灌流功能評估

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1 灌流功能評估臨床數據判讀與護理意涵課程邱艶芬教授

2 循環功能的評估循環功能主要為組織灌流決定組織灌流之三主要因素 : Blood volume:cvp Cardiac pumping:sbp Vascular tone:dbp 評估血量心臟與動脈靜脈微血管評估血壓

3 心臟功能與組織灌流 Pul. veins LA LV Tissue Perfusion take O2 (brain, kidney, heart. Pul. cap. JV exit CO2 SVC Liver Pul. artery Spleen RV RA IVC Oxygenation Pumping CO2 removal (alveoli- capillary) (ventricle) Bring O2, nutrients Remove CO2, metabolites (capillary bed)

4 EKG information Pacing maker Arrhythmia 心房肥大心室肥大 Ischemia Injury Infarction

5 心電傳導方向

6 心房心室去極化

7 EKG 波形與意義波形意義正常圖型 P 波心房去極化向上圓型 <3 小格 QRS 波心室去極化瘦高型 <3 小格 ST 段心室再極化等平線上 T 波心室再極化向上

8 心房變大 P 波型的變異 A B P 波變高 : 右心房肥大 P 波變寬 : 左心房肥大 A: 正常心房去極化 B: 右心房肥大 C D C: 左心房肥大 D: 左右心房均肥大

9 心室變大 QRS 波的變異右心室肥大 : V1.V2 出現向上波 V5.V6 出現向下波右心室導程左心室肥大 : V1.V2 S 波加深 V5.V6 R 波加高左心室導程

10 心肌去極化的節律 Named by pacing foci Sinus rhythm Atrial rhythm Junctional rhythm Ventricular rhythm Pacemaker rhythm

11 心肌缺氧的變化 ST 與 T 波的變異 ST 波 : 心肌受傷時上升, 心肌疲累時下降 T 波 : 缺氧時出現向下倒立

12 從十二導程心電圖推知心肌梗塞的部位 avr I avl II III V1 V2 V3 V5 V6 V4 avf

13 梗塞區的判斷 avr I avl II II I V 1 V 2 V 3 V 4 V V 6 5 avf 右心室的梗塞應會在 I II avf 與 V1 V2 上反映左心室之梗塞應會在 I III avl avf 與 V4 V5 V6 上反映前壁與心中膈的梗塞可自 I V2 V3 V4 上反映胸前導程 (V1-6) 上有變化之導程越多, 梗塞範圍越大

14 心律不整嚴重度判斷是否引起 BP drop MBP<70 affect brain MBP<60 affect heart MBP<50 affect kidney 致死性心律不整 ventricular tachycardia ventricular flutter ventricular fibrilization 危險性心律不整

15 危險性心律不整常為致死性心律不整的前兆 VPCs Frequent VPC:>6 次 / 分 paired PVC( 成對出現 Couplet) triplet PVC( 成串出現 Triplet 又稱 short run VT ) Bigeminy( 每兩個正常心電圖及有一個 VPC) Trigeminy( 每三個正常心電圖即有一個 VPC) Multifocal: VPC 型態不一 R-on-T AVB CAVB 2 AVB type II AF with RVR, Af with RVR

Bigeminy( 每兩個正常心電圖及有一個 VPC) Trigeminy( 每三個正常心電圖即有一個

16 Vascular physiology Artery 管道 Vascular tone Veins 管道 Vascular tone Capillary 交換場所 permeability

17 The vascular tone The blood contained in a single heart contraction (the stroke volume) stretches out the arteries, so that their elasticity continues to squeeze on the blood, keeping it moving during diastole.

the arteries, so that their elasticity continues to

18 The permeability nature of capillary Capillary walls are a single endothelial cell in thickness. Intercellular clefts assist the exchange.

19 Venous return At rest, most of the blood volume is in the veins. Sympathetically mediated venoconstriction can substantially increase venous return to the heart. Venous flow is assisted by skeletal muscle squeeze working in combination with one-way valves.

20 週邊循環動脈循環不良時 : 冰涼蒼白脈搏弱靜脈循環不良時 : 發紺腫脹微血管循環不良時 : 回填度不佳水腫回填度不佳 : 動脈收縮

21 Change of skin color and temperature in cardiac failure: affect arterial flow first, then venous flow pink, warm pale cold cyanosis, cold in compartment syndrom: affect venous flow first, then arteial flow; pink, warm cyanotic, warm cyanotic, cold

22 週邊水腫原理 Albumin 3.5~5.5 g/dl BP 120/80 mmhg Oncotic pressure 25 mmhg 血管內壓 35~45 mmhg 血管內壓 13~15 mmhg Interstitial pressure 3~5 mmhg Lymphatic drainage

23 肺水腫原理肺動脈血管內壓 25~15 mmhg Oncotic pressure 25 mmhg 肺靜脈血管內壓 <12 mmhg Interstitial pressure 3~5 mmhg Lymphatic drainage

24 Perfusion pressure Determined by Volume pumped out by heart Vascular tone Measured by MBP = 1/3 SBP + 2/3 DBP Pulse pressure = SBP DBP Perfusion pressure = BPin-BPout

25 評估的徵象 :blood pressure perfusion pressure( 灌流壓 ): 將血液推往前之力量 systemic perfusion pressure( 系統性灌流壓 ): MBP-CVP cerebral perfusion pressure ( 腦灌流壓 ) : MBP-ICP (50 mmhg, in injured brain > 70 mmhg) myocardial perfusion pressure ( 心肌灌流壓 ) : DBP-CVP (>50 mmhg) glumerular filtration pressure ( 腎濾過壓 ) : MBP- 膠質滲透壓 - 鮑式囊內壓

26 Hypertension emergrncy Hypertensive encephalophathy: MBP >150 mmhg, 超過 cerebral autoregulation 引起 vasospasm ischemia edema hemorrhage seizure Malignant hypertension: DBP>130mmHg, 快速引起 end organ damage LV hypertrophy, LV failure, 溶血性貧血, hematuria proteinuria, 視乳突水腫 Threaten to life: S/S:

27 Hypotension inadequate perfusion to organ MBP< 70mmHg to brain MBP< 60mmHg to heart MBP< 50mmHg to kidney

28 反映組織灌流不足的徵象 -- impaired functions of the perfused organ Brain: change of LOC Kidney: decrease U/O Heart: myocardial ischemia, Lung: poor oxygenation results in vascular constriction Liver: in congestion, 心源性肝小葉壞死 GI track: ischemic Limbs:pale and cold, thread pulse, poor capillary refilling

29 EFFECT OF AUTOMONIC SYSTEM SYMPATHETIC SA node Heart rate heart rate PARA-SYMPATHETIC AV node conduction conduction Atrial muscle contractility contractility Ventricular muscle contractility No significant effect Sympathetic stimulation α1: arterial vasoconstriction α2: venous vasoconstriction β: vasodilation

30 Factors determine cardiac output activity of sympathetic nerve to veins Peripheral veins Venous pressure Blood volume Skeletal muscle pump Venous return Atrial pressure End-diastolic ventricular pressure Cardiac muscle stroke volume Plasma epinephrine Inspiration movement SA node heart rate activity of parasympathetic nerve to heart activity of sympathetic nerve to heart Cardiac output

31 A summary of dynamic changes in MAP and TPR. Stroke volume Heart rate Arterial radius Blood viscosity Cardiac output Total peripheral resistance Mean Arterial Pressure MBP=Cardiac output X Total peripheral resistance

32 Hemodynamic measures Cardiac output (CO) CO=SV x HR Normal CO: 4 to 8 L/min Cardiac index (CI) cardiac output divided by the body surface area. Normal cardiac index: 2.5 to 4 L/min/m2 Central venous pressure (CVP) Normal CVP: 2 to 8 mm Hg. Preload the volume of blood in the ventricle at the end of diastole. also called the left ventricular end-diastolic pressure. Clinically, the preload is measured as the pulmonary artery occlusive pressure or the "wedge" pressure.

33 Hemodynamic measures( 續 ) Afterload the amount of work the ventricles must overcome to eject blood referred to as systemic vascular resistance (SVR). SVR = [(MAP - CVP)/CO] x 80. Normal SVR : 800 ~ 1200 dynes/sec/cm-5 Stroke volume (SV) Normal stroke volume is 60 to 80 ml/beat. Pulmonary artery pressure (PAP) Normal values : Systolic PAP: 15 to 30 mm Hg, Diastolic PAP: 8 to 15 mm Hg, Mean PAP: 10 to 20 mm Hg Pulmonary artery occlusive pressure (PAOP) called the wedge pressure. Normal pulmonary artery occlusive pressure is 8 to 15 mm Hg

34 Pressure and volume changes in the left heart during a contraction cycle. SV

35 Pulmonary Circulation Pressure Pressure changes in the right heart during a contraction cycle.

36 S-G catheter

37 The position of SG

38 Pressure and wave in the four chambers RAP RVP PAP LAP/PCWP

39 IABP

40 Benefits of IABP Unassisted SBP assisted SBP Augmented DBP inflation Un-reduced EDP deflation assistededp

41 MALFUNCTION OF IABP EARLY INFLATION EARLY DEFLATION LATE INFLATION LATE DEFLATION

42 Pulse Contour Cardiac Output PiCCO plus

43 心肺容積監視器 PiCCO 心肺容積量 + 連續血流動力學評估 PiCCO 利用經肺式熱稀釋法和脈搏曲線分析法結合計算求得胸內血容積量 (Preload) 肺血管外水容積量和測量心臟功能 (C.O. Afterload Contractility) 的監視系統所獲得之參數可直接使用於臨床診斷和治療

44 CVP PiCCO A-Line 經肺式溫度稀釋法 Transpulmonary thermodilution CV 端注入冰水 (<8 ) 或室溫水 (<24 ) PiCCO 動脈熱稀釋導管測量溫差變化 ( 求得 CO,ITBV,EVLW,PVPI ) 脈搏曲線分析法 Pulse Contour analysis PiCCO 動脈導管監測動脈波形脈搏波形 ( 求得 CCO,SVR,SVV )

45 經肺式溫度稀釋測量獲得心胸容積參數心輸出量 CI Cardiac Index 心臟功能指示 CFI Cardiac Function Index 心臟舒張末期容積量 GEDI Global end-diastolic diastolic Volume Index 胸內血容積量 ITBI Intrathoracic Blood Volume Index 肺血管外水容積量 EVLWI Extravascular lung water Index 收縮能力參數容積量參數肺部狀況參數

46 脈搏曲線分析連續獲得血流動力參數連續心輸出量 PCCI Pulse Continuous Cardiac Index 動脈血壓 AP Arterial Blood Pressure 心跳 HR Heart Rate 心動排出量 SV Stroke Volume 全身血管阻力 SVR Systemic Vascular Resistance 左心室收縮力 dpmx Index of Left Ventricular Contractility 心動排出變化率 SVV Stroke Volume Variation 每 12 秒更新乙次血流動力參數

47 Normal ranges - T t - P t

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