重症病患动脉导管监测

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1、重症病患血液動力監測導管之護理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

2、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(wav

3、eform) 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

4、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

5、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

6、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(di

7、sconnection)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 cathet

8、er)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

9、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

10、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412H2Ocm17mmHgGuide to interpretation of the CVP in the hypotensive patientCVP reading:LowRapid pulseBlood pressure normal or lowLow urine

11、 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 inotropesCVP reading:Low Rapid pulseSigns of infectionPyrexiaVasodilatio

12、nDiagnosis to consider:SepsisTreatment:Ensure adequate circulating volume (as above) and consider inotropes or vasoconstrictorsCVP reading:NormalRapid pulseLow urine outputPoor capillary refillDiagnosis to consider:HypovolaemiaTreatment:Treat as above. Venoconstriction may cause CVP to be normal. Gi

13、ve 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 drainCVP reading:HighBreathlessnessThird heart sou

14、ndPink frothy sputumOedemaTender liverDiagnosis to consider:Heart failureTreatment:Oxygen, diuretics, sit up, consider inotropesCVP reading:Very HighRapid pulseMuffled heart soundsDiagnosis to consider:Pericardial tamponadeTreatment: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

15、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FluidchallengeIn 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

16、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 diarrh

17、oea/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 t

18、o 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)Thenursewillbeunabletoidentifythenormalarterialwaveformandtroubles

19、hoot(檢修故障)anydeviationsasneeded.Duringflushing(沖洗管路),thenursewillobservetheskinatthesiteanddistally(遠端)forblanching.Compared(比較)todirectarterialpressuremeasurementswiththeindirectmeasurements.Thepulse,color,sensation,andtemperature,distaltothesitewillbeassessed(評估)everytwotofourhours.Thenursecaringf

20、orapatientwitharteriallinemustbeabletochangetheflushsolution,tubinganddressing,accordingtohospitalguidelines.Inspect(監測)forsignsofinfection.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 t

21、he 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 measurementsWhenaccuracy(準確)inbloodpressuremeasurementisneededFrequ

22、ency(持續)ofbloodpressureisneededSome of those are as follows Gradual(漸進的)oracutehypotensionorhemorrhage.Circulatoryorcardiacarrest(暫停).Hypertensivecrisis(危象).Sepsisarerespiratoryfailure.Neurologicinjury.Post-operativecomplications.Whenthepatientisonvasoactivedrugs(血管作用藥物)suchasdopamine,nitroglycerin,

23、ThearteriallinemayalsobeusedwhenthepatientrequiresfrequentABGsorotherbloodwork.Limitations of arterial linesThearteriallinepressuresshouldbe5to20mmHghigher(較高)thencuffedmeasurements.Ifthearteriallinepressure5-20mmHgovercuffpressuremeasurement,oneofthefollowingisoccurring:cuffistoosmallfortheptarm,wi

24、llreadhigh.cuffistoolargeforthep/tarm,willreadtolow.Equipmentmalfunction(發生故障).insevereshock,orhypothermia,occlusiveperipheralvasculardisease.Potential(潛在的 )complications. Hemorrhage.Airemboli.Equipmentmalfunction.Inaccuratepressures.Dysarhythmias.Infections.Tubingseparation.Alteredskinintegrity.Imp

25、aredcirculationtoextremities.Alteredhemodynamics.導管的插入與部位插管部位說明橈動脈(radialartery)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(brachialartery)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(femoralartery)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(dorsalispedisartery)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

26、用的部位。EQUIPMENT500mlsHeparinizeNormalSaline(premixed)PressureBag2x5ml.syringesSurgicalmaskSterileglovesInsitecannula20Gx2MonitoringcableandmoduleDisposablepressuremonitoringkitOPsiteSterileNormalSalineflushx2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

27、 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 years. Initially developed for the management of

28、 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 des

29、pite 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 toda

30、y. The heart and pulmonary systemINDICATIONS-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(SvO2)Therapeutic-AspirationofairemboliINDICATIONS-2DiagnosticDiagnosisofshockstates(休克狀態)Differentiation(區別)ofhigh-versuslow-pressurepulmonaryedemaDiagnosisofprimary(原發性)pulmonaryhypertension肺高壓(PPH)Diagnosi

31、sofvalvulardisease,intracardiacshunts(分流),cardiactamponade,andpulmonaryembolus(PE)MonitoringandmanagementofcomplicatedAMIAssessing(評估)hemodynamicresponsetotherapiesManagementofmultiorgan(多重器官)systemfailureand/orsevereburnsManagementofhemodynamicinstability(不穩定)aftercardiacsurgeryAssessmentofresponse

32、totreatmentinpatientswithPPHContraindications (禁忌症 )Tricuspidorpulmonaryvalvemechanicalprosthesis(置換)Rightheartmass(thrombusand/ortumor)Tricuspidorpulmonaryvalveendocarditis導管簡介110cmlong,withextraconnectingtubesforattachmenttothepressuretransducerPAlumenordistal(遠端)lumen:開口在尖端RAlumenorproximal(近端)lu

33、men:開口在距導管尖端30公分處,測量RAP,相當於CVPThermistor(溫度偵測)lumen:距導管尖端4公分處有對溫度敏感的金屬絲,istheusedtomeasuretemperaturechangesforcalculationofCO.(以溫度稀釋法)Balloonlumen:距導管尖端1公分處FourlumenFivelumen-CCOSixlumen-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), estimate

34、d 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 (校正校正)Dynamic動態的動態的 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 str

35、aightest 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 di

36、fficult, 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. http:/ insert

37、ing 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 m

38、onitor 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 a

39、ppears, the catheter may be coiling in the RV. fluoroscopy may be necessary to visualize the catheter and remove the knot. PADPAWPLEVEDPLAP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PADLAP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

40、黏液瘤Forpulmonarycapillarywedgepressure(PCWP)tobereliable,thecathetertipmustlieinzone3(左心房下之肺區,教能正確反應LAP.Pulmonaryarterypressure(Ppa)isgreaterthanpulmonaryvenouspressure(Ppv),whichisgreaterthanalveolarpressure(Palv)atend-expiration.Inzones1and2,PpwreflectsPalvifPalvisgreaterthanPpv.Physiologiclungzone

41、s(肺臟血流的分佈)zone1肺泡壓比肺動脈及肺靜脈壓大,因此肺微血管沒有血流zone2肺泡壓比肺靜脈壓大但比肺動脈低足夠允許一些血流zone3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

42、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BalloonRupture,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CardiacOutput的因素CO心收縮力PreloadAfterloadHRSV右心CVPRAP左心PAPPAWPLAP右心PVR左心SVRFrank-StarlingLawPreload: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

43、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septicshock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http:/ =CCOmboVolumetrics此導管在右心室的地方有一段加熱纖維,溫度最高限制在440CCO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提供有關氧氣供應.需求.輸送與消耗的訊息監測心肺系統、疾病壓力、組織灌流情形SvO2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)

44、 (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 SvO2臨床意義 SvO2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COHb(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COHb(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)

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