心臟移植的ICU護(hù)理ppt課件

1、ICU care for heart transplantation臺(tái)大醫(yī)院心臟外科?？谱o(hù)理師李秋慧接獲移植命令 病床調(diào)整單人房、遠(yuǎn)離感染床. 病室清潔與消毒紫外線燈消毒2小時(shí)Immediate post-op.Primary Goals To promote adequate gas exchange and hemodynamic stability to ensure adequate peripheral blood flow and systemic organ perfusion To address the concerns specific to cardiac transpl

2、antPost-OP problemsvbleedingvhypovolemiavCardiac tamponadevOxygenationvdysrhythmiavRenal functionvHypothermiavPain controlSpecific problems Early identification of bleeding Monitor and treatment of dysrhythmia Prevention of right heart failure Detection of rejection Immunosuppression Screening of in

3、fection Infectious disease prophylaxis Education of the patientTask of the ICU nurse Make sense out of Chaos Critical thinking Be alert ! Be careful ! Report of unusual data Timing for call help Integrity of medical recordCPB (Cardiac-Pulmonary Bypass)After CPB q 體液分布改變：血液稀釋，水腫q 腎功能改變：腎血管灌注缺乏q 血壓改變：

4、術(shù)後25小時(shí)變化大q 心臟功能改變：既存功能缺損，心跳停頓時(shí)間過長q 血液功能改變：肝素，血小板功能缺損, 抗凝血功能q 肺功能改變：肺無血流灌注，低溫q 電解質(zhì)改變：血液稀釋，細(xì)胞內(nèi)外液、內(nèi)分泌改變，酸檢平衡q 高血糖：低溫抑制胰島素釋放，肝醣分解q 神經(jīng)功能改變：栓塞，腦血流灌注減少，麻醉 q 免疫功能改變：免疫反應(yīng)活化護(hù)理目標(biāo) 維持心臟血管功能，組織灌流，穩(wěn)定生命徵象 促進(jìn)呼吸功能及氧氣交換 維持體液電解質(zhì)平衡及營養(yǎng)給予 舒適及止痛 神經(jīng)功能評(píng)估 預(yù)防術(shù)後合併癥BleedingqCauseqPre-op status: liver functionqCPB effect qSurgica

5、l bleedingqHypothermiaqPharmaceutical effectBleedingqManagement :qcheck CBC and coagulation labqMonitor vital signs closelyqKeep chest tube patent and milking frequentlyqComponent therapy if neededqHypertension must be managedqMedication: Transamin, Vit K1 , DDAVP, factor VII(NovoSeven)Component the

6、rapy in HTX 照放射線血品 -Irradiated Blood: 可以抑制淋巴球活性，而能防止輸血所引起之移植物抗宿主反應(yīng)(GVHD)，但會(huì)影響紅血球、血小板和顆粒球之功能。 減少CMV的感染。Component therapy in HTX 保羅過濾器 (40 um)去除儲(chǔ)存時(shí)所產(chǎn)生的微凝體(Microaggregate) 普通輸血套(170um)許多病毒如EBV,CMV,HIV等常存在於白血球中,這些病毒可藉輸血傳染給病人,尤其在免疫功能有缺損者常引起致命的感染,另外一些輸血副作用如發(fā)燒,發(fā)冷等也常因血液中含有白血球而產(chǎn)生.因此如何去除減少血液中白血球成為預(yù)防病毒傳染及減少輸血副

7、作用的重要處置.白血球過濾器又分為紅血球及血小板專用兩種 減少感染巨細(xì)胞病毒(CMV)之機(jī)率。Leukocyte filterCardiac tamponadeCVPCVPirritable, dyspnea, cyanotic ,HR( low C.O)irritable, dyspnea, cyanotic ,HR( low C.O)chest tube drainagechest tube drainagePulsus paradoxus: Pulsus paradoxus: 吸氣時(shí)吸氣時(shí)SBPSBP下降下降cardiac echo (First excluding mechanical

8、 factors)cardiac echo (First excluding mechanical factors)Pericardial effusioncardiac echo cardiac echo Low cardiac outputq癥狀癥狀 q四肢冰冷末梢血管收縮四肢冰冷末梢血管收縮q尿量少尿量少renal blood blowrenal blood blowq皮膚潮濕交感神經(jīng)刺激汗腺分泌皮膚潮濕交感神經(jīng)刺激汗腺分泌q脈壓狹窄脈壓狹窄qirritableirritable腦部血流缺乏腦部血流缺乏qAcidosis (Acidosis (組織缺氧產(chǎn)生過多乳酸組織缺氧產(chǎn)生過多乳酸)

9、)Low cardiac outputqCause:qHeart failureqpericardial TamponadeqhypovolemiaqArrthymiaqProlong CPB (心肌保護(hù)不適當(dāng))BP= SVR X C.OqDeterminate of C.O:qHRqPreloadqContractilityqAfter loadDysrhythmiaqCause:qIncomplete myocardial preservationqProlonged period of ischemiaqPulmonary hypertensionqCardiac edemaqAcute

10、 rejectionqElectrolyte imbalanceqDrug toxicity DysrhythmiaManagementMonitor EKGKeep electrolytes balance according to Lab dataDefibrillatorsynchronize vs. unsynchronizedMedicationPacemakerRight heart failure after HTqCause:q 1. Pulmonary hypertensionq 2. Chronic congestive heart failureq 3. Fluid ov

11、erloadqS/S:q HR, CVPq U/O , SVO2Right heart failure after HT Management: 1. Use of inotropic agent 2. Vasodilators: NTG, Nitroprusside, PGE1, Primacor 3. NO inhalation via ventilator (monitor BP, methemoglobin) 4. Diuretics or CRRT ( Continuous Renal Replacement Therapy )CAVInfectionRejectionCAV：Car

12、diac allograft vasculopathyInfection Multiple invasive central lines Surgical wound: delayed wound closure Nosocomial infection Opportunistic infections (CMV, EBV,Herpes simplex, Herpes Zoster, Varicella Zoster, EBV,HBV, HCV) MalnutritionInfectionqNursing management:qPhysical & wound assessmenta

13、t least QDqProtective isolationqStrict aseptic techniqueqRecord fever curveqPrevent catheter infection and early q line removalInfectionqNursing management:qObtain cultures & infection workups routinely and prn.qAdminister anti-microbial agent q (right time & right way)qPatient educationqVis

14、itor restriction Nutrition Early enteral feeding as tolerate Strict blood sugar control 訂餐：隔離消毒餐 TPN support *乳靡胸 (chylothorax)Rejection-when hemodynamic compromise IVS 變厚RejectionqRelated terms:qHyperacuteqAcuteqChronicqCellular rejectionqHumeral rejectionImmunosuppressants RATGqPrevention of anaph

15、ylactic shock: q由CVP給藥第一次給藥時(shí)，10 c.c./1st hrqpremedication (solumedrol, scanol, vena)q第二個(gè)小時(shí)起才改成40 c.c./hrq通常只用於前35天，除非術(shù)後有急性腎衰竭，常見副作用有:發(fā)燒白血球和血小板減少。Cyclosporine ( Sandimmune, Neoral) 給藥劑量是按照最低血中濃度(C0)來調(diào)整劑量，所以抽血一定要在給藥之前，以免判讀困難。(C2: 給予cyclosporine 2 hrs 後測血中濃度) 病人假設(shè)長期運(yùn)用利尿劑，使鎂離子流失。加上cyclosporine會(huì)使鎂離子從尿中流失

16、，因此移植病人常會(huì) hypomagnesemia。Tacrolimus Tacrolimus FK506FK506，Prograf Prograf 空腹服用，給藥時(shí)間為飯前一小時(shí)或飯空腹服用，給藥時(shí)間為飯前一小時(shí)或飯後兩小時(shí)，因食物會(huì)影響其吸收後兩小時(shí)，因食物會(huì)影響其吸收 依給藥前血中濃度調(diào)整劑量依給藥前血中濃度調(diào)整劑量 HyperglycemiaCellceptMMF Mycophenolate mofetil沒有腎毒性。多運(yùn)用在有高度排斥免疫風(fēng)險(xiǎn)的個(gè)案，價(jià)錢較imuran貴很多。為減少cyclosporineor FK506之劑量，運(yùn)用全量MMF後，約可減CyAFK5061/3之劑量，而仍有一樣的抗排斥力。Steroid Solumedrol 120 mg IV, q8hr X 1 day 口服prednisolone 0.5 mg/kg/day，每次biopsy，視排斥狀況逐漸減量。Azathioprine Imuran 目標(biāo)是WBC : 4000 6000，手術(shù)後可以開始口服即開始給藥。 因會(huì)骨髓抑制，呵斥WBC and Plat，所以每日check CBC，視WBC調(diào)整劑量。 假設(shè)有infection的S/S，暫停imuran 。 EMB ( endomyocardi