Pre-ICU training CV CR 蕭智忠
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Transcript of Pre-ICU training CV CR 蕭智忠
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Pre-ICU training
CV CR 蕭智忠
Pre-ICU training
CV CR 蕭智忠
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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
• 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
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OrientationOrientation
• 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)
• 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)
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OrientationOrientation
• 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
• 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
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AMIAMI• 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
• 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
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CHF with pulmonary edemaCHF with pulmonary edema
• Nitrate + Diuretics and keep I/O negative
• ACEI
• O2
• Correct hypoalbuminemia
• Swan-ganz monitor
• Nitrate + Diuretics and keep I/O negative
• ACEI
• O2
• Correct hypoalbuminemia
• Swan-ganz monitor
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TPM or PPMTPM or PPM
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IndicationIndication
• 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
• 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
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Swan-ganzSwan-ganz
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IndicationIndication
• 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
• 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
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肺動脈導管 臨床應用
肺動脈導管 臨床應用
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導管介紹導管介紹
• 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
• 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
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CCOmbo VolumetricsPulmonary Artery Catheter
Continuous Right Ventricular End Diastolic Volume (RVEDV) and Right Ventricular Ejection Fraction (RVEF)
measurements.
Swan-Ganz CCOmbo Pulmonary Artery Catheter
Swan-Ganz Continuous Cardiac Output, Mixed Venous Oxygen
Saturation monitoring (CCO/SVO2)pulmonary artery catheter
Thermodilution Catheter and IntroFlex Sheath with No Latex Components
Swan-Ganz Catheter with Non Latex components for assessment of right heart pressures, cardiac
output
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LumenLumen• 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)
• 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)
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目的目的• 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
• 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
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IndicationsIndications
• 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
• 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
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ContraindicationsContraindications
• Tricuspid or pulmonary valve mechanical prosthesis
• Right heart mass (thrombus and/or tumor)
• Tricuspid or pulmonary valve endocarditis
• Tricuspid or pulmonary valve mechanical prosthesis
• Right heart mass (thrombus and/or tumor)
• Tricuspid or pulmonary valve endocarditis
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placementplacement
• 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.
• 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.
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Normal rangeNormal range
右心房 (RA)
平均值 1~7mmHg
肺動脈 (PA)
收縮壓 (PASP) 15~25mmHg舒張壓 (PADP) 8~15mmHg
右心室 (RV)
收縮壓 15~25mmHg 舒張壓 0~8mmHg
肺微血管楔壓 (PCWP)
6~12mmHg
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Complications from the techniqueComplications 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
• 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
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Complications from the catheterComplications 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 )
• 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 )
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技術技術• 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
• 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
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
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程序程序執行前
• 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 )
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
• 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
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執行中執行中
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
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
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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
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
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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
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
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肺動脈導管的原理 (1)肺動脈導管的原理 (1)
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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
• 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
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Thermodilution 測量出 Cardiac Output 圖解 Thermodilution 測量出 Cardiac Output 圖解
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測量肺動脈楔壓 (PCWP)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
• 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
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測量 CO 之步驟測量 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 ")
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 ")
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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
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
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測量結果測量結果
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
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
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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
• 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
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肺動脈導管的數據解讀 (1)正常各腔室壓
肺動脈導管的數據解讀 (1)正常各腔室壓
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肺動脈導管的數據解讀 (1)各類血行動力學術據
肺動脈導管的數據解讀 (1)各類血行動力學術據
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IABPIABP
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IndicationIndication
• 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
• 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
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IndicationIndication
• 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
• 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
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ContraindicationContraindication
• 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
• 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
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ComplicationComplication
• A. Vascular – Ischemia– Bleeding
• B. Infection
• C. Balloon rupture
• D. Balloon entrapment
• E. RBC and platelet destruction
• F. Others
• A. Vascular – Ischemia– Bleeding
• B. Infection
• C. Balloon rupture
• D. Balloon entrapment
• E. RBC and platelet destruction
• F. Others
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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
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Figure 1b.Early inflation. May result in premature closure of aortic valve, increase in LVEDV and LVEDP, increased afterload, increased myocardial oxygen demand
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Late inflation. Results in sub-optimal coronary perfusion.
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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.
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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.