Hemodynamic Monitoring in ICU

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????????

• ??? ??
• ????????
• ?? ??

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????????

• ??????
• ???????
• ?????

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???????
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• ?? catheter
• ?????????? fluid-filled pressure tubing system
• ???transducer
• ??? monitor

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????(??)?????????????

• ????????????,??????????????,??????????????????

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?????????????????????,????????????????????
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??????????????,?????????????
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????????????

• ?????????
• (Static response)
• ?????????
• (Overdamping)
• ??????????????????????
• (Improper determination)

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??????

• Static Response

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(No Transcript)
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• ?????????????????????????,????????? (pulmonary
  artery wedge pressure, PAWP) ?????

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?????????

• Inadequate Dynamic Response

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• ???????????????????
• ????????,???????

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????????

• Fast Flush TestSquare Test

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???????

• ????????
• ????????,?????????????
• ?????????? (waveform)

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????????

• B?, ??(????)???????????????? (Overdamp)

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• ??????,?????????????? (Underdamp)

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????????????

• ??????
• ??????
• ????????????? (T-connection)
• ???????????

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????????????

• ????????
• ??????? 300 mmHg
• ?????????????
• ?????????

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• ?????? (Overdamp)

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?????

• Pulmonary Artery Catheterization

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????????????????????????????????????

• Intensive Care Medicine 1998 24147-151

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????,??1970??,??4500??????????? Chest 2002
121 2009-2015

• ???????????????

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??????????????????????(circulatory
disorders)??????

• ????????????????????,??????????????

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??????,?????????????(circulatory
shock)???????????????????????????????,?????38???
80?

• Chest 2002 121 2009-2015

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????????????

• ?? (cardiogenic, distributive, obstructive,
  hypovolemic)
• ??? vs. ???????? (ARDS)
• ???? (pulmonary hypertension)
• Acute mitral regurgitation, pericardial
  tamponade, etc
• Critical Care Clinics 2001

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????????????????????????????

• ????????,????????,????????,??????????

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????????????????????????????

• ?????????????(thermodilution)????????????????(gold
  standard)

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????,????
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• ?????,PAWP ????????????
• (LVEDPleft ventricular end-diastolic pressure).
• ??? (mitral valve) ???PAWP ?? LVEDP
• ???? (heart compliance) ???PAWP ?? LVEDP

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• LVEDP ? LVEDV ????????? (compliance) ???.
  ????????? (??), ????? LVEDP (PAWP) ????????????
  LVEDV (Preload).

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PAWP?????????(Preload)?????????

• ??????(PAWP)???????Fluid Challenge???????????PAWP?

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???????
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?????????

• ??????????????????EKG?????(pressure waveform)
  ,??????????

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(No Transcript)
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• ?EKG?P???????????? A (atrial) wave, ???QRS???
• ? V (ventricular) wave ??EKG?T?????

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• ??? V Wave
• ??????? (Mitral insufficiency)
• ??????? (Decreased left atrial compliance)
• ??????? (Overdistended left artium)

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• PAWP?
• ????????????? V ????? ?????? (fluid overload)

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???(intrathoracic pressure)?PAWP???

• PAWP?????????????,????????????,?????????????
• ???????????PAWP,????????????????????

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??????????????????????????????????????????,???????
?????????????
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• ?? CMV ?
• Wedge pressure ??????????,??????????????

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• ????
• Wedge pressure ??????????,??????????????

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• RAP
• PAP
• PAWP

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• RAP
• PAP
• PAWP

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(No Transcript)
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• ???PAWP?????????????
• ??????(digital display)????????????PAWP?????

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• ???????????????????
• ???,??????????????,???????????????

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• ?????????,????????,????????????????????????????(??
  ???)?20 mmHg?
• ?? short-acting paralyzing agent???????????????wed
  ge pressure?10 mmHg(??)

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Overwedging
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• ???ARDS,??PADP-PAWP??????
• ?? ???, ???PAWP?????????(PADP) incomplete
  wedge pressure
• ?? ????????????????, ????PADP-PAWP??

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Wests Zone Model

• Zone 1 No flow
• Zone 2 Intermittent flow
• Zone 3 Constant flow

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Non-zone 3 ???????,?

• ????????????????
• PEEP ???? PEEP ?????
• ???? (left atrial pressure) ?

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• ??????????????,PAWP ?????????? (PRA )
  ,???????non-zone 3 ???,??????????PAWP
  ?????????????????

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• ?????PEEP????, ????,PAWP ????????????????
  (injured lung) ?????,??????PAWP????
  Hassan et al., 1985

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??? ARDS ????

• ????????, zone 3 ???????????,?????? PEEP ??????
  (PLA) ?

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PEEP?PAWP???

• PEEP 15 cm H2O12 mmHg
• ??? PAWP 16 mmHg
• ½ ?12 mmHg (6 mmHg) PEEP ??????
• ?????PAWP ?16- (6-2) 12 mmHg

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Auto-PEEP

• Auto-PEEP?????PAWP????? applied PEEP ???

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Intrinsic PEEP ???

• ????????????????,????auto-PEEP ???,??auto-PEEP????
  ?,???????? (venous return)
• ?????????
• Cardiac output?
• BP ?
• PAWP ?

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??????????????????????????????????

• ???????????????????,???????????????,?????????????,
  ?????????

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??????????????????????????

• ????????????????????????,???????????????????