1、重症病患血液動力監測導管之護理重症病患动脉导管监测1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。重症病患动脉导管监测2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
2、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)可供需要時使用重症病患动脉导管监测3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(mon
3、itor)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。重症病患动脉导管监测4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
4、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。重症病患动脉导管监测5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。重症病患动脉导管监测6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
5、(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重症病患动脉导管监测7重症病患动脉导管监测8 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
6、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)。重症病患动脉导管监测9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)重症病患动脉导管监测10監測系統常見的問題重症病患动脉导管监测11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)。重症病患动脉导管监测12出血
7、(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。重症病患动脉导管监测13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
8、(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。重症病患动脉导管监测14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)重症病患动脉导管监测15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 重症病患动脉导管监测16插入部位與優缺點插入部位優點缺點鎖骨下靜脈穿刺容
9、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重症病患动脉导管监测17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
10、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 值時重症病患动脉导管监测18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
11、、zeroing)，即可得知病人的CVP 波形與數值正常值4 12 H2O cm 17 mmHg重症病患动脉导管监测19Guide to interpretation of the CVP in the hypotensive patientCVP reading：LowRapid pulseBlood pressure normal or lowLow urine outputPoor capillary refillDiagnosis to consider:HypovolaemiaTreatment:Give fluid challenges*until CVP rises and do
12、es not fall back again.If CVP rises and stays up but urine output or blood pressure does not improve consider inotropes重症病患动脉导管监测20CVP reading：Low Rapid pulseSigns of infectionPyrexiaVasodilationDiagnosis to consider:SepsisTreatment:Ensure adequate circulating volume(as above)and consider inotropes
13、or vasoconstrictors重症病患动脉导管监测21CVP reading：NormalRapid pulseLow urine outputPoor capillary refillDiagnosis to consider:HypovolaemiaTreatment:Treat as above.Venoconstriction may cause CVP to be normal.Give fluid challenges*and observe effect as above.重症病患动脉导管监测22CVP reading：HighUnilateral breath soun
14、dsAssymetrical chest movementResonant chest with tracheal deviationRapid pulseDiagnosis to consider:Tension pneumothoraxTreatment:Thoracocentesis then intercostal drain重症病患动脉导管监测23CVP reading：HighBreathlessnessThird heart soundPink frothy sputumOedemaTender liverDiagnosis to consider:Heart failureTr
15、eatment:Oxygen,diuretics,sit up,consider inotropes重症病患动脉导管监测24CVP reading：Very HighRapid pulseMuffled heart soundsDiagnosis to consider:Pericardial tamponadeTreatment:Pericardiocentesis and drainage重症病患动脉导管监测25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
16、血症使用血管擴張劑 重症病患动脉导管监测26Fluid 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,pulse,urine output and capillary refill(再充填).Repeat the challenges(補充液體)until the CVP shows a sustained
17、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.重症病患动脉导管监测27
18、動脈導管(artery catheter)導管的插入與部位 臨床應用 重症病患动脉导管监测28Minimum 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.Suppor
19、t 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)重症病患动脉导管监测29The nurse will be unable to identify the normal arterial waveform and troubleshoot(檢修
20、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 t
21、o 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.重症病患动脉导管监测30The nurse caring for a patient with an arterial line must be able to obtain(獲得)blood samples(血液檢
22、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.重症病患动脉导管监测31Indications for arterial blood press
23、ure measurementsWhen accuracy(準確)in blood pressure measurement is neededFrequency(持續)of blood pressure is needed 重症病患动脉导管监测32Some 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
24、 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.重症病患动脉导管监测33Limitations of arterial linesThe arterial line pressures should be 5 to 20 mmHg
25、 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,o
26、cclusive peripheral vascular disease.重症病患动脉导管监测34Potential(潛在的潛在的)complications.Hemorrhage.Air emboli.Equipment malfunction.Inaccurate pressures.Dysarhythmias.Infections.Tubing separation.Altered skin integrity.Impared circulation to extremities.Altered hemodynamics.重症病患动脉导管监测35導管的插入與部位插管部位說明橈動脈(rad
27、ial 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。重症病患动脉导管监测36EQUIPMENT500 mls Heparinize Normal Saline(premix
28、ed)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重症病患动脉导管监测37重症病患动脉导管监测38重症病患动脉导管监测39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。重症病患动脉导管监测40抽動脈血 一般血液生化檢查動脈血液氣體分析不可
29、用來作血液培養(blood culture)。重症病患动脉导管监测41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重症病患动脉导管监测42重症病患动脉导管监测43重症病患动脉导管监测44正常動脈波型各部位動脈導管壓力波型重症病患动脉导管监测45重症病患动脉导管监测46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重症病患动脉导管监测47IntroductionThe flow-directed(流量指引)balloon-tipped pulmonary artery(PA)cathete
30、r 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.重症病患动脉导管监测48History In 1929,Werner Forssmann wa
31、s 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 o
32、f measuring cardiac output(CO)was incorporated(結合)into the catheters use.This basic design remains in use today.重症病患动脉导管监测49The heart and pulmonary system重症病患动脉导管监测50INDICATIONS-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-Aspiration of air emboli重症病患动脉导管监测51INDICATIONS-2Diagnost
33、ic 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 Assess
34、ing(評估)hemodynamic response to therapiesManagement 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重症病患动脉导管监测52Contraindications(禁忌症)Tricuspid or pulmonary valve mechanical p
35、rosthesis(置換)Right heart mass(thrombus and/or tumor)Tricuspid or pulmonary valve endocarditis 重症病患动脉导管监测53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)lu
36、men: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公分處重症病患动脉导管监测54Four lumen重症病患动脉导管监测55Five lumen-CCOSix lumen-CCO,SvO2重症病患动脉导管监测56重症病患动脉导管监测57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(
37、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(校正校正)Dynamic動態的動態的 tuning 重症病患动脉导管监测58Insertion Preference(選擇)considerations for cannulation of the great veins are as follows:Right internal jugular vein(RIJ)右內頸靜脈-
38、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 hear
39、t can be difficult,especially if the right-sided cardiac chambers are enlarged.導管插入護理措施重症病患动脉导管监测59Trendelenburg 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
40、.http:/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).重症病患动脉导管监测60Always use continuous pressure monitoring from the d
41、istal 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
42、initial RV pattern appears,the catheter may be coiling in the RV.fluoroscopy may be necessary to visualize the catheter and remove the knot.重症病患动脉导管监测61重症病患动脉导管监测62重症病患动脉导管监测63重症病患动脉导管监测64PADPAWPLEVEDP 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重症病患动脉导管监测65PAD
43、 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重症病患动脉导管监测66For 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
44、 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,且肺泡壓力恆定重症病患动脉导管监测67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
45、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,勿沖洗導管重症病患动脉导管监测68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,重症病患动脉导管监测6
46、9心輸出量Cardiac Output影響Cardiac Output的因素CO心收縮力PreloadAfterloadHRSV右心 CVPRAP左心 PAPPAWPLAP右心 PVR左心 SVRFrank-Starling LawPreload: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重症病患动脉导管监测70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重症病患动脉导管监测71間歇Q8h or QD C
47、heck由近端管腔注入N/S 10,5,2.5 ml40C 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440C CO之測量方法重症病患动脉导管监测72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 重症病患动脉导管监测73SvO2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
48、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 重症病患动脉导管监测74SvO2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)重症病患动脉导管监测75
