1、.重癥病患血液動力監(jiān)測導(dǎo)管之護(hù)理.基本概念血液動力學(xué)監(jiān)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(jiān)測心電圖、非侵入性血壓測量(NBP)、脈衝式血氧監(jiān)測 (SPO2 ) 、超音波等侵入性方式：侵入性的導(dǎo)管，放置在重要的血管( 動脈或靜脈) 或心臟內(nèi)，利用高科技儀器來直接監(jiān)測該處的壓力或血液成分的變化，使醫(yī)護(hù)人員快速、準(zhǔn)確、持續(xù)的評估病人。.監(jiān)測的基本配備 導(dǎo)管依照所欲監(jiān)測的部位( 例如中心靜脈、動脈、肺動脈) 選擇適當(dāng)?shù)膶?dǎo)管(cathter) 插入，在臨床上常使用的導(dǎo)管包括中心靜脈導(dǎo)管、動脈導(dǎo)管、肺動脈導(dǎo)管等壓力管材質(zhì)較一般的輸液管來的堅硬，可減少導(dǎo)管彈性

2、、熱脹冷縮、導(dǎo)管彎曲的影響。導(dǎo)管長度不宜過長或過短，導(dǎo)管過長會影響壓力傳導(dǎo)，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(dǎo)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(zhuǎn)換器壓力感受器(dome) 一端與壓力管相連，一端與壓力轉(zhuǎn)換器(transducer)相扣。當(dāng)血管內(nèi)的壓力波動經(jīng)由壓力管傳至壓力感受器時，其內(nèi)側(cè)的膜面(diaphragm) 會震動、突出，此時震動、突出的膜面則撞擊壓力轉(zhuǎn)換器上的金屬膜，壓力轉(zhuǎn)換器則將金屬膜上的壓力轉(zhuǎn)換成電訊息(electrical signal)，並將電訊息放大在監(jiān)視器(monitor) 上呈現(xiàn)出壓力的波形

3、(waveform) 與數(shù)值(value)。舊式的壓力感受器與轉(zhuǎn)換器之間可分開使用或更換，現(xiàn)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(jī)會。.連續(xù)沖洗系統(tǒng)整個監(jiān)測系統(tǒng)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(dǎo)管通常使用在較高壓力的血管內(nèi)，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(jìn)入病人體內(nèi)，以維持導(dǎo)管的通暢。由於沖洗溶液中的肝素(heparin) 可能產(chǎn)生出血的副作用

4、，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(jiān)測的步驟與校正 維持適當(dāng)?shù)淖藙萜教裳雠P通常被認(rèn)為是獲得正確血液動力數(shù)據(jù)的標(biāo)準(zhǔn)姿勢當(dāng)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(shù)值，因此測量的姿勢應(yīng)以病人舒適，不增加胸內(nèi)壓的情況為準(zhǔn)，不管採用何種姿勢，每次測量時應(yīng)維持一致的姿勢，若姿勢改變時應(yīng)在記錄上加以註明。 .轉(zhuǎn)換器水平(leveling)將壓力轉(zhuǎn)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(rèn)是否水平)，其主要目的為減少血液重量產(chǎn)生的靜水壓對壓

5、力轉(zhuǎn)換器的影響。當(dāng)壓力轉(zhuǎn)換器低於體外零點的高度時，壓力轉(zhuǎn)換器會多承受此高度差異所產(chǎn)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(dāng)壓力轉(zhuǎn)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(zhuǎn)動壓力轉(zhuǎn)換器上的三路活塞(3-way) 與大氣相通，使壓力轉(zhuǎn)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(zhuǎn)換器的影響。實際操作的步驟為：轉(zhuǎn)動壓力轉(zhuǎn)換器上的三路活塞使病人導(dǎo)管端關(guān)閉( 關(guān)病人) 使壓力轉(zhuǎn)換器與大氣端相通( 通大氣) 按下監(jiān)測儀器上的歸零按鈕( 按Zero) 使壓力轉(zhuǎn)換器與大氣端關(guān)閉( 關(guān)大氣) 使壓力轉(zhuǎn)換器與病人導(dǎo)管端相通( 通病人)。

6、.監(jiān)測系統(tǒng)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(jiān)測系統(tǒng)常見的問題.常見之合併癥與護(hù)理 感染(infection) 導(dǎo)管插入時的無菌技術(shù)需嚴(yán)格執(zhí)行導(dǎo)管留置期間的導(dǎo)管護(hù)理需確實維持導(dǎo)管傷口清潔、乾燥，導(dǎo)管護(hù)理的常規(guī)因各醫(yī)院有所不同( 一般來說，導(dǎo)管傷口應(yīng)每天換藥連續(xù)沖洗系統(tǒng)溶液或輸液應(yīng)每天更換監(jiān)測系統(tǒng)導(dǎo)管應(yīng)每3 天更換一次、插入導(dǎo)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(dǎo)管因為壓力高，因此拔管後傷口應(yīng)直接加壓510 分鐘以上，以避免出血或血腫。導(dǎo)管的接頭需

7、確實連接妥當(dāng)，避免因接頭鬆脫(disconnection)而造成大出血。對於躁動的病人，應(yīng)予適當(dāng)?shù)谋Ｗo(hù)性約束或鎮(zhèn)靜藥物，以避免自拔導(dǎo)管造成大出血。 .栓塞(embolism) 連續(xù)沖洗系統(tǒng)溶液內(nèi)含少量肝素，並且在溶液外維持加壓袋300mmHg 的壓力，均可預(yù)防血栓的形成導(dǎo)管內(nèi)的空氣或血塊可能產(chǎn)生血管內(nèi)栓塞，因此監(jiān)測系統(tǒng)內(nèi)若有空氣或血塊，應(yīng)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(nèi)。血栓與導(dǎo)管的留置( 尤其是動脈導(dǎo)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(cè)肢體的膚色、溫度、脈搏強(qiáng)度、有無疼痛或麻痺等感覺異常的情形。 .常用的監(jiān)測導(dǎo)管 中心靜脈導(dǎo)管

8、(central venous catheter) 動脈導(dǎo)管(artery catheter) 肺動脈導(dǎo)管(pulmonary artery catheter 或稱Swan-Ganz catheter).中心靜脈導(dǎo)管(central venous catheter) 插入部位與優(yōu)缺點 臨床應(yīng)用 測壓方法 判讀 .插入部位與優(yōu)缺點插入部位優(yōu)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(nèi)頸靜脈較少發(fā)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(fā)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(guān)節(jié)彎

9、曲受限感染與血栓發(fā)生率高.臨床應(yīng)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(xué)藥物、dopamine)。測量中心靜脈壓中心靜脈導(dǎo)管若連接測壓計(水柱式或血液動力監(jiān)測系統(tǒng)) 可測量到該處的中心靜脈壓力(central venous pressure; CVP) CVP值可作為反應(yīng)病人血液動力狀態(tài)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(nèi)頸靜脈插入至右心房處，方能測得到較準(zhǔn)確的CVP 值時.測壓方法測壓方式水柱測壓計血液動力監(jiān)測系統(tǒng)數(shù)值特性間歇

10、(intermittent) 數(shù)值， 多久測量一次則視病人病情而定持續(xù)(continued) 數(shù)值測量步驟在測壓前應(yīng)將水柱測壓計的零點與病人的體外零點調(diào)整至同一水平線上(leveling)， 然後轉(zhuǎn)動水柱測壓計的三路活塞加以測量CVP 數(shù)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(shù)值正常值4 12 H2O cm 17 mmHg.Guide to interpretation of the CVP in the hypotensive patientCVP reading：LowR

11、apid pulseBlood pressure normal or lowLow urine outputPoor capillary refillDiagnosis to consider:HypovolaemiaTreatment: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

12、 Rapid pulseSigns of infectionPyrexiaVasodilationDiagnosis to consider:SepsisTreatment:Ensure adequate circulating volume (as above) and consider inotropes or vasoconstrictors.CVP reading：NormalRapid pulseLow urine outputPoor capillary refillDiagnosis to consider:HypovolaemiaTreatment:Treat as above

13、. Venoconstriction may cause CVP to be normal. Give fluid challenges* and observe effect as above. CVP reading：HighUnilateral breath soundsAssymetrical chest movementResonant chest with tracheal deviationRapid pulseDiagnosis to consider:Tension pneumothoraxTreatment:Thoracocentesis then intercostal

14、drain. CVP reading：HighBreathlessnessThird heart soundPink frothy sputumOedemaTender liverDiagnosis to consider:Heart failureTreatment:Oxygen, diuretics, sit up, consider inotropes. CVP reading：Very HighRapid pulseMuffled heart soundsDiagnosis to consider:Pericardial tamponadeTreatment:Pericardiocen

15、tesis and drainage.影響CVP 值的因素 血液總量靜脈壓胸內(nèi)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(jī)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癥使用血管擴(kuò)張劑 .Fluid challengeIn 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

16、, 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 resusc

17、itation. Saline or Ringers lactate should be used for diarrhoea/bowel bstruction /vomiting /burns etc. .動脈導(dǎo)管(artery catheter)導(dǎo)管的插入與部位 臨床應(yīng)用 .Minimum Competency(Nurse)Must be able to identify the indications(適應(yīng)癥) for arterial pressure monitoring.The nurse must payable to assemble necessary equipment(設(shè)

18、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).

19、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(yuǎn)端) for blanching.Compared(比較) to direct arterial pressure measurements with the indirect measurements.The

20、 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(jiān)測) for signs of infection. .The nurs

21、e 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(guān)的) infor

22、mation on the flow sheet and clinical record. .Indications for arterial blood pressure measurementsWhen accuracy(準(zhǔn)確) in blood pressure measurement is neededFrequency(持續(xù))of blood pressure is needed .Some of those are as follows Gradual (漸進(jìn)的 )or acute hypotension or hemorrhage. Circulatory or cardiac

23、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. .Limit

24、ations of arterial linesThe 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 ar

25、m, will read to low. Equipment malfunction(發(fā)生故障 ). in severe shock, or hypothermia, occlusive peripheral vascular disease. .Potential(潛在的潛在的 )complications. Hemorrhage. Air emboli.Equipment malfunction.Inaccurate pressures.Dysarhythmias.Infections.Tubing separation. Altered skin integrity.Impared ci

26、rculation to extremities.Altered hemodynamics. .導(dǎo)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(cè)支循環(huán)，對末梢循環(huán)影響的機(jī)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(jīng)，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(yuǎn)使數(shù)據(jù)偏高，通常是其他部位無法插入

27、時考慮使用的部位。.EQUIPMENT500 mls Heparinize Normal Saline ( premixed) Pressure Bag2 x 5 ml. syringes Surgical mask Sterile gloves Insite cannula 20 G x 2 Monitoring cable and moduleDisposable pressure monitoring kit OP siteSterile Normal Saline flush x 2.臨床應(yīng)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

28、般血液生化檢查動脈血液氣體分析不可用來作血液培養(yǎng)(blood culture)。.監(jiān)測血壓 校正第四肋間與腋中線交叉點導(dǎo)管插入部位為體外零點.正常動脈波型各部位動脈導(dǎo)管壓力波型.肺動脈導(dǎo)管(pulmonary artery catheter or Swan-Ganz catheter)導(dǎo)管簡介 插管部位與步驟臨床應(yīng)用http:/ 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 y

29、ears. 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

30、.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(jié)合) into the cath

31、eters use. This basic design remains in use today. .The heart and pulmonary system.INDICATIONS-1評估左心功能反應(yīng)強(qiáng)心劑在降低Preload & Afterload之效果監(jiān)測混合靜脈血氧飽和濃度(SvO2)Therapeutic - Aspiration of air emboli.INDICATIONS-2Diagnostic Diagnosis of shock states (休克狀態(tài))Differentiation(區(qū)別) of high- versus low-pressure pu

32、lmonary edema Diagnosis of primary(原發(fā)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 therapiesManagement of multiorgan(多重器官) sy

33、stem failure and/or severe burns Management of hemodynamic instability(不穩(wěn)定 ) after cardiac surgery Assessment of response to treatment in patients with PPH.Contraindications (禁忌癥 )Tricuspid or pulmonary valve mechanical prosthesis(置換 )Right heart mass (thrombus and/or tumor) Tricuspid or pulmonary v

34、alve endocarditis .導(dǎo)管簡介110 cm long, with extra connecting tubes for attachment to the pressure transducer PA lumen or distal(遠(yuǎn)端) lumen:開口在尖端RA lumen or proximal(近端) lumen:開口在距導(dǎo)管尖端30公分處,測量RAP,相當(dāng)於CVP Thermistor(溫度偵測) lumen:距導(dǎo)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

35、 of CO. (以溫度稀釋法)Balloon lumen:距導(dǎo)管尖端1公分處.Four lumen.Five lumen-CCOSix lumen-CCO,SvO2.插管部位與步驟Zero reference歸零歸零 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)

36、.Calibration (校正校正)Dynamic動態(tài)的動態(tài)的 tuning .Insertion Preference(選擇) considerations for cannulation of the great veins are as follows: Right internal jugular vein (RIJ) 右內(nèi)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

37、 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(dǎo)管插入護(hù)理措施.Trendelenburg position is used f

38、or 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.

39、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

40、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 remo

41、ve the knot. .PADPAWPLEVEDP LAP相差15mmHg當(dāng)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(dāng)於LV之Preload評價左心的功能及預(yù)後的重要指標(biāo)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(dāng)病人出現(xiàn)下列情況:PAWPLVEDP時無法反映左心功能胸內(nèi)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(qū),教能正確反應(yīng)LAP. Pulmonary artery pressure (Ppa) is greater than pulmonary venous pressure (Ppv), which is greater than alveolar pressure (Palv)