重症病患动脉导管监测

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,重症病患动脉导管监测,基本概念,血液動力學監測分,非侵入性方式：身體檢查與評估技巧,(,如測量頸靜脈壓、水腫程度、呼吸音變化等,),、監測心電圖、非侵入性血壓測量,(NBP),、脈衝式血氧監測,(SPO2 ),、超音波等,侵入性方式：侵入性的導管，放置在重要的血管,(,動脈或靜脈,),或心臟內，利用高科技儀器來直接監測該處的,壓力,或,血液成分的變化,，使醫護人員快速、準確、持續的評估病人。,監測的基本配備,導管,依照所欲監測的部位,(,例如中心靜脈、動脈、肺動脈,),選擇適當的,導管,(cathter),插入，在臨床上常使用的導管包括中心靜脈導管、動脈導管、肺動脈導管等,壓力管,材質較一般的輸液管來的堅硬，可減少導管彈性、熱脹冷縮、導管彎曲的影響。,導管長度不宜過長或過短，導管過長會影響壓力傳導，過短會使病人活動受限，因此通常大約為,34,呎,(,不超過,90120,公分,),導管中間有一個三路活塞,(,不超過,3,個,),可供需要時使用,壓力感受器與壓力轉換器,壓力感受器,(dome),一端與壓力管相連，一端與,壓力轉換器,(transducer),相扣。,當血管內的壓力波動經由壓力管傳至壓力感受器時，其內側的,膜面,(diaphragm),會震動、突出，此時震動、突出的膜面則撞擊壓力轉換器上的金屬膜，壓力轉換器則將金屬膜上的壓力轉換成,電訊息,(electrical signal),，並將電訊息放大在,監視器,(monitor),上呈現出壓力的,波形,(waveform),與,數值,(value),。,舊式的壓力感受器與轉換器之間可分開使用或更換，現在大多將兩者合併製作，改為單一使用即棄式以減少感染的機會。,連續沖洗系統,整個監測系統使用前作管路排氣之用外，還可藉此維持管路的通暢。,臨床上最常使用含有少量肝素,(,通常為,1 U heparin/1 ml),的生理食鹽水，以避免血栓形成。,由於此,導管通常使用在較高壓力的血管,內，因此沖洗溶液外必需使用,加壓袋,(pressure bag),加壓至,300mmHg,，,可避免管路回血阻塞，另外還可藉此壓力使沖洗液以,3 ml/hr,的速度進入病人體內，以維持導管的通暢。,由於沖洗溶液中的,肝素,(heparin),可能產生,出血,的副作用，因此臨床上多考量病人情況，以決定沖洗溶液中是否加入肝素。,監測的步驟與校正,維持適當的姿勢,平躺仰臥通常被認為是獲得正確血液動力數據的標準姿勢,當病人平躺會造成,呼吸困難,、,疼痛,、,躁動,時，讓病人採不同程度的半作臥姿勢反而才能的到較正確的數值，因此測量的姿勢應以病人舒適，,不增加胸內壓,的情況為準，不管採用何種姿勢，每次,測量時應維持一致的姿勢,，若姿勢改變時應在,記錄,上加以註明。,轉換器水平,(leveling),將,壓力轉換器,(transducer),與正確的,體外零點,(external reference point),放置在同一水平線上,(,可使用水平儀確認是否水平,),，其主要目的為,減少血液重量產生的靜水壓,對壓力轉換器的影響。,當壓力轉換器低於體外零點的高度時，壓力轉換器會多承受此高度差異所產生的靜水壓力，而使所測得的壓力值比真正壓力值來的高,當壓力轉換器高於體外零點的高度時，所測得的壓力值會比真正壓力值來的低,歸零,(zeroing),藉由轉動壓力轉換器上的,三路活塞,(3-way),與大氣相通，使壓力轉換器視大氣壓力為相對性的零點，其主要目的是去除大氣壓力對壓力轉換器的影響。,實際操作的步驟為：,轉動壓力轉換器上的三路活塞使病人導管端關閉,(,關病人,), 使壓力轉換器與大氣端相通,(,通大氣,), 按下監測儀器上的歸零按鈕,(,按,Zero), 使壓力轉換器與大氣端關閉,(,關大氣,), 使壓力轉換器與病人導管端相通,(,通病人,),。,監測系統常見問題與處理方法,壓力的波形,波形,高而尖,(underdamped),波形,低而平緩,(overdamped),監測系統常見的問題,常見之合併症與護理,感染,(infection),導管插入時的,無菌技術,需嚴格執行,導管,留置期間,的導管護理需確實維持導管傷口清潔、乾燥，導管護理的常規因各醫院有所不同,(,一般來說，導管,傷口,應每天,換藥,連續,沖洗系統溶液,或輸液應每天,更換,監測系統導管,應每,3,天更換一次、,插入導管,每,7,天更換一次等,),。,出血,(hemorrhage),滲血,(oozing),，可以紗布直接加壓止血，尤其是動脈導管因為壓力高，因此拔管後傷口應直接加壓,510,分鐘以上，以避免出血或血腫。,導管的接頭需確實連接妥當，,避免,因,接頭,鬆脫,(disconnection),而造成大出血。,對於躁動的病人，應予適當的保護性約束或鎮靜藥物，以,避免自拔,導管造成大出血。,栓塞,(embolism),連續沖洗系統溶液內含少量肝素，並且在溶液外維持加壓袋,300mmHg,的壓力，均可預防血栓的形成,導管內的空氣或血塊可能產生血管內栓塞，因此監測系統內若有空氣或血塊，應以回抽的方式抽出，不可以管路沖洗的方式將空氣或血塊沖入體內。,血栓與導管的留置,(,尤其是動脈導管,),均可能影響該血管的血液灌流，因此需特別注意,末梢的血循狀況,，並且比較雙側肢體的膚色、溫度、脈搏強度、有無疼痛或麻痺等感覺異常的情形。,常用的監測導管,中心靜脈導管,(central venous catheter),動脈導管,(artery catheter),肺動脈導管,(pulmonary artery catheter,或稱,Swan-Ganz catheter),中心靜脈導管,(central venous catheter),插入部位與優缺點,臨床應用,測壓方法,判讀,插入部位與優缺點,插入部位,優點,缺點,鎖骨下靜脈,穿刺容易,病人活動不受限制,可能造成,氣胸,可能傷及鎖骨下動脈,內頸靜脈,較少發生氣胸,病人活動不受限制,可能傷及頸動脈,敷料固定不易,頸部活動受限,肘前靜脈,沒有氣胸的危險,出血的危險性較小,穿刺較不易,感染與血栓發生率高,股靜脈,穿刺容易,沒有氣胸的危險,可能傷及股動脈,髖關節彎曲受限,感染與血栓發生率高,臨床應用,作為輸液的管路,可用來作輸液管路，可方便於給予大量或特殊輸液,(,例如,TPN),，以及特殊藥物,(,例如化學藥物、,dopamine),。,測量中心靜脈壓,中心靜脈導管若連接測壓計,(,水柱式或血液動力監測系統,),可測量到該處的,中心靜脈壓力,(central venous pressure; CVP),CVP,值可作為反應病人血液動力狀態之用,有意義的,CVP,值是指,右心房,(right atrium; RA),或靠近右心房的,腔靜脈,(vena cava),壓力值，因此由鎖骨下靜脈或內頸靜脈插入至右心房處，方能測得到較準確的,CVP,值時,測壓方法,測壓方式,水柱測壓計,血液動力監測系統,數值特性,間歇,(intermittent),數值，,多久測量一次則視病人病情而定,持續,(continued),數值,測量步驟,在測壓前應將水柱測壓計的零點與病人的體外零點調整至同一水平線上,(leveling),，,然後轉動水柱測壓計的三路活塞加以測量,CVP,數值,在第一次測量時,(,之後至少每隔,8,小時,),作一次前述的校正,(calibration),動作,(,含,leveling,、,zeroing,),，即可得知病人的,CVP,波,形與數值,正常值,4 12 H,2,O cm,17 mmHg,Guide to interpretation of the CVP in the hypotensive patient,CVP reading：Low,Rapid pulseBlood pressure normal or lowLow urine outputPoor capillary refill,Diagnosis to consider:Hypovolaemia,Treatment:Give fluid challenges* until CVP rises and does not fall back again. If CVP rises and stays up but urine output or blood pressure does not improve consider inotropes,CVP reading：Low,Rapid pulseSigns of infectionPyrexiaVasodilation,Diagnosis to consider:Sepsis,Treatment:Ensure adequate circulating volume (as above) and consider inotropes or vasoconstrictors,CVP reading：Normal,Rapid pulseLow urine outputPoor capillary refill,Diagnosis to consider:Hypovolaemia,Treatment:Treat as above. Venoconstriction may cause CVP to be normal. Give fluid challenges* and observe effect as above.,CVP reading,：,High,Unilateral breath sounds,Assymetrical,chest movementResonant chest with tracheal deviationRapid pulse,Diagnosis to consider:Tension,pneumothorax,Treatment:Thoracocentesis,then,intercostal,drain,CVP reading,：,High,BreathlessnessThird heart soundPink frothy sputum,Oedema,Tender liver,Diagnosis to consider:Heart failure,Treatment:Oxygen, diuretics, sit up, consider,inotropes,CVP reading,：,Very High,Rapid pulseMuffled heart sounds,Diagnosis to consider:Pericardial,tamponade,Treatment:Pericardiocentesis,and drainage,影響,CVP,值的因素,血液總量,靜脈壓,胸內壓,心室功能,CVP,值上升,輸液過量,使用血管收縮劑,上腔靜脈受壓,呼吸機使用,PEEP,氣胸,躁動不安,心包填塞,心臟衰竭,肺高壓,CVP,值下降,大出血,脫水,腹瀉,敗血症,使用血管擴張劑,Fluid challenge,In hypotension associated (伴隨)with a CVP in the normal range give repeated boluses(大量 )of intravenous fluid (250 - 500mls).,Observe the effect on CVP, blood pressure, pulse, urine output and capillary refill(再充填). Repeat the challenges(補充液體) until the CVP shows a sustained rise and/or the other cardiovascular parameters return towards normal.,With severe blood loss, blood transfusion will be required after colloid or crystalloid have been used in initial resuscitation. Saline or Ringers lactate should be used for diarrhoea/bowel bstruction /vomiting /burns etc.,動脈導管,(artery catheter),導管的插入與部位,臨床應用,Minimum Competency(Nurse),Must be able to identify the indications(適應症) for arterial pressure monitoring.,The nurse must payable to assemble necessary equipment(設備) for insertion of an arterial catheter.,The nurse must be able to perform a,Allens test,.,Support the patients wrist and dorsiflex the radius to assist the physician during insertion.,Level the transducer with the phlebostatic axis. This must be repeated at least every four hours and as needed.(零點水平),The nurse will be unable to identify the normal arterial waveform and troubleshoot(檢修故障) any deviations as needed.,During flushing(沖洗管路), the nurse will observe the skin at the site and distally(遠端) for blanching.,Compared(比較) to direct arterial pressure measurements with the indirect measurements.,The pulse, color, sensation, and temperature, distal to the site will be assessed(評估) every two to four hours.,The nurse caring for a patient with arterial line must be able to change the flush solution, tubing and dressing, according to hospital guidelines. Inspect(監測) for signs of infection.,The nurse caring for a patient with an arterial line must be able to obtain(獲得) blood samples(血液檢體) from the arterial catheter using the needless system.,After the arterial catheter is removed pressure(加壓) will be held directly over the site for 10 minutes.,The nurse with document(文件) all pertinent(相關的) information on the flow sheet and clinical record.,Indications for arterial blood pressure measurements,When accuracy(準確) in blood pressure measurement is needed,Frequency(持續)of blood pressure is needed,Some of those are as follows,Gradual (漸進的 )or acute hypotension or hemorrhage.,Circulatory or cardiac arrest(暫停).,Hypertensive crisis(危象).,Sepsis are respiratory failure.,Neurologic injury.,Post-operative complications.,When the patient is on,vasoactivedrugs (血管作用藥物),such as dopamine, nitroglycerin,The arterial line may also be used when the patient requires frequent ABGs or other blood work.,Limitations of arterial lines,The arterial line pressures should be 5 to 20 mmHg higher(較高) then cuffed measurements.,If the arterial line pressure 5-20 mmHg over cuff pressure measurement, one of the following is occurring:,cuff is too small for the pt arm, will read high.,cuff is too large for the p/t arm, will read to low.,Equipment malfunction(,發生故障,).,in severe shock, or hypothermia,occlusive peripheral vascular disease.,Potential(潛在的 )complications.,Hemorrhage.,Air emboli.,Equipment malfunction.,Inaccurate pressures.,Dysarhythmias.,Infections.,Tubing separation.,Altered skin integrity.,Impared circulation to extremities.,Altered hemodynamics.,導管的插入與部位,插管部位,說明,橈動脈,(radial artery),易插入，有尺動脈側支循環，對末梢循環影響的機會較小，表淺近骨突處所以傷口較易止血，在臨床上最常用。,臂動脈,(brachial artery,),易插入，易,影響肢體活動,，須注意影響前臂血流，若血腫可能壓迫到正中神經，在臨床上常見。,股動脈,(femoral artery,),休克時較其他部位易插入，較易感染，可能影響下肢血流。,足背動脈,(dorsalis pedis artery,),血管管徑較小，較,易影響末梢血,循，離心較遠使數據偏高，通常是其他部位無法插入時考慮使用的部位。,EQUIPMENT,500 mls Heparinize Normal Saline ( premixed),Pressure Bag,2 x 5 ml. syringes,Surgical mask Sterile gloves,Insite cannula 20 G x 2,Monitoring cable and module,Disposable pressure monitoring kit,OP site,Sterile Normal Saline flush x 2,臨床應用,抽血檢查,測量血壓,不可使用沖洗溶液以外的靜脈輸液，以避免動脈組織的壞死或硬化。,抽動脈血,一般血液,生化檢查,動脈血液氣體分析,不可用來作,血液培養,(blood culture),。,監測血壓,校正,第四肋間與腋中線交叉點,導管插入部位為體外零點,正常動脈波型,各部位動脈導管壓力波型,肺動脈導管,(pulmonary artery catheter,or,Swan-Ganz catheter),導管簡介,插管部位與步驟,臨床應用,Introduction,The flow-directed(,流量指引),balloon-tipped pulmonary artery (PA) catheter,The Swan-Ganz catheter SGC) has been in clinical,use for almost 30 years,.,Initially developed for the,management of acute myocardial infarction (AMI),Now has,widespread(,普及的 ),use in the,management,of a,variety of critical illnesses,and surgical procedures.,History,In 1929, Werner Forssmann was to develop a technique for direct delivery(,傳送 ),of drugs to the heart.,H.J.C. Swan noticed a sailboat moving quickly despite the calm weather. This led to the initial idea of devising a catheter with a parachutelike(,類似延緩落體的裝置),or sail-like device attached.,William Ganz on the thermodilution(,溫度稀釋),method of measuring cardiac output (CO) was incorporated(,結合),into the catheters use. This basic design remains in use today.,The,heart and pulmonary,system,INDICATIONS-1,評估左心功能,反應強心劑在降低Preload & Afterload之效果,監測混合靜脈血氧飽和濃度(SvO,2,),Therapeutic - Aspiration of air emboli,INDICATIONS-2,Diagnostic,Diagnosis of shock states (休克狀態),Differentiation(區別) of high- versus low-pressure pulmonary edema,Diagnosis of primary(原發性) pulmonary hypertension肺高壓 (PPH),Diagnosis of valvular disease, intracardiac shunts(分流), cardiac tamponade, and pulmonary embolus (PE),Monitoring and management of complicated AMI,Assessing (評估) hemodynamic response to therapies,Management of multiorgan(多重器官) system failure and/or severe burns,Management of hemodynamic instability(不穩定 ) after cardiac surgery,Assessment of response to treatment in patients with PPH,Contraindications (禁忌症 ),Tricuspid or pulmonary valve mechanical prosthesis(置換 ),Right heart mass (thrombus and/or tumor),Tricuspid or pulmonary valve endocarditis,導管簡介,110 cm long, with extra connecting tubes for attachment to the pressure transducer,PA lumen or distal(遠端) lumen,:開口在尖端,RA lumen or proximal(近端) lumen,:開口在距導管尖端30公分處,測量RAP,相當於CVP,Thermistor(溫度偵測) lumen,:距導管尖端4公分處有對溫度敏感的金屬絲, is the used to measure temperature changes for calculation of CO. (以溫度稀釋法),Balloon lumen,:距導管尖端1公分處,Four lumen,Five lumen-CCO,Six lumen-CCO,SvO,2,插管部位與步驟,Zero reference,歸零,The reference point for this is the midpoint of the,left atrium,(LA), estimated as the,fourth intercostal space(,第四助間),in the,midaxillary line,(,腋中腺),with the patient in the,supine position(,平躺),.,Calibration (,校正),Dynamic,動態的,tuning,Insertion,Preference(,選擇),considerations for cannulation of the great veins are as follows:,Right internal jugular vein (RIJ),右內頸靜脈,- Shortest and straightest path to the heart,Left subclavian,右鎖骨下靜脈,- Does not require the SGC to pass and course at an acute angle to enter the SVC (compared to the right subclavian or left internal jugular LIJ),Femoral veins,股靜脈,- These access points are distant sites, from which passing a SGC into the heart can be difficult, especially if the right-sided cardiac chambers are enlarged.,導管插入護理措施,Trendelenburg position is used for venous access(,取得),Before insertion, check the SGC for cracks(,破裂,) and kinks.,Check balloon function, connect all lumens to stopcocks, and flush them to eliminate air bubbles.,After inserting the SGC as far as the 20-cm mark (30-cm mark if the femoral route used), the balloon is inflated with air. Inflation should be slow and controlled (1 cc/s) and should not surpass the recommended volume (usually 1.5 cc).,Always use,continuous pressure monitoring,from the distal lumen.,Watch,the monitor for,changes,in the,waveform,and abnormal cardiac rhythms. The RA is entered at approximately 25 cm,The RV at approximately 30 cm, The PA at approximately 40 cm;,The PCWP can be identified at approximately 45 cm.,If an RV waveform still present approximately 20 cm after the initial RV pattern appears, the catheter may be coiling in the RV. fluoroscopy may be necessary to visualize the catheter and remove the knot.,PAD,PAWP,LEVEDP,LAP,相差,15mmHg,當肺,血管,僧帽瓣及左心室功能正常時,PAWP-,間接代表左心的壓力,也相當於,LV,之,Preload,評價左心的功能及預後的重要指標,決定藥物治療的重要因素,PAD,LAP,正常相差15mmHg,肺高壓或肺栓塞相差會大於5mmHg,當病人出現下列情況:PAWPLVEDP時無法反映左心功能,胸內壓明顯上升,肺靜脈阻塞,僧帽瓣狹窄,左心房黏液瘤,For pulmonary capillary wedge pressure (PCWP) to be reliable, the catheter tip,must lie in zone 3(,左心房下之肺區,教能正確反應,LAP,.,Pulmonary artery pressure (,Ppa,) is greater than pulmonary venous pressure (,Ppv,), which is greater than alveolar pressure (,Palv,) at end-expiration. In zones 1 and 2,Ppw,reflects,Palv,if,Palv,is greater than,Ppv,.,Physiologic lung zones(肺臟血流的分佈),zone 1,肺泡壓比肺動脈及肺靜脈壓大,因此肺微血管沒有血流,zone 2,肺泡壓比肺靜脈壓大但比肺動脈低足夠允許一些血流,zone 3,肺動脈及肺靜脈壓大於肺泡壓,肺微血管暢通持續都有血流,且肺泡壓力恆定,護理措施,測量PAWP時,勿充氣超過1.5ml,以避免造成氣嚢與血管破裂之危險,充氣時間不超過15秒,若充氣小於1.2ml就出現PAWP的波形或Overwedged,表示導管進入太深而到小血管,如此會增加血管破裂之危險,應立即放氣,並通知醫師將導管緩慢拉出12cm,導管尖端可能太淺而滯留於右心室,引起心室的不穩定與心律不整的危險,需將氣囊充氣使其重新漂入肺動脈,當氣囊在充氣狀態時,勿沖洗導管,充氣管腔不可輸注液體,當充氣時沒有出現PAWP波型,且感到阻力消失,此時可能是Balloon Rupture,不可再充氣,並將充氣管腔關閉並註明,所有壓力之測量應在吐氣末期測出,導管的拔除:需減少空氣栓塞之危險,自發性呼吸的病人應在吐氣期拔除,使用呼吸器的病人應在吸氣期拔除,心輸出量Cardiac Output,影響Cardiac Output的因素,CO,心收縮力,Preload,Afterload,HR,SV,右心 CVP,RAP,左心 PAP,PAWP,LAP,右心 PVR,左心 SVR,Frank-Starling Law,Preload:心舒期,存於心室的血量,Afterload:心室收縮打出去血液時所遇到的阻力,前負荷下降,前負荷增加,前負荷下降,前負荷增加,體液容積減少,靜脈擴張,心摶過快,體液容積增加,靜脈收縮,心摶過緩,動脈擴張,septic shock,血液粘稠度降低,動脤血壓增加,動脈收縮,動脈硬化,主動脈狹窄,心因性休克,僧帽瓣閉鎖不全,間歇,Q8h or QD Check,由近端管腔注入N/S 10,5,2.5 ml,4,0,C or 室溫,由Stewart-hamilton公式(考量溶液,血液本身的體積,比重,比熱,溫度等因素)計算CO,持續,此導管在右心室的地方有一段加熱纖維,溫度最高限制在44,0,C,CO之測量方法,混合靜脈血氧飽和濃度,全身靜脈血回流的終點,監測,心肺系統、疾病壓力、組織灌流情形,SvO,2,測量方式與步驟,間歇測量:,經由,Swan-Ganz,導管的遠側管腔，抽取肺動脈血液檢體，再經由氣體分析儀器檢查血液中氧氣分壓、二氧化碳分壓、氧氣飽和度、酸鹼度等數值，其中以氧氣分壓,) (PVO2,與氧氣飽和度,) (SVO2),的臨床意義最為重要。,持續測量:,必須使用前端含有光纖維的,Swan-Ganz,導管才可使用此方式持續監測病人的混合靜脈血氧飽和度,) (SvO2,，此種方法是藉由紅血球對光的反應，再經電腦每,5,秒計算,1,次,2 SvO,，而達到持續監測的目的,SvO,2,臨床意義,SvO,2,上升,下降,影響因素,氧氣供應增加,組織需氧減少,氧氣供應減少,組織需氧增加,常見原因,CO,Hb(輸血),SaO2(,氧氣治療、氧氣解離曲線左移,),使用麻醉、止痛、,肌肉鬆弛劑、,體溫過低,甲狀腺功能低下等,CO,Hb(出血,貧血),SaO2,(,肺病、抽痰、氧氣解離曲線右移,組織消耗氧氣增加(,發燒、疼痛、顫抖、外傷、感染、運動、焦慮等),Thank You,世界触手可及,携手共进，齐创精品工程,谢谢观赏！,2020/11/5,77,