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1、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 catheter.N Eng J Med 1970;283:447,Swan-Ganz导管,Swan-Ganz,Sw
2、an-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 Lumen Hub,Thermocouple wire on the surface of the catheter,
3、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
4、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
5、,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 Determinations,Forward Blood FlowAdequate Mixing of Blood and InjectateSt
6、eady pulmonary artery baseline temperature,Swan-Ganz 测量,Intermittent Bolus Thermodilution,Swan-Ganz 测量,Intermittent CO Measurements Technical Issues,Smooth steady injectionAppropriate volume of injectateTiming of injectateAveraging strategyAppropriate computation constant,Swan-Ganz 测量,8 am CO/CI 6.0
7、/3.04 pm CO/CI 3.6/1.8,Room injectate.bag on monitor and warmer than measured injectate,1 degree C Room temp=7.7%error1 degree C Iced temp=2.7%error,Swan-Ganz 测量,What is the cause of the low CO?,Continuous Cardiac Output,Swan-Ganz 测量,CCO Modified Swan-Ganz Catheter,Swan-Ganz 测量,2010-3-28,Swan-Ganz C
8、atheter 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,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
9、,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 Catheter CuiNa,Contractility,Definition:The inotropic state of the myocardium The velocity a
10、nd 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 pulmonary circulations.,How to assess:,RV pulmonary vascular resistance,LV systemic vascular resist
11、ance,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 resistance,PVR),Swan-Ganz 数据解读,2010-3-28,Swan-Ganz Catheter CuiNa,Preload,Frank-Starling Curve,Assumpti
12、on,=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 state 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
13、-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 CuiNa,Right&Left Ventricle,彼此独立，相互依赖共同目的，显著差异,RV Volumetric Parameters,Stroke volumeEnd diastolic vol
14、umeEnd systolic volumeRV 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 in the ventricle at the end of systoleNormal RVESV:50-100 mlNormal RVESVI:30-60 ml/m2,Definition:the percentag
15、e of blood in the ventricle with each beatNormal 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 volume of blood in the ventricle at the end of diastoleNormal RVEDV:100-160 mlNormal RVEDVI:60-100 ml/m2,EDV is derived from,
16、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 Catheter 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,Resus
17、citation to normal vital signs may lead to occult hypoperfusion,Stroke 2004:What is“adequate resuscitation”,Provide therapeutic goal for resuscitation,Not feasible in early resuscitationWe are too often late to resuscitate,SvO2 Monitoring requires PA catheter,ScvO2 easy to measure,Combine volume wit
18、h flow surrogate,Swan-Ganz 数据解读,ScvO2 correlates with SvO2 in shock states,Superior vena cava,r=0.86Right atrium,r=0.95,Feasible in 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
19、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”.,
