查房-低心排.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2017/11/19,#,SICU-1,Low Cardiac,Output Syndrome,低心排综合征,Low Cardiac Output Syndrome,低心排综合征,(Low Cardiac Output Syndrome,，,LCOS),，简称低心排，是心脏外科最严重的生理异常，正常人的心排出量按每平方米面积计算，也就是心指数为,3-4L/(minm2),，如心指数降低至,3L/(minm2),以下而有周围血管收缩，组织灌注不足的现象，称为低心排出量综合征。,1,contents,5,2,4,observing and nursing,care,Treatments,clinicalmanifestations,Cases introduction,3,causes of LCOS,Cases introduction,Name:,Zhu Changyin,Gender,:Male,Age:,59,Admission time:,2017-08-06,Operation time:,2017-08-17,Main complaint:,chest tightness,wheeze for 4 months,姓名：祝长银,性别：男,年龄：,59,岁,入院时间：,2017-08-06,手术时间：,2017-08-17,主诉：胸闷、憋喘,4,月余,Cases introduction,Diagnosis:,heart valve stenosis,tricuspid regurgitation,Operation:,aortic valve replacement,诊断：,主动脉瓣狭窄 三尖瓣返流,手术名称：,主动脉瓣置换术,History of present illness,现病史,chest tightness,胸闷,suppress asthma,憋喘,cough,咳嗽,sputum,咳痰,without significant factors in April this year,diagnosis:,pleural effusion,Af,worse,night orthopnea,夜间端坐呼吸,cannot lay down.,diagnosed with,heart valve disease,.,admitted to the clinic with valvular disease.,past history,既往史,Diabetes,（糖尿病）,history for 2 years.,Paroxysmal atrial fibrillation,（阵发性房颤）,for4 months.,Postoperative low cardiac performance,术后低心排表现,the,oxygen saturation,reduced from 98 to 88.,CVP,11-12,，,slowly rose to 21-22,Blood pressure,is down from 130-140/80 to 110/70,no,urine,at the same time,Heart color ultrasound revealed:,no effusion of pericardial fluid,a small amount of fluid in the right side of the thoracic cavity,the,left ventricular wall moving lower,EF,38,causes of LCOS,低心排的原因,(1),Pulmonary hypertension,肺动脉高压,cardiac insufficiency,心功能差,Arhythmia,心律失常,unsuccessful correction of cardiac malformation,心脏畸形矫正不良,causes of LCOS,低心排的原因,(2),Coronary aeroembolism,-cardial infarction,冠脉气栓,心梗,Hypovolemia,血容量不足,cardiaccontractiledysfunction,心肌收缩不全,pericardial tamponade,心包填塞,patho-physiologic change,病理生理变化,主动脉阻断,复灌,无氧代谢增加,能量生成减少,乳酸,增多,Na,泵功能障碍,细胞酸中毒,心肌水肿，内膜下出血,clinicalmanifestations,临床表现,Mind change,神志变化,palecomplexion,Cold limbs,面色苍白、,四肢湿冷,tachycardia,心动过速,Fast andshallow,breathing,呼吸浅快,Monitoring indicators,监护指标,BP,Early blood pressure does not necessarily decrease,and once low blood pressure is shown,the condition is severe,CVP,Differential diagnosis for patients with low cardiac,syndrome,ABG,血气分析,PaO,2,decreased,standard bicarbonate and PH decreased,Urine Volume,尿量,the most sensitive indication,Treatments,治疗,(1),保证前负荷的情况下若血压低，可选用增强心肌收缩力的药物。,Dopamine,:5-10,g/kg/min,10,g/kg/min,收缩肾脏血管,Epinephrine,：,正性肌力，收缩全身血管，关注尿,Noradrenaline,：,增加外周阻力,Treatments,治疗,(2),Arythmia,心律失常,SVT(,室上速,),：,西地兰：正性肌力 减慢心率,注意钾与钙,Af,(,房颤,),：,可达龙：常见心动过缓,Bradycardia(,心动过缓,),：,异丙肾上腺素,临时起搏器,Treatments,治疗,(3),机械通气治疗低氧血症必须在补足血容量、增强心肌收缩力和降低外周血管阻力的基础上进行。,应用镇静剂，应用呼吸机辅助呼吸改善氧交换可,减少心脏做功,20%,，待低心排纠正方可撤离呼吸机。,该病人术后低心排的治疗措施,：,1,、,多巴胺,3-6,g/kg/min,，,肾上腺素,0.006,g/kg/min,。,2,、鼻加面双吸氧，,SpO,2,92-94%.,血气,:,氧分压,41-48,，给予气管插管。接,呼吸机辅助呼吸,。,3,、病人插管之后，不配合，,异丙酚,20ml/h,，,艾贝宁,7ml/h,效果不佳，静推,吗啡,一支。病人生命体征逐渐平稳，艾贝宁减到了,5ml/h,，异丙酚,10ml/h.,氧分压升到,76,。,4,、病人尿量少，速尿,40mg,静推效果不好，改成,速尿,200mg,静推泵入,2ml/h,，尿量,80-100ml/h,，速尿逐渐减停。,5,、夜班加用吗啡,10mg,，,镇静,效果较好。生命体征平,稳,Treatments,治疗,(4),IABP,主,动,脉,内,球,囊,反,搏,泵,IABP,原理,心脏舒张期：主动脉关闭、气囊充盈,舒张压明显增高,冠脉血流量增加,改善心肌供血,心脏收缩期：主动脉开放、气囊放气,主动脉腔空虚产生相对负压,心脏后负荷降低,增加了心排血量,observing and nursing care(1),观察与护理重点,Hemodynamic monitoring,血流动力学监测,1cardiac rhythm(,心律,)/HR,药物、疼痛、发热、心室功能低下,心动过速心动过缓,低心排,2,、,BP,BP,不低于术前,血压高,心脏负荷增加,心肌耗氧增多,20-30mmHg,血压低,器官灌注少,器官缺血,3,、,CVP,反应血容量和右心功能的客观指标,4,、,Peripheral Circulation,末梢循环,反应外周的循环状态,observing and nrsing care(2),观察与护理重点,肾功能的监护,体外循环红细胞破坏,/,肾灌注不足 肾功能不全 关注尿的色质量的变化，调节利尿剂用量,心包引流管的护理,无菌密闭,/,色质量变化 观察有无心包填塞征象,血管活性药物的合理应用,谢谢观看！,