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1、Orientation,工作态度会客时主动告知病情CV病人病情变化快速 对家属解释病情应预留空间,切勿解释病情稳定而应解释原病情改善较为恰当,如有不明之处可与白天住院医师或主治医师讨论后再行解释如有病情急速变化(如病人非预期死亡)或有纠纷case应尽快通知主治医师CCU病人如果血型动力不稳定且需要离开CCU做检查(如CT)鹰知会当科主治医师并告知家属可能发生的风险 病历每天书写2次主动反应问题,1,谢谢观赏,2019-6-29,Orientation,值班人员应熟悉ACLS,对于该实行电击的病人按照ACLS的guildline施行,切勿害怕电击或只给口服药物病人如发生CPR时,应该call总值
2、协助处理,切勿自己一人和护理人员施行病人如有arrthymia在可能情况下应尽量取得complete EKG,再实施治疗(如电击or drug),2,谢谢观赏,2019-6-29,Orientation,ICU会诊原则上为急会诊,并应电话通知会诊医师病人如有血压不稳定即使给予输液及升压剂人无法维持血压稳定及严重心律不整应考虑气管插管 呼吸器使用以建立呼吸道如有on机的病人发生hypoxia,SOB情形应将pneumothorax放入鉴别诊断,除PE外并考虑CXR以排除此一诊断病人如有发烧情形且感染源不明确,应做血液培养并针对可能感染源加以检查或留置检体培养,并考虑病人于近期内接受过的proce
3、dure,评估是否有catheter infection切勿只是给予退烧药及打抗生素,3,谢谢观赏,2019-6-29,AMI,EKG,cardiac enzyme serially check,CXRAspirin,Plavix,Enoxaparin,IIB-IIIa,statin,Nitrite,ACEI,B-blocker and diuretic 视情形给与Heart echo值班时注意AMI的多种complication 如 VSD,acute MR,cardiac rupture,cardiac tamponade,如有怀疑应call CR 施行紧急心脏超音波或pericardio
4、centesis with drainageIntervention的时机AMI病人如有unstable hemodynamic status,on going chest pain,new EKG change 应call duty CV CR 评估是否放置IABP or 施行紧急心导管,4,谢谢观赏,2019-6-29,CHF with pulmonary edema,Nitrate+Diuretics and keep I/O negativeACEI O2Correct hypoalbuminemiaSwan-ganz monitor,5,谢谢观赏,2019-6-29,TPM or P
5、PM,6,谢谢观赏,2019-6-29,Indication,Bradycardia with symptom and refractory to medication病人如有bradycardia,high degree AV block with unstable BP 应放置TCP 并call duty CR 评估是否放置TPM病人放置PPM或曾施行CVP puncture,如Ablation 应f/u CXR 注意有无pneumothorax,位置是否正确,有无移位并f/u EKG注意是否有相应的变化,7,谢谢观赏,2019-6-29,Swan-ganz,8,谢谢观赏,2019-6-2
6、9,Indication,Shock D/DPulmonary artery catheter 可帮助鉴别cardiogenic or no-cardogenic shock,区别pulmonary edema or ARDS,病人如有上述情形应考虑置放Pulmonary artery catheter 以为鉴别,亦可当作治疗指标Monitor fluid and C/O and adjust medicationSwan-Gan会开立固定测量时间(q6h,q8h),但如果病情有需要即应及时测量,9,谢谢观赏,2019-6-29,肺动脉导管 临床应用,10,谢谢观赏,2019-6-29,导管介
7、绍,肺动脉导管pulmonary Artery catheter 一般称为Swan-Ganz catheter，全长110cm，其尖端为一可充气之球体，可随血流漂动至右心房，右心室再到肺动脉处，来测得病人血液动力学上的一些压力数值,11,谢谢观赏,2019-6-29,12,谢谢观赏,2019-6-29,Lumen,Distal lumen-可测得肺动脉压、肺楔压及可由此抽取混合静脉血Balloon-离远端1cm，可充气放气，在放置过程随血流飘进 Proximal lumen在导管30cm处，可测得右心房之压力 温度感应器-借以测出血液温度变化，进而算出心输出量混合静脉血氧饱和度mixed ve
8、nous oxygen saturation(SVO2)代表身体氧气供应消耗的平衡状态连续性心输出量continues cardiac output(CCO),13,谢谢观赏,2019-6-29,目的,间接监测左心室舒张末期的压力(LVEDP)，做为输液指标，确知病患有无心衰竭、肺水肿情形测知左心室填充情形测量心输出量，评估左心室功能抽血、右心房SVO2，肺动脉-混合静脉血，可诊断心室中隔缺损(VSD)等疾病,14,谢谢观赏,2019-6-29,Indications,Diagnostic Diagnosis of shock states Differentiation of high-ve
9、rsus 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 fail
10、ure 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,15,谢谢观赏,2019-6-29,Contraindications,Tricuspid or pulmonary valve mechanical prosthesis Right heart mass(thrombus and/or tu
11、mor)Tricuspid or pulmonary valve endocarditis,16,谢谢观赏,2019-6-29,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 criticall
12、y ill patients.,17,谢谢观赏,2019-6-29,18,谢谢观赏,2019-6-29,Normal range,19,谢谢观赏,2019-6-29,Complications from the technique,vascular damage hematoma infection pulmonary thrombosis kinking of catheter premature atrial contractions premature ventricular contractions ventricular fibrillation complete heart arr
13、est right bundle branch block 发生于导管顶端通过右心房时,20,谢谢观赏,2019-6-29,Complications from the catheter,气球破裂或导管打结血栓 thrombosis 菌血症 bacteremia 心内膜炎 endocarditis 穿破瓣膜 valve rupture 肺栓塞 pulmonary embolus 肺动脉穿破 pulmonary artery rupture 死亡率4675%,危险因子包括老年,女性,肺高压及用抗凝剂者.肺梗塞(balloon忘了放开),21,谢谢观赏,2019-6-29,技术,用物及设备7Fr.
14、Swan ganz catheter-1个8Fr Puncture sheeth-1个CAP kit及加压袋-各1个压力传送器(Transducer)-1个IV stand 与固定座(Holder)-1个注射液 NS 500ml-1包心导管包、口罩、帽子-各1个切开包或小缝合包-1包C.O Module及Transducer-1个Recorder-1个,CD车-1台(75%Alcohol、AI-BI solution、无菌冲洗棉棒、44纱布数片、2%Xylocain、NS 20ml无菌数瓶)无菌手套(依order)-1-2付20ml、10ml空针-1-2支23号针头-1支缝线(黑丝线)-1包3
15、M、彩虹标签贴纸、op site-1片去颤器与急救车-stand by,22,谢谢观赏,2019-6-29,程序,执行前准备用物核对病人，向病人或家属解释洗手医生以三消方式消毒穿刺部位、戴口罩、帽子*先用75%Alcohol棉棒清洁(干)再用A1-BI棉枝消毒(干)Alcohol(去色此步骤可省略),CAP kit 接上NS排气，一端接distal lumen，一端接proximal lumen，加压袋加压至200-300Hg，并病人平躺对腋中线第四肋间归零monitor上之pressure scale，设定 0-30 mmHg or 0-60 mmHg，设定好recorder穿刺部位选择：锁
16、骨下静脉、内颈静脉 股静脉,23,谢谢观赏,2019-6-29,执行中,1.打开心导管包，协助戴无菌手套、穿无菌衣，铺好无菌区2.打开小缝合包，将无菌生理食盐水倒入弯盆内，把缝线浸入生理食盐水中，及放入纱布数片3.医生以10ml 空针抽取 2%xylocaine，抽后换23号针头4.医生sheeth 及 Swan ganz导管，注意无菌操作,24,谢谢观赏,2019-6-29,5.医生先将 Swan-Ganz 之 balloon 端打入1.5 ml 之air，测试 balloon 是否有漏气，若完好，请医生将 catheter 尾端丢出，予Distal 端 及 Proximal端 与 CAP
17、kit 相接，并将导管排气6.医生进行局部麻醉，确定插入穿刺部位，开始放置 catheter。藉压力波变化判定导管所在位置，观察 monitor wave，待 monitor show 出 RA wave 时，协助 balloon on,25,谢谢观赏,2019-6-29,7.Recorder RAP、RVP、PAP、PCWP 波形及记录数值 8.Record PCWP waveform 后，将 balloon off时即出现PA waveform，当 balloon on 时出现 PAWP waveform9.sheath与无菌塑胶套前端衔接处转至mark O予lock 10.消毒伤口，并固
18、定导管位置，照X-ray,26,谢谢观赏,2019-6-29,27,谢谢观赏,2019-6-29,肺动脉导管的原理(1),28,谢谢观赏,2019-6-29,C.O Measurement,心输出量利用温度析释法(Thermodilution)测量出心输出量(Cardiac Output)调整计算常数(Adjust Constant)：使用C.O.前须先输入计算常数，该计算常算请参阅各Swan-Ganz之说明书，因不同厂的Swan-Ganz有不同之计算常数,29,谢谢观赏,2019-6-29,Thermodilution 测量出Cardiac Output 图解,30,谢谢观赏,2019-6-
19、29,31,谢谢观赏,2019-6-29,测量肺动脉楔压(PCWP),相当于LVEDP(Left Ventricular End Diastolic Pressure)，但有肺阻塞的病患则不然按下Procedures Wedge 按下Swang-Ganz 导管量压力的气球(balloon，1.5 c.c air)测量3 4个呼吸周期后 当Wedge波稳定后，机器自动停止扫描，亦可手动按下停止键(stop)按编辑(editor)，用 来编辑资料，以呼吸波型最低(吐气末期)为准PCWP 受 Fluid status、myocardial contractility 及 valve and pulm
20、onary circulation integrity 影响,32,谢谢观赏,2019-6-29,测量CO之步骤,1.CO Module 及 Transducer 与 Computer 连接好，感温棒置于DW无菌单瓶内2.由C.O Module 进入C.O 设定，于计算机上输入系数(依空针 注入液体量、温度而不同)3.10ml 空针接于近端(CVP)3way处，按 测量CO键出现可以开始测量了按开始测量CO现在注入.4秒内注入液体稍后，准备下一次的测量可以开始测量了重复3-5次编辑CO，选择要/不要纳入平均按确认计算机自动算出 CI 及 CO4.于计算机上输入身高及体重(由监视程序注册病患资料
21、身高、体重用键盘输入数值并按确定),33,谢谢观赏,2019-6-29,5.编辑CO(Edit CO)：连续测量多次数 值后，按编辑 CO，将不要的数值，按删除键，再按确定键计算机自动算出 CI 及 CO6.进入血流动力计算(Hemo Calc)，在病患资料中需输入身高、体重，PCWP，余计算机会自动捕抓资料。按计算键，即可计算出资料，如图,34,谢谢观赏,2019-6-29,35,谢谢观赏,2019-6-29,测量结果,CO：SV HR(4-8 L/min)C I：CO/BSA(2.5-4 L/min/m2)SVRI：SVR BSA CO、PCWP NormalCO、PCWP Hypervo
22、lemia CO、PCWP Hypovolemia CO、PCWP heart failure,36,谢谢观赏,2019-6-29,Mixed Venous Oxygen Saturation,是决定cardiac output，tissue perfusion 最好的指标评估氧气输送与需求是否达平衡状态影响SvO2的因素：PaO2、Hb、C.O.SvO2下降 贫血、低血氧 心输出量降低、组织耗氧量增加SvO2上升 氧运送量增加、组织耗氧量减少 左向右分流、二尖瓣闭锁不全,37,谢谢观赏,2019-6-29,肺动脉导管的数据解读(1)正常各腔室压,38,谢谢观赏,2019-6-29,肺动脉导管
23、的数据解读(1)各类血行动力学术据,39,谢谢观赏,2019-6-29,IABP,40,谢谢观赏,2019-6-29,Indication,A.cardiogenic shockBridge to revascularizationBridge to tertiary centerB.Refractory unstable anginaC.Acute MI cathter based perfusion D.High risk percutaneous revascularizationE.End stage cardiomyopathy/bridge to heart transplanta
24、tion,41,谢谢观赏,2019-6-29,Indication,G.Mechanical complication of acute MI.Acute MR and VSDH.decompensated aortic stenosisI.Refractory ventricular arrythmiasJ.Weaning from cardiopulmonary bypass/post operative pump failure,42,谢谢观赏,2019-6-29,Contraindication,A.Aortic dissectionB.Abominal or thoracic ane
25、urysmC.Severe peripheral vascular diseaseD.Descending aortic and peripheral vascular graftE.Coagulopathy or contraindication to heparinF.moderate to severe aortic insufficiency,43,谢谢观赏,2019-6-29,44,谢谢观赏,2019-6-29,Complication,A.Vascular IschemiaBleedingB.InfectionC.Balloon ruptureD.Balloon entrapmen
26、tE.RBC and platelet destructionF.Others,45,谢谢观赏,2019-6-29,46,谢谢观赏,2019-6-29,47,谢谢观赏,2019-6-29,48,谢谢观赏,2019-6-29,49,谢谢观赏,2019-6-29,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 ballo
27、on waveform with reduced systolic pressure,50,谢谢观赏,2019-6-29,Figure 1b.Early inflation.May result in premature closure of aortic valve,increase in LVEDV and LVEDP,increased afterload,increased myocardial oxygen demand,51,谢谢观赏,2019-6-29,Late inflation.Results in sub-optimal coronary perfusion.,52,谢谢观
28、赏,2019-6-29,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.,53,谢谢观赏,2019-6-29,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.,54,谢谢观赏,2019-6-29,55,谢谢观赏,2019-6-29,
