Nursingul cardiovascular al pacientului critic -...
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Nursingul cardiovascular al pacientului critic
A.Brinzeu
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Introducere
Aparatul cardio – vascular :
asigura functia circulatorie, repectiv irigatiasanguina a tesuturilor si organelor.
Irigatia sanguina a tesuturilor: are drept obiectivaportul de oxigen si de substrat nutritiv catretesuturi si indepartarea produsilor de metabolism
→asigurarea necesarului energetic celular.
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Introducere
Irigatia depinde de :
Debitul cardiac: Frecventa Cardiaca X Volumul sistolic
Presiunea de perfuzie a unui anumit tesut
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Introducere
Debitul cardiac este influentat de :
• Volumul sanguin
• Intoarcerea venoasa a sangelui catre inima
• Rezistenta vasculara periferica
Presiunea de perfuzie :
• La nivel cerebral PPC – presiunea de perfuziecerebrala = PAM – PIC
• La nivelul miocardului: presiunea diastolica–presiunea intramurala
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Introducere
• In rinichi fluxul sanguin este dirijat prinmecanisme complexe, hipovolemia determinandscaderea filtratului glomerular
Hipovolemia si scaderea debitului cardiac de orice cauzascad fluxul sanguin renal, debitul urinar si pot determinainsuficienta renala acuta organica
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Sidroame cardiovasculare la pacientulcritic
• Oprirea circulatiei
• Insuficienta circulatorie acuta - socul
• Tulburari de ritm cardiac
• Edemul pulmonar acut
• Sindromul coronarian acut – infarctulmiocardic acut
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Aptitudinile cerute asistentei de reanimare in ceea cepriveste ingrijirea cardiocirculatorie - dupa SRLF 2011
• Sa identifice oprirea circulatiei si sa porneascamanevrele de resuscitare cardio – respiratorie
• Sa identifice semnele starii de soc si sa le prezinte medicului
• Sa organizeze supravegherea ( monitorizarea ) parametrilor functiilor vitale
• Sa aplice masurile de tratament al insuficientei circulatorii in functie de cerintelesectiei/ serviciului respectiv
11.11.2016 7Societe de Reanimation de Langue Francaise
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Aptitudinile cerute asistentei de reanimare in ceea ce priveste ingrijirea cardiocirculatorie -
dupa SRLF 2011
• Sa cunoasca si sa utilizeze mijloacele de monitorizare hemodinamica ale sectiei in care lucreaza
• Sa fie capabila sa verifice pertinentamijloacelor de monitorizare hemodinamica pecare le foloseste
11.11.2016 8Societe de Reanimation de Langue Francaise
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Competentele asistentei de TI in ingrijireapacientilor cu insuficienta circulatorie
acuta - dupa SRLF 2011
• Conduce ingrijirile de igiena si asigura confortulpacientului care beneficiaza de monitorizarehemodinamica in conditii de siguranta
• Adapteaza administrarea catecholaminelor( substantelor vasoactive ) dupa prescriptiamedicala si adapteaza dozele in functie de datelemonitorizarii hemodinamice
11.11.2016 9Societe de Reanimation de Langue Francaise
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Oprirea circulatiei
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Bolnav monitorizat:
Modificare EKS :• Fibrilatie ventriculara• Asistola• Disociatie electromecanica !!!( EKS prezent, unda pulsatilaabsenta pe: SpO2, la palpare)
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Insuficienta circulatorie acuta - socul
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Toate starile de soc au in comun deficitul de oxigen la nivel tisular : deficit de transport sau un deficit de
utilizare a oxigenului .
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Insuficienta circulatorie acuta - socul
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Diagnostic clinic!!!
Socul trebuie recunoscut pe bazasemnelor clinice .
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Recunoasterea clinica a socului
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TAS < 90 mmHg sauScaderea TA cu peste 30 % la un hipertensiv
cunoscut
Centralizarea circulatiei
Rinichi,intestinin muschi, piele
↓Inima,CreierDebit pastrat
Dupa Pr. JJ.Rouby Etats de Choc
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Insuficienta circulatorie acuta - socul
Semne clinice datorate consecintelor socului :
• Hipoxia cerebrala – obnubilare, confuzie
• Hipoperfuzie renala – oligurie
• Hipoperfuzie tisulara generalizata cu hipoxietisulara si acidoza metabolica ( lactica) –dispnee polipneica
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Insuficienta circulatorie acuta - socul
Semne datorate mecanismului de producere a socului :
Soc hipovolemic: puls mic, filiform, paloare, intoarcere venoasa scazuta, PVC ↓
Soc cardiogen: semne de insuficienta cardiaca, insuficienta ventriculara stanga, staza pulmonara, EPA
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dupa - Semeiologie des etats de choc , B. Valet, E. Wiel, E. Robin - SFAR - adaptat
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Insuficienta circulatorie acuta - socul
Soc septic: febra, semne de infectie, tegumentecalde , congestionate
Soc anafilactic : edem Quincke, urticarie, prezentaalergenului
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Waugsberg - Wikipedia
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Insuficienta circulatorie acuta - socul
SOCUL HIPOVOLEMIC : cel mai frecvent
Soc hemoragic : pierdere de sange
Hemoragii :
traumatisme,
hemoragii digestive,
epistaxis,
metroragie
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Wikipedia
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Soc nonhemoragic:
• arsura (plasmoragie)
• cauze digestive - ocluzia intestinala,peritonitapancreatita (spatiu III, diaree, varsaturi + lipsa de aport)
• Diabet insipid-pierdere de urina11.11.2016 19
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Fiziopatologie: elemente caracteristice
Socul hipovolemic :
scaderea volemiei cu peste 25 %
scaderea tensiunii arteriale
stimulare simpatica : adrenalina, noradrenalina
centralizarea circulatiei : vasoconstrictia splanhnica, vasoconstrictie cutanata – creste rezistenta vascularaperiferica – se pastreaza debitul cerebral si coronarian
Debitul cardiac se reface ( temporar)
Renina – angiotensina - aldosteron
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Insuficienta circulatorie acuta - socul
Socul cardiogen
Scaderea functiei de pompa a inimii:
• Infarct miocardic
• Miocardite
• Traumatisme – contuzie miocardica
• Miocardopatii
• Insuficiente valvulare acute : mitrala si aortica
• Anomalii de umplere ventriculara
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Infarct miocardic acut
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Insuficienta circulatorie acuta - socul
Alte cauze care afecteaza functia de pompa a inimii:
• Tamponada cardiaca prin : pericardita, hemopericard
• Pneumotoraxul sub presiune
• Embolia pulmonara masiva
• Insuficienta cardiaca hipodiastolica in tulburari de ritm cu tahicardie severa
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Fiziopatologie: elemente caracteristice
Socul cardiogen:
Scade debitul cardiac si indexul cardiac
Scade tensiunea arteriala
Centralizarea circulatiei
Creste rezistenta vasculara periferica
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Insuficienta circulatorie acuta - socul
• Socul septic: soc + febra / hipotermie+ focarinfectios + leucocitoza
• Socul anafilactic : contact cu un alergen
• Socul neurogen: traumatism cranian, sectiuneamedulara
Au ca mecanism comun de producere maldistributiafluxului sanguin tisular.
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Fiziopatologie: elemente caracteristice
Socul septic:
Hipoxie tisulara prin deficit de utilizare a oxigenului –blocaj enzimatic prin endotoxine bacteriene
Eliberare de citokine : vasodilatatie, scaderearezistentei vasculare periferice, cresterea debituluicardiac
Tegumente calde
TA scazuta
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Y_tambe Wikipedia
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Fiziopatologie: elemente caracteristice
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Scade contractilitatea ( MDF ) - urmeaza fazahipodinamica, vasoconstrictie, tegumente reci
Agregare palchetara
Initial DO2 crescuta dar utilizarea celulara scazuta = disfunctie multipla de organe ( SDOM ) ulterior MSOF ( insuficienta multipla de organe)
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Fiziopatologie: elemente caracteristice
Socul anafilactic
• Eliberare masiva de histamina prin degranulareamastocitelor
• Vasodilatatie
• Scaderea presiunii arteriale
• Bronhoconstrictie
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Wikipedia - imagine publica
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Socul neurogen
• Fractura cervicala cu sectiune medulara
• Suferinta cerebrala grava – moarte cerebrala
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Imagine din colectia personala
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Monitorizarea in starile de soc
• Frecventa cardiaca
• Pletismografia pulsului periferic, saturatia sangelui periferic(pulsoximetru)
• Tensiunea arteriala prin metoda noninvaziva : TAS, TAD, TAM
• Diureza : indicator al perfuziei tisulare ; scaderea sa pe oraindica hipoperfuzie tisulara
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Monitorizarea in starile de soc
• Monitorizarea invaziva a presiunii arteriale
• Presiunea venoasa centrala – cateter venos central
• Analiza curbei pulsului periferic : cateter arterial
debitul cardiac, indexul cardiac ,volumul sistolic, rezistenta vascularaperiferica
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Lactatemia < 2 mmol /lExcesul de baze ±2 mmol/l
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Monitorizare hemodinamicabazata pe analiza curbei
pulsului perifericImagine din colectia personala
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Principii de tratament in soc
Administrarea de oxigen si ventilatia mecanica
Creste continutul de oxigen al sangelui si oferta de oxigen catre tesuturi
Scade efortul respirator al pacientului
Administrarea de lichide
Optimizarea volemiei pacientului
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Principii de tratament in soc
Administrarea de catecholamineCresterea contractilitatii miocardice, cresterearezistentei vasculare periferice, cresterea intoarceriivenoase
Administrarea de vasodilatatoarepentru scaderea rezistentei vasculare periferice
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Efectele catecholaminelor
Receptor farmacologic α1
vasoconstrictori
α2
vasodilatatori
β1tonicardiac
β2vasodilatator
Δdiuretic
Noradrenalina +++ +
Adrenalina ++ +++ +
Dopamina ++ ++ ++
Dobutamina +++ ++
11.11.2016 35Dupa Pr. JJ.Rouby Etats de Choc
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Socul hipovolemic
• Hemostaza :
interventie chirurgicala,ORL,ginecologica,factori de coagulare
• Corectarea hipovolemiei
Sange, plasma
Solutii macromoleculare : HAES,Voluven
Solutii cristaloide : Nacl 0,9%, Ringer, Ringer lactat
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Socul septic
• Tratamentul focarului infectios :
Chirurgie, Antibioterapie
• Catecholamine i.v. continuu :
Noradrenalina ± Dobutamina
• Hemofiltrarea continua
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37Wikipedia
Wikipedia
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Socul anafilactic
• Oprirea/ eliminarea antigenului
• Perfuzii cu sol. cristaloide sau macromolecule
• Adrenalina i.v. continuu sau 0,1 – 1 mg i.v. pana la remisiune
• Corticoizi, antihistaminice, bronhodilatatoare
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11.11.2016 39Imagine din colectia personala