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1、糖尿病下肢血管病变检查Vascular Assessment 北京迪美德尔科技有限公司 医学部整理Educational ProgramsEducating to perform 血管检查培训血管检查培训 Vascular Assessment ABI(臂踝指数)检查 ABI Assessment 多普勒波形及声音 Doppler waveforms and sounds 足趾动脉PPG检查 Arterial PPG 足趾血压和TBI检查 TBPI using Arterial PPG PPG下肢静脉功能检查Venous PPGABI ( (踝臂指数踝臂指数) ) 检查检查ABI Assess
2、ment使用多普勒使用多普勒 Why Use Doppler Vascular Assessment Training Session - Introductory 足部的触诊是不充分的.Palpation of foot pulses is not sufficient (Moffatt 1995) 踝部血压用普通听诊器无法测得.BP measurement at the ankle using a Stethoscope are difficult (Yao 1993) 10%的病人缺失足背动脉的脉搏.10% of patients have absent Dorsalis Pedis p
3、ulses (Callam 1987)所有存在溃疡的病人都需要有一个受过专业培训的人员使用多普勒进行ABI检测来监测动脉病变的情况.All patients presenting with an ulcer should be screened for arterial disease by Doppler measurement of ABI by staff who are trained to undertake this measurement. Clinical Practice Guidelines (RCN 1998).解释检查程序 Explain and reassure pa
4、tient of the procedure保持室温舒适Ensure ambient temperature of the room is comfortable, (Moffatt 1990)松解上下肢体衣裤 Remove any tight clothing from both arms and stockings socks etc. from legs保护溃疡伤口 Remove any dressings from current ulcers and cover with a clear film, (Kenny 1997)患者保持安静休息1520分钟Rest the patient
5、 for 15-20 minutes, (Yao 1993; Williams 1993)患者仰卧 Position the patient supine,(Stubbing 1996)患者准备患者准备 Preparation of the Patient Vascular Assessment Training Session - Introductory正常静脉血流音 Sounds of normal vein血流声音血流声音Vascular Assessment Training Session - Introductory正常动脉血流声 Sound of normal arteryTh
6、e posterior tibial pulse is located in the hollow behind the medial malleolus, and the dorsalis pedis pulse is felt between the first and second metatarsals. (K.R Vowden, 1996)足部动脉足部动脉 Arteries of the Foot Vascular Assessment Training Session - Introductory足動脈前面後脛骨動脈後腓骨動脈貫通枝腓骨動脈前脛骨動脈弓状動脈 外側内側足根動脈 足背
7、動脈 外側内側足底動脈 足底動脈弓 貫通枝（深足底枝）後脛骨動脈内果後方部流、触診検査行適前腓骨動脈貫通枝足足踝踝血血压压 Ankle Pressures Vascular Assessment Training Session - Introductory 右足背右足背动脉收缩压动脉收缩压 Right DP Systolic Pressure足足踝踝血血压压 Ankle Pressures Vascular Assessment Training Session - Introductory 右胫后动脉收缩血压压 Right PT Systolic PressureABI检查检查 How t
8、o examine the ABI Vascular Assessment Training Session - IntroductoryABI计算计算 How to Calculate the ABI Vascular Assessment Training Session - Introductory8580145150120115足背動脈 Dorsalis Pedis後脛骨動脈 Posterior Tibial上臂 Brachial右右ABI Right ABI左左ABI Left ABI Normal ABI ratio is equal or greater than 0.90 bu
9、t not greater than 1.3(check local policy)= 85150= 0.57= 120150= 0.80ABI計算法計算法 ABI calculations足関節収縮期血圧最大測定値(両足) Highest ankle systolic pressure上腕収縮期血圧最大測定値 Highest brachial systolic pressure上臂 Brachial後脛骨動脈 Posterior TibialABI结果解释结果解释 How to interpret the ABI Vascular Assessment Training Session -
10、IntroductoryABI 0.9 - 1.3ABI = 0.7 - 0.9ABI = 0.4 - 0.7ABI 1.3 动脉正常 Unlikely to be arterial in origin轻度动脉疾病 Mild peripheral disease显著动脉疾病 Significant of arterial disease严重动脉疾病Severe arterial disease检测足趾血压Measure toe pressures or refer to specialistApply compression therapyApply compression therapy w
11、ith caution Do not compress refer to specialist Do not compress refer urgently to vascular specialist may vary according to local protocolsABI检查周期检查周期 Repeat ABI checks Vascular Assessment Training Session - Introductory每12周一次 It is recommended that the ABI is checked every 12 weeks (Simon 1994)howe
12、ver; if the patients condition changes during that time i.e. pain, the procedure should be repeated as necessary If an ulcer re-occurs, repeat the Doppler assessment Do not presume it is of the same origin影响影响ABI结果的因素结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Sessio
13、n - Introductory 动脉硬化 Atherosclerosis Hardening of arteries causing falsely elevated readings 心律不齐 Cardiac Arrhythmias (Vowden, K.P. 1996).More difficult to assess the sound 准备不足 Inadequate preparation i.e. room temperature血管收缩 Vaso constriction 患者焦虑 Patient and clinician anxious and unrelaxed血压升高 R
14、esulting into increased blood pressure 患者体位不舒服 Incorrect positioning of patientFalsely elevated ankle pressures 超声耦合剂不足 Inappropriate Gel空气气泡 Interference due to air bubbles 血压袖带不合适Incorrect size of sphyg cuff血压测量不准 Incorrect pressure measurements 多普勒探头不对 Inappropriate Doppler probe Ultrasound canno
15、t penetrate to depth of vessel 探头位置不正确 Incorrect position of Doppler probe over vessel血压测量不正确 Incorrect pressure measurements 对血管施压过大 Excessive pressure on vessel during procedure血管挤压Collapses vessels 血圧袖带放气过快Releasing sphyg cuff too rapidly Risk of missing systolic pressure point 血管加压时间过长Prolonged
16、inflation of the cuff/re-inflation Hyperemic effect on limb 血管反复加压Mid procedure/repeated inflation (Vowden K. P. 1996)Hyperemic effect on limb 检测过程中探头移动Moving Doppler during measurementIncorrect pressure measurement 检测经验不足Inexperience of the procedure(Anderson 1995)practical skill requiring assessme
17、nt by peers影响影响ABI结果的因素结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Session - Introductory多普勒波形和声音多普勒波形和声音Doppler waveforms and sounds心脏收缩期迅速升高的血流速心脏舒张期前期血液回流心脏舒张期后期血液顺流下肢动脉血流波形图多普勒波形和声音多普勒波形和声音 Doppler Waveforms & Sounds多普勒波形和声音多普勒波形和声音 Doppler Waveforms & Sounds 正常三
18、时相波形Triphasic Waveform - NormalVideo clip of Triphasic waveform 单相波形异常Monophasic Waveform2 - Abnormal 多普勒波形和声音多普勒波形和声音 Doppler Waveforms & Sounds失去多相波单失去多相波单元元单向波单向波波峰圆钝波峰圆钝NormalNormal正常正常坚锐的上升支坚锐的上升支三相波单元三相波单元Mildobstruction轻度梗阻轻度梗阻Moderate obstructionModerate obstruction中度梗阻中度梗阻Severe Obstruction
19、Severe Obstruction严重梗阻严重梗阻波峰消失波峰消失多普勒波形和声音多普勒波形和声音 Doppler Waveforms & Sounds足趾动脉足趾动脉PPGPPG检查检查Measuring Toe pressures and TBPI光电容积光电容积PPG原理原理 PPG Shift Explained Vascular Assessment Training Session - Introductory光电容积描记仪发射并接收红外线，红外线遇到组织时出现散射，遇到红细胞时则被其吸收。肢体的皮下微循环内血容量增加时被反射的红外线密度减少；反之则增大。影响影响PPG检查的因素
20、检查的因素 Factors affecting APPG measurements 室内温度应保持在2024摄氏度。The room temperature should be between 20 - 24C 检查前足趾不应裸露在外。Always keep toes covered until tests are started 患者检查局部的温度会影响波形（如凉手、凉足） Patient temperature - cold hands and feet will alter the waveform 吸烟-尼古丁会影响波形。Smoking - nicotine will distort
21、the waveform 患者肢体运动检测过程中应保持不动。 Patient movement - patients should remain still during the examinationPPG波形解释波形解释 APPG Waveform Interpretation正常Normal异常Abnormal下降坡重搏切迹尖峰基线重搏切迹消失，下降支轻度上弓上升支轻度下弓上升支延迟波峰园钝波幅减小足趾血压和足趾血压和TBITBI检查检查TBI using Arterial PPG糖尿病患者足趾血压糖尿病患者足趾血压 Diabetics and Toe PressuresABPI1.3时
22、，需进行足趾血压测定和时，需进行足趾血压测定和TBPI检查。检查。Undertake toe pressures and TBPI when ABPI1.3 (Brooks, 2001) 血管钙化很少发生在趾端动脉血管钙化很少发生在趾端动脉 Calcification rarely extends to digital arteries (Vowden, 1999) 足趾血压直接与足溃疡愈合相关足趾血压直接与足溃疡愈合相关 Toe pressures directly relate to foot ulceration healing (Carter, 1993) 对于糖尿病患者应给予更加关注
23、，需进行特殊的动脉检查，如足趾血压检查。对于糖尿病患者应给予更加关注，需进行特殊的动脉检查，如足趾血压检查。“In patients with Diabetes Mellitus additional care should be taken and further arterial investigations undertaken such as toe pressures” (ETRS guideline 2003)糖尿病患者足趾血压糖尿病患者足趾血压 Diabetics and Toe Pressures 动脉PPG是检查足趾血压的最佳手段。Arterial PPG is the pr
24、eferred technique to measure toe pressures (Vowden, 2002) 检测脚趾血压比多普勒操作简单得多Easier than Doppler to measure toe pressures 消除通过声音探测脉搏恢复Eliminates the need to audibly detect the return of the pulse 探头容易连接手指和脚趾Sensors easily attach to fingers & toes血压测定时，充气袖带放气速度应为23mmHg/秒Cuffs should be deflated at 2-3mm
25、Hg/sec (BHS, 2000)糖尿病患者足趾血压糖尿病患者足趾血压 Diabetics and Toe Pressures PPG检测足趾血压Toe Pressures using PPG135140上臂BrachialTBI計算法計算法 TBPI calculations足趾収縮期血圧Toe systolic pressure上臂収縮期血圧最大測定値Highest brachial systolic pressure14014075115足趾Toe= 75= 0.54= 115= 0.82右右TBIRight TBPI左左TBILeft TBI 上臂Brachial糖尿病患者足趾血压糖
26、尿病患者足趾血压 Diabetics and Toe Pressures糖尿病患者足趾血压糖尿病患者足趾血压 Diabetics and Toe Pressures正常TBI 0.7临界值TBI 0.65-0.7病变TBI 5540%85%97%73%100%100%(Carter,1993)PPG下肢静脉功能检查下肢静脉功能检查Using PPG for venous assessment 应用红外光传感器检查微循环的静脉血流Uses infrared light sensor to measure venous blood volume in the microcirculation 检查
27、整体的静脉循环情况Assesses overall venous circulation 不针对单个静脉血管Not vessel specific 通过止血袖带可以区分表浅静脉和深静脉的功能不全Can diagnose difference between superficial and deep venous incompetence using tourniquets 可用于筛查深静脉血栓形成Can screen for the absence of DVT应用应用PPG检查静脉检查静脉 Venous Assessment Using PPG 脱去鞋袜Remove stockings an
28、d footwear 将足放在绝缘板上Place foot on insulated mat 调节高度使足部承担压力最小Adjust height to minimise weight on feet 肥胖患者应适当依靠以减少静脉压迫Obese patients should be reclined to reduce venous compression传感器置于内踝上方10cm处（蓝线指示）Fit sensor 10cm above the medial malleolus (blue cable)使用使用ES-100V3检查时患者姿态检查时患者姿态 Patient Position us
29、ing Rheo Dopplex正常静脉正常静脉PPG曲线曲线 Normal PPG Curve 正常波形Normal Waveform正常患者的静脉PPG曲线应有正常的静脉再充盈时间（RT）应用应用PPG检查静脉检查静脉 Venous Assessment Using PPG如果在5次足部背曲运动后, 静脉回复时间20秒则提示下肢静脉瓣膜正常. If Refill Time (RT) is greater than 20 seconds, then venous insufficiency is not present or is not significant.RT20s 静脈再充満期（休
30、憩中）静脉排空时相（运动时）异常静脉异常静脉PPG波形波形 Abnormal PPG Curve 异常波形Abnormal WaveformDVT患者的VPPG曲线可以得到ACV/CFDI证实应用应用PPG检查静脉检查静脉 Venous Assessment Using PPG如果在5次足部背曲运动后, 静脉回复时间20秒则提示下肢静脉瓣膜功能不全, 可使用止血带法鉴别病变部位. If Refill Time (RT) is less than 20 seconds then venous reflux is present. Apply the tourniquet cuff at the
31、appropriate positions to determine the level of venous insufficiency, RT20S应用应用PPG检查静脉检查静脉 Venous Assessment Using PPG静脉血从动脉端再充盈Venous refill from arterial inflow存在静脉功能不全Venous incompetence present预示存在深静脉血栓Deep venous obstruction/insufficiency应用应用PPG检查静脉检查静脉 Venous Assessment Using PPG 使用止血袖带检查PPGVP
32、PG assessment using tourniquets第一部：使用用UTTq(大腿)止血带, 加压50-60mmHg。阻断大隐静脉回流（浅静脉）。进行测试：静脉回复时间正常 提示大隐静脉瓣膜功能不全。静脉回复时间不正常 提示病变部位不在大隐静脉。第二部：使用用AKTq(膝上)止血带, 加压50-60mmHg。阻断大隐静脉及膝上交通支静脉回流。进行测试：静脉回复时间正常 提示膝上交通支静脉瓣膜功能不全。静脉回复时间不正常 提示病变部位不在膝上浅静脉。第三部：使用用BKTq(小腿)止血带, 加50-60mmHg。阻断小隐静脉回流。进行测试：静脉回复时间正常 提示大小隐静脉瓣膜功能不全。静脉
33、回复时间不正常 提示病变部位不在浅静脉，病人可能存在深静脉病变。总结总结Summary总结总结 Summary 针对高危人群需进行血管检查针对高危人群需进行血管检查 Undertake vascular assessment for higher risk patients (NICE No. 10, 2004) 用手持式多普勒测量用手持式多普勒测量ABI评估下肢慢性溃疡是必要的评估下肢慢性溃疡是必要的,“Measurement of ABI by hand-held Doppler is essential inthe assessment of chronic leg ulcers”. (SIGN, 1998)针对血管钙化的患者进行足趾血压及针对血管钙化的患者进行足趾血压及TBI测定测定Measure toe pressures in patients with calcification (Vowden 1999)使用使用PPG整体静脉功能不全整体静脉功能不全 Use VPPG to determine overall venous function (King, 2004) 应用应用PPG筛查筛查DVT的存在的存在Screen for the absence of DVT using VPPG (Da Silva, 2000)北京迪美德尔科技有限公司
