况应谨慎使用 No absolute contraindication，but hemodynamic monitoring should be undergone carefully in these conditions ①肝素过敏heparin-hypersensitive ②穿刺局部疑有感染或已有感染 infection at the site of puncturation ③严重出血性疾病，或溶栓和应用大剂量肝素抗凝 severe hemorrhagic disease or thrombolysis and the high-dose usage of heparin ④完全性左束支传导阻滞 complete left bundle branch block ⑤心脏及大血管内有附壁血栓 parietal thrombus in heart and great vessels

  11. 并发症 Complications • 插管相关 Catheter insertion 心律失常 dysrhythmia 导管打结 catheter knotting 肺动脉破裂 PA rupture • 留管相关： Catheter retention

  12. 压力监测及临床意义Pressure Monitoring and Clinical Significance

  13. 测压系统的准备Prepare for Pressure Monitoring System 压力监测系统包括 include ①导管和测压连接管 catheter and connection tube ②压力传感器 transducer ③冲洗装置 flush device ④压力监测仪 monitor

  14. 压力测定的条件Preparation of Pressure Monitoring (1)压力传感器的连接 Conjunction of pressure capsule (2)监护仪的设置 Installations of monitor (3)参照点的选择及调零 Reference point selection and zero setting (4)测压系统的阻尼检测 Amortization detection (5)测压系统的通畅及冲洗 System irrigation (6)导管准备 Catheters preparation

  15. 导管置入Catheter Insertion 置管途径Pathway到达右心房的距离Length to RA(cm) 颈内静脉internal jugular vein 15~20 锁骨下静脉subclavian vein 10~15 股静脉femoral vein 30~40 左或右贵要静脉basilic vein 40~50

  16. 导管插入过程 Insertion

  17. 压力波形检测Waveform readings

  18. PAP to PAWP tracing

  19. （五)正常压力波形Normal Waveform 1、心房压力波 Atrial pressure wave 2、心室压力波 Ventricular pressure wave 3、肺动脉压力波 Pulmonary artery pressure wave 4、肺动脉嵌顿压波 PAWP wave

  20. 压力监测的注意事项和波形分析Waveform readings 换能器及其相关因素Transducer and Correlated Factors • 调零 zero setting • 参考点 reference point • 换能器位置 site of transducer

  21. 压力传感器参考点的确定The Reference Point

  22. 换能器位置Site Of Transducer(10cmH2O=8mmHg)

  23. 操作因素Insertion

  24. 导管尖端的理想位置Ideal site Of cannulation

  25. 呼吸因素Respiratory Variation • 平静呼气末 end expiration in peaceful and quiet conditions呼吸肌肉处于充分舒张状态respiratory muscles relaxed thoroughly • 肺容积为FRC位 lung volume at FRC point • 呼气末PAWP最为准确 At the end of the expiration, PAWP is the most accurate

  26. 呼吸困难/用力呼吸对PAWP的影响The interference of dyspnea to PAWP Forced breathing Apply Muscle relaxant

  27. 呼吸困难患者PAWP的测定Measure PAWP In Patients With Dyspnea • 镇静或肌松后，测定呼气末的PAWP Calmed or muscle relaxed, PAWP at the end expiration • 测定平均PAWP，较呼气末的PAWP准确 Mean PAWP， accurater

  28. 血流动力学测量指标Hemodynamic parameters • 直接测量 Direct parameters • 间接测量 Indirect parameters

  29. 直接测量指标Direct parameters • 平均动脉压 mean arterial blood pressure (MAP) • 右房压 right atrial pressure (RAP) • 平均肺动脉压 mean pulmonary arterial pressure (PAP) • 肺动脉嵌顿压 pulmonary artery wedge pressure (PAWP) • 心排出量(CO) cardiac output (CO)

  30. 间接测量指标Indirect parameters • 心脏指数 CI=CO/BSA • 每搏输出量 SV=CO/HR • 每搏指数 SVI=SV/BSA • 体循环阻力 SVR=80(MAPCVP)/CO • 体循环阻力指数 SVRI=80(MAPCVP)/CI • 肺循环阻力 PVR=80(PAPPAWP)/CO • 肺循环阻力指数 PVRI=80(PAPPAWP)/CI • 左室每搏功指数 LVSWI=SVI(MAPPAWP) 0.0136 • 右室每搏功指数 RVSWI=SVI(PAPCVP) 0.0136

  31. 临床综合应用Clinical Applications • 心功能曲线 cardiac function curve • 心功能分区图 heart function zonation graph • 血流动力学“ABC”理论 “ABC” theory of hemodynamics

  32. 左心室功能曲线Left Ventricular Function Curve

  33. 心功能分区图Heart Function Zonation Graph

  34. 血流动力学ABC理论“ABC” Theory Of Hemodynamics

  35. 氧代谢监测Monitoring Of Oxygen Metabolism • 氧输送 Oxygen transportation(DO2) • 氧耗 Oxygen consumption(VO2) • 氧摄取率 Oxygen uptake(O2ER)

  36. Thank you for your attention!

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