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1、充血性心力衰竭,（congestive heart failure),概念,是指在各种原因所致的心脏疾病后期，在静脉回流量正常的前提下，由于心肌收缩力下降使心排出量不能满足机体代谢的需要，导致组织器官灌流不足，同时出现肺循环和（或）体循环静脉淤血。,小儿心衰特点,1.病因新生儿、婴幼儿先心病 学龄前、学龄期风心病、病毒性心肌炎少儿期肺炎,小儿心衰特点,2.病理生理特点心脏代偿功能较差 收缩性差、心脏储备力差交感神经占优势心率代偿潜力小 左右心衰之间差别不明显,年长儿的临床表现,心衰的症状,FACES.FatigueActivities limitedChest congestionEdema
2、or ankle swellingShortness of breath,一、肺循环充血,呼吸困难劳力性呼吸困难夜间阵发呼吸困难端坐呼吸肺水肿,劳力性呼吸困难,体 力 活 动,缺氧、二氧化碳储留,刺激呼吸中枢,心率加快,左心室充盈减少,回心血量增加,肺淤血加重,肺顺应性降低,通气作功增加,气急,呼 吸 困 难,夜间阵发性呼吸困难,患 者 入 睡,膈上移胸腔容积减少,回心血量增加，肺淤血加重,迷走神经相对兴奋，呼吸道阻力增加,中枢神经系统相对抑制,PaO2下降,端坐呼吸,端 坐 位,减少回心血量,膈下移，胸腔容积增大，,减少水肿液的吸收,减轻肺淤 血,肺活量增 加,肺水肿,急性左心衰竭最严重的表
3、现肺毛细血管压升高毛细血管通透性加大,二、体循环淤血,静脉淤血和静脉压升高右心房压升高，静脉回流受阻水钠潴留、血容量扩大水肿肝肿大压痛和肝功能异常右心衰竭早期表现肝静脉压升高，肝小叶淤血，肝窦扩张、出血、水肿长期变性、坏死，肝纤维化,三、心排出量不足,皮肤苍白或发绀心排出量不足，交感神经兴奋肺循环淤血、血循环时间延长疲乏无力、失眠、嗜睡尿量减少心源性休克,婴幼儿的临床表现,喂养困难、烦躁多汗、哭声低弱颈静脉怒张、水肿和肺部湿啰音不明显,儿童心功能分级,I级：活动不受限制，日常活动不引起临床症状。II级：一般活动可引起乏力、呼吸困难和心悸等症状，活动轻度受限。III级：轻度活动即引起上述症状，活
4、动明显受限。IV级：不能从事任何活动，即使安静休息时也有症状，活动完全受限。,婴儿心功能分级,0级：无心衰的表现I级：轻度心衰II级：中度心衰III级：重度心衰,婴儿I级心衰特点,每次哺乳量150次/分，可有奔马律肝脏肋下2cm,婴儿II级心衰特点,每次哺乳量60次/分，呼吸形式异常心率160次/分，有奔马律肝大肋下23cm,婴儿III级心衰特点,每次哺乳量60次/分，呼吸形式异常心率170次/分，有奔马律肝大肋下3cm以上,临床诊断指征,安静时心率增快，婴儿180次/分，幼儿160次/分，不能用发热或缺氧解释者；呼吸困难，青紫突然加重，安静时呼吸60次/分；肝在短时间内较前肿大，而不能以横膈
5、下移等原因解释者，或肝脏肿大超过肋缘下3cm以上；心音明显低钝或出现奔马律；,临床诊断指征,突然烦躁不安，面色苍白或发灰，而不能用原有疾病解释者尿少和下肢浮肿，除外其他原因造成者。以上前4项为主要临床诊断依据，也可根据其他表现和12项辅助检查综合分析。,治疗要点,（一）防治基本病因、消除诱因（二）改善心脏舒缩功能增强心肌收缩功能改善心肌舒张功能（三）减轻心脏前、后负荷（四）控制水肿,护理措施,休息原则：I度：可起床活动，增加休息时间；II度：限制活动，延长卧床时间；III度：绝对卧床休息，病情好转后逐渐起床活动，以不出现症状为限。,护理措施,保持大便通畅：多吃水果蔬菜，避免用力排便合理营养：低
6、盐或无盐饮食，少量多餐。婴儿喂奶避免吸吮费力，输液控制量（75ml/kg/d）和速度（5ml/kg）给氧密切观察病情,护理措施用药护理,洋地黄制剂用药前测脉搏：婴儿脉率90次/分，年长儿70次/分时需暂停；严格遵医嘱给药防止毒性反应并处理利尿剂：多进食含钾丰富的食物防治低血钾血管扩张剂：硝普钠避光，现用现配,The End,Clinical example-1,A 60-year-old man sustained an extensive acute myocardial infarction 4 years before his recent admission.Since that ti
7、me,he has become progressively more breathless on exertion.During the past 6 months,he developed swelling of his abdomen and feet despite vigorous diuretic and digoxin therapy.Examination revealed an emaciated man who was breathless even at rest.Cardiac rhythm was regular and blood pressure was 90/6
8、0 mm Hg.Jugular venous pressure was elevated and there was ankle edema,hepatomegaly,and ascites.,Clinical example-1,Heart sounds were faint but a loud third sound was audible.Chest x-ray revealed marked cardiac enlargement,bilateral pleural effusions,and pulmonary venous congestion.Cardiac catheteri
9、zation revealed severe inoperable three-vessel coronary artery disease,poor left ventricular function with marked elevation of left ventricular end-diastolic pressure,and low cardiac output.,Clinical example-2,A 35-year-old man presented with a complaint of increasing shortness of breath.This initia
10、lly occurred with exertion,but now occurred at rest as well.He had no previous cardiac symptoms.His father suffers from chest pain and heart failure.Examination revealed a normal upstroke and bifid systolic impulse on palpation of the carotid artery.Presystolic and forceful sustained systolic apical
11、 impulses were palpable.,Clinical example-2,The first and second sounds were normal.A loud fourth sound was heard.A systolic ejection murmur that increased with valsalva was heard along the left sternal border.Echocardiogram revealed a markedly hypertrophied left ventricle with disporportionate thickening of the septum and a small left ventricular cavity.,
