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Pre-ICU training CV CR 蕭智忠 PowerPoint PPT Presentation


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Pre-ICU training CV CR 蕭智忠. Orientation. 工作態度 會客時主動告知病情 CV 病人病情變化快速 對家屬解釋病情應預留空間 , 切勿解釋病情穩定而應解釋原病情改善較為恰當 , 如有不明之處可與白天住院醫師或主治醫師討論後再行解釋 如有病情急速變化 ( 如病人非預期死亡 ) 或有糾紛 case 應盡快通知主治醫師 CCU 病人如果血型動力不穩定且需要離開 CCU 做檢查 ( 如 CT) 鷹知會當科主治醫師並告知家屬可能發生的風險 病歷每天書寫 2 次 主動反應問題. Orientation.

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Pre-ICU training CV CR 蕭智忠

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Pre icu training cv cr

Pre-ICU training

CV CR 蕭智忠


Orientation

Orientation

  • 工作態度

  • 會客時主動告知病情

    • CV病人病情變化快速 對家屬解釋病情應預留空間, 切勿解釋病情穩定而應解釋原病情改善較為恰當,如有不明之處可與白天住院醫師或主治醫師討論後再行解釋

    • 如有病情急速變化(如病人非預期死亡)或有糾紛case應盡快通知主治醫師

    • CCU病人如果血型動力不穩定且需要離開CCU做檢查(如CT)鷹知會當科主治醫師並告知家屬可能發生的風險

  • 病歷每天書寫2次

  • 主動反應問題


Orientation1

Orientation

  • 值班人員應熟悉ACLS,對於該實行電擊的病人按照ACLS的guildline施行,切勿害怕電擊或只給口服藥物

  • 病人如發生CPR時,應該call總值協助處理,切勿自己一人和護理人員施行

  • 病人如有arrthymia在可能情況下應盡量取得complete EKG,再實施治療(如電擊or drug)


Orientation2

Orientation

  • ICU會診原則上為急會診,並應電話通知會診醫師

  • 病人如有血壓不穩定即使給予輸液及升壓劑人無法維持血壓穩定及嚴重心律不整應考慮氣管插管 ± 呼吸器使用以建立呼吸道

  • 如有on機的病人發生hypoxia, SOB情形應將pneumothorax放入鑑別診斷,除PE外並考慮CXR以排除此一診斷

  • 病人如有發燒情形且感染源不明確,應做血液培養並針對可能感染源加以檢查或留置檢體培養,並考慮病人於近期內接受過的procedure,評估是否有catheter infection切勿只是給予退燒藥及打抗生素


Pre icu training cv cr

AMI

  • EKG, cardiac enzyme serially check , CXR

  • Aspirin, Plavix, Enoxaparin , IIB -IIIa , statin ,

  • Nitrite , ACEI , B-blocker and diuretic 視情形給與

  • Heart echo

    • 值班時注意AMI的多種complication 如 VSD , acute MR ,cardiac rupture, cardiac tamponade,如有懷疑應call CR 施行緊急心臟超音波或pericardiocentesis with drainage

  • Intervention的時機

    • AMI病人如有unstable hemodynamic status , on going chest pain ,new EKG change 應call duty CV CR 評估是否放置IABP or 施行緊急心導管


Chf with pulmonary edema

CHF with pulmonary edema

  • Nitrate + Diuretics and keep I/O negative

  • ACEI

  • O2

  • Correct hypoalbuminemia

  • Swan-ganz monitor


Tpm or ppm

TPM or PPM


Indication

Indication

  • Bradycardia with symptom and refractory to medication

    • 病人如有bradycardia , high degree AV block with unstable BP 應放置TCP 並call duty CR 評估是否放置TPM

    • 病人放置PPM或曾施行CVP puncture , 如Ablation 應f/u CXR 注意有無pneumothorax,位置是否正確,有無移位並f/u EKG注意是否有相應的變化


Swan ganz

Swan-ganz


Indication1

Indication

  • Shock D/D

    • Pulmonary artery catheter 可幫助鑑別cardiogenic or no-cardogenic shock , 區別pulmonary edema or ARDS, 病人如有上述情形應考慮置放Pulmonary artery catheter 以為鑑別, 亦可當作治療指標

  • Monitor fluid and C/O and adjust medication

  • Swan-Gan會開立固定測量時間(q6h,q8h),但如果病情有需要即應及時測量


Pre icu training cv cr

肺動脈導管 臨床應用


Pre icu training cv cr

導管介紹

  • 肺動脈導管pulmonary Artery catheter

    一般稱為Swan-Ganz catheter,全長110cm ,其尖端為一可充氣之球體,可隨血流漂動至右心房,右心室再到肺動脈處,來測得病人血液動力學上的一些壓力數值


Lumen

Lumen

  • Distal lumen---- 可測得肺動脈壓、肺楔壓及可由此抽取混合靜脈血

  • Balloon--離遠端1cm,可充氣放氣,在放置過程隨血流飄進

  • Proximal lumen—在導管30cm處,可測得右心房之壓力

  • 溫度感應器----藉以測出血液溫度變化,進而算出心輸出量

  • 混合靜脈血氧飽和度mixed venous oxygen saturation(SVO2)

    代表身體氧氣供應消耗的平衡狀態

  • 連續性心輸出量continues cardiac output (CCO)


Pre icu training cv cr

目的

  • 間接監測左心室舒張末期的壓力(LVEDP),做為輸液指標,確知病患有無心衰竭、肺水腫情形

  • 測知左心室填充情形

  • 測量心輸出量,評估左心室功能

  • 抽血、右心房SVO2,肺動脈-混合靜脈血,可診斷心室中隔缺損(VSD)等疾病


Indications

Indications

  • Diagnostic

    • Diagnosis of shock states

    • Differentiation of high- versus low-pressure pulmonary edema

    • Diagnosis of primary pulmonary hypertension (PPH)

    • Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE)

    • Monitoring and management of complicated AMI

    • Assessing hemodynamic response to therapies

    • Management of multiorgan system failure and/or severe burns

    • Management of hemodynamic instability after cardiac surgery

    • Assessment of response to treatment in patients with PPH

  • Therapeutic - Aspiration of air emboli


Contraindications

Contraindications

  • Tricuspid or pulmonary valve mechanical prosthesis

  • Right heart mass (thrombus and/or tumor)

  • Tricuspid or pulmonary valve endocarditis


Placement

placement

  • Right heart catheterization involves the passage of a catheter (a thin flexible tube) into the right side of the heart to obtain diagnostic information about the heart and for continuous monitoring of heart function in critically ill patients.


Normal range

Normal range


Complications from the technique

Complications from the technique

  • vascular damage

  • hematoma

  • infection

  • pulmonary thrombosis

  • kinking of catheter

  • premature atrial contractions

  • premature ventricular contractions

  • ventricular fibrillation

  • complete heart arrest

  • right bundle branch block 發生於導管頂端通過右心房時


Complications from the catheter

Complications from the catheter

  • 氣球破裂或導管打結

  • 血栓 thrombosis

  • 菌血症 bacteremia

  • 心內膜炎 endocarditis

  • 穿破瓣膜 valve rupture

  • 肺栓塞 pulmonary embolus

  • 肺動脈穿破 pulmonary artery rupture

    • 死亡率46~75%, 危險因子包括老年, 女性,肺高壓及用抗凝劑者.

  • 肺梗塞 ( balloon忘了放開)


Pre icu training cv cr

用物及設備

7Fr.Swan ganz catheter------1個

8Fr Puncture sheeth ----------1個

CAP kit及加壓袋---------------各1個

壓力傳送器(Transducer)--------1個

IV stand 與固定座(Holder)-----1個

注射液 NS 500ml-----------------1包

心導管包、口罩、帽子-------各1個

切開包或小縫合包----------------1包

C.O Module及Transducer------1個

Recorder----------------------------1個

CD車--------------------------------1台

(75%Alcohol、AI-BI solution、

無菌沖洗棉棒、4×4紗布數片、

2%Xylocain、 NS 20ml無菌數瓶)

無菌手套(依order)-------------1-2付

20ml、10ml空針---------------1-2支

23號針頭---------------------------1支

縫線(黑絲線)----------------------1包

3M、彩虹標籤貼紙、op site--1片

去顫器與急救車----------- stand by

技術


Pre icu training cv cr

執行前

準備用物

核對病人,向病人或家屬解釋

洗手

醫生以三消方式消毒穿刺部位、戴口罩、帽子

*先用75%Alcohol棉棒清潔(乾)

→再用A1-BI棉枝消毒(乾)

→Alcohol(去色此步驟可省略)

CAP kit 接上NS排氣,一端接distal lumen,一端接proximal lumen,加壓袋加壓至200-300㎜Hg,並病人平躺對腋中線第四肋間歸零

monitor上之pressure scale,設定 0-30 mmHg or 0-60 mmHg,設定好recorder

穿刺部位選擇:

鎖骨下靜脈、內頸靜脈

股靜脈

程序


Pre icu training cv cr

執行中

1. 打開心導管包 ,協助戴無菌手套、穿無菌衣,

舖好無菌區

2. 打開小縫合包,將無菌生理食鹽水倒入彎盆內,

把縫線浸入生理食鹽水中,及放入紗布數片

3. 醫生以10ml 空針抽取 2%xylocaine,抽後換23號針頭

4. 醫生sheeth 及 Swan ganz導管,注意無菌操作


Pre icu training cv cr

5. 醫生先將 Swan-Ganz 之 balloon 端打入1.5 ml 之air,測試 balloon 是否有漏氣,若完好, 請醫生將 catheter 尾端丟出,予Distal 端 及 Proximal端 與 CAP kit 相接,並將導管排氣

6. 醫生進行局部麻醉,確定插入穿刺部位,開始放置catheter。藉壓力波變化判定導管所在位置,觀察 monitor wave,待 monitor show 出 RA wave 時,協助 balloon on


Pre icu training cv cr

7. Recorder RAP、RVP、PAP、PCWP 波形及記錄數值

8. Record PCWP waveform 後,將 balloon off時即出現PA waveform,當 balloon on 時出現 PAWP waveform

9. sheath與無菌塑膠套前端銜接處轉至mark

"O"予lock

10. 消毒傷口,並固定導管位置,照X-ray


Pre icu training cv cr

肺動脈導管的原理(1)


C o measurement

C. O Measurement

  • 心輸出量利用溫度析釋法 (Thermodilution )測量出心輸出量 (Cardiac Output )

  • 調整計算常數 (Adjust Constant ):使用C.O.前須先輸入計算常數,該計算常算請參閱各Swan-Ganz之說明書,因不同廠的Swan-Ganz有不同之計算常數


Thermodilution cardiac output

Thermodilution 測量出Cardiac Output 圖解


Pre icu training cv cr

測量肺動脈楔壓 (PCWP)

  • 相當於LVEDP (Left Ventricular End Diastolic Pressure ),但有肺阻塞的病患則不然

  • 按下Procedures → Wedge → 按下Swang-Ganz 導管量壓力的氣球(balloon,1.5 c.c air) → 測量3 ~ 4個呼吸週期後 → 當Wedge波穩定後,機器自動停止掃描,亦可手動按下停止鍵(stop)

  • 按編輯(editor),用↓ ↑來編輯資料,以呼吸波型最低(吐氣末期)為準

  • PCWP 受 Fluid status、myocardial contractility 及 valve and pulmonary circulation integrity 影響


Pre icu training cv cr

測量CO之步驟

1. CO Module 及 Transducer 與 Computer 連接好,感溫棒置於DW無菌單瓶內

2. 由C.O Module 進入C.O 設定,於電腦上輸入係數(依空針 注入液體量、溫度而不同)

3. 10ml 空針接於近端(CVP)3way處,按 測量CO鍵出現可以開始測量了按開始測量CO現在注入…..4秒內注入液體稍後,準備下一次的測量可以開始測量了重複3-5次編輯CO,選擇要/不要納入平均按確認電腦自動算出 CI 及 CO

4. 於電腦上輸入身高及體重(由監視程序註冊病患資料身高、體重用鍵盤輸入數值並按"確定")


Pre icu training cv cr

5. 編輯CO (Edit CO):連續測量多次數

值後,按編輯 CO ,將不要的數值,按刪除鍵,再按確定鍵電腦自動算出 CI 及 CO

6. 進入血流動力計算 (Hemo Calc),在病患資料中需輸入身高、體重,PCWP,餘電腦會自動捕抓資料。按計算鍵,即可計算出資料,如圖


Pre icu training cv cr

測量結果

CO:SV × HR ( 4-8 L/min)

C I:CO / BSA ( 2.5-4 L/min/m2)

SVRI:SVR × BSA

  • CO↑、 PCWP↓  Normal

  • CO↑、 PCWP↑  Hypervolemia

  • CO↓、 PCWP↓  Hypovolemia

  • CO↓、PCWP↑  heart failure


Mixed venous oxygen saturation

Mixed Venous Oxygen Saturation

  • 是決定cardiac output, tissue perfusion 最好的指標

  • 評估氧氣輸送與需求是否達平衡狀態

  • 影響SvO2的因素:PaO2、Hb、C.O.

  • SvO2下降 貧血、低血氧

    心輸出量降低 、 組織耗氧量增加

  • SvO2上升 氧運送量增加、組織耗氧量減少

    左向右分流 、 二尖瓣閉鎖不全


Pre icu training cv cr

肺動脈導管的數據解讀(1)正常各腔室壓


Pre icu training cv cr

肺動脈導管的數據解讀(1)各類血行動力學術據


Pre icu training cv cr

IABP


Indication2

Indication

  • A. cardiogenic shock

    • Bridge to revascularization

    • Bridge to tertiary center

  • B. Refractory unstable angina

  • C. Acute MI cathter based perfusion

  • D. High risk percutaneous revascularization

  • E.End stage cardiomyopathy/bridge to heart transplantation


Indication3

Indication

  • G. Mechanical complication of acute MI. Acute MR and VSD

  • H.decompensated aortic stenosis

  • I. Refractory ventricular arrythmias

  • J. Weaning from cardiopulmonary bypass /post operative pump failure


Contraindication

Contraindication

  • A. Aortic dissection

  • B. Abominal or thoracic aneurysm

  • C. Severe peripheral vascular disease

  • D. Descending aortic and peripheral vascular graft

  • E. Coagulopathy or contraindication to heparin

  • F. moderate to severe aortic insufficiency


Complication

Complication

  • A. Vascular

    • Ischemia

    • Bleeding

  • B. Infection

  • C. Balloon rupture

  • D. Balloon entrapment

  • E. RBC and platelet destruction

  • F. Others


Pre icu training cv cr

Red line represents actual pressure tracing with an initial systolic waveform followed by an pump generated waveform and then the systolic waveform seen following a balloon waveform with reduced systolic pressure


Pre icu training cv cr

Figure 1b.

Early inflation. May result in premature closure of aortic valve, increase in LVEDV and LVEDP, increased afterload, increased myocardial oxygen demand


Pre icu training cv cr

Late inflation. Results in sub-optimal coronary perfusion.


Pre icu training cv cr

Early deflation. Sharp drop following diastolic augmentation. Diastolic augmentation sub-optimal. Results in sub-optimal coronary perfusion, potential for retrograde coronary and carotid blood flow, sub-optimal afterload reduction and increase myocardial oxygen demand.


Pre icu training cv cr

Late deflation. Afterload reduction almost absent. Increased myocardial oxygen demand du to LV ejecting against a greater resistance and a prolonged isovolumic contraction phase. Increased afterload.


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