有創(chuàng)血壓監(jiān)測(cè)

1、有創(chuàng)動(dòng)脈血壓監(jiān)測(cè)有創(chuàng)動(dòng)脈血壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): Stephen Hales, 1711母馬銅管進(jìn)行股動(dòng)脈插管9英尺玻璃管有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): Poiseuille, 1828Jean-Leonard-Marie PoiseuilleHemodynamometer有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 現(xiàn)實(shí)現(xiàn)實(shí)68名受試者學(xué)位: 學(xué)士或以上61.8%工作經(jīng)驗(yàn)n護(hù)理工作超過4年94.1%nICU工作超過4年83.9%n有創(chuàng)動(dòng)脈壓監(jiān)測(cè) 1或2次/周 97.1%調(diào)查問卷(18個(gè)問題)n有創(chuàng)動(dòng)脈壓生理學(xué)n有創(chuàng)動(dòng)脈壓監(jiān)測(cè)技術(shù)n有創(chuàng)動(dòng)脈壓波形解讀有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 現(xiàn)實(shí)現(xiàn)實(shí)平均

2、得分36.7 11.8%(11.1 61.1%)McGhee BH, Woods SL. Critical care nurses knowledge of arterial pressure monitoring. Am J Crit Care. 2001;10:43-51.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 適應(yīng)癥適應(yīng)癥實(shí)時(shí)監(jiān)測(cè)動(dòng)脈血壓n收縮壓, 舒張壓, 平均壓留取動(dòng)脈血標(biāo)本進(jìn)行血?dú)鈾z查有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)脈插管動(dòng)脈插管動(dòng)脈置管方向應(yīng)與血流方向相反動(dòng)脈插管應(yīng)為20 G (粉色)14G (Orange)16G (Grey)18G (Green)20G (Pink)22G (Blu

3、e)24G (Yellow)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)脈插管動(dòng)脈插管并發(fā)癥: 影響插管部位遠(yuǎn)端肢體灌注護(hù)理措施: 檢查側(cè)支循環(huán)情況置管前n橈動(dòng)脈: Allen試驗(yàn)n其他動(dòng)脈(腋, 肱, 股, 足背): 肢體顏色, 溫度, 毛細(xì)血管充盈時(shí)間, 運(yùn)動(dòng)置管過程中n經(jīng)常觀察n將氧飽和度傳感器留置在動(dòng)脈插管遠(yuǎn)端有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): Allen試驗(yàn)試驗(yàn)有關(guān)橈動(dòng)脈與尺動(dòng)脈完整性的檢查操作過程n檢查者壓迫患者的橈動(dòng)脈與尺動(dòng)脈n要求患者反復(fù)握拳直至手掌發(fā)白n檢查者松開患者的橈動(dòng)脈或尺動(dòng)脈n觀察患者手部循環(huán)及顏色恢復(fù)情況n對(duì)另一動(dòng)脈重復(fù)相同檢查結(jié)果n手部顏色應(yīng)在6秒鐘之內(nèi)恢復(fù)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)

4、脈壓監(jiān)測(cè): Allen試驗(yàn)試驗(yàn)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): Allen試驗(yàn)試驗(yàn)Allen試驗(yàn)陰性n安全地進(jìn)行橈動(dòng)脈穿刺置管n臨界值尚存在爭(zhēng)議Allen試驗(yàn)陽性n阻斷橈動(dòng)脈時(shí)超聲多普勒或數(shù)字血壓測(cè)量有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)脈插管動(dòng)脈插管并發(fā)癥: 動(dòng)脈出血護(hù)理措施:n動(dòng)脈插管部位暴露在視線之內(nèi)n透明敷料覆蓋n三通鎖定n插管部位固定有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)脈插管動(dòng)脈插管并發(fā)癥: 導(dǎo)管相關(guān)感染護(hù)理措施:n置管過程中無菌操作n常規(guī)更換無菌敷料n經(jīng)常檢查插管部位有無感染征象有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 技術(shù)要點(diǎn)技術(shù)要點(diǎn)沖洗液體為500 ml 0.9% NS通過管路與傳感器相連接加壓

5、袋內(nèi)壓力為300 mmHgn持續(xù)沖洗速度3 5 ml/hrn防止動(dòng)脈血液返流或堵塞管路有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 技術(shù)要點(diǎn)技術(shù)要點(diǎn)使用肝素鹽水防止導(dǎo)管血栓形成n其實(shí)并無必要研究比較肝素鹽水及普通生理鹽水n“與肝素抗凝相比, 加壓下的持續(xù)沖洗才起到保證管路通暢的作用”n這一研究表明沖洗袋中液體僅需要加壓, 而不需要肝素化Gamby, A., & Bennett, J (1995). A feasibility study of the use of non-heparinised 0.9% sodium chloride for transduced arterial and venous

6、lines. Intensive and Critical Care Nursing, 11 (3), 148 150. 有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 技術(shù)要點(diǎn)技術(shù)要點(diǎn)傳感器n氣液平面n監(jiān)測(cè)動(dòng)脈血壓變化由患者動(dòng)脈插管至傳感器的液柱n傳導(dǎo)壓力有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 氣泡氣泡管路中的氣泡是導(dǎo)致血流動(dòng)力學(xué)監(jiān)測(cè)錯(cuò)誤的最常見原因氣泡通常會(huì)使機(jī)械信號(hào)的傳導(dǎo)減弱或發(fā)生衰減n導(dǎo)致波形衰減, 壓力讀數(shù)錯(cuò)誤即使1 mm直徑的氣泡也可以導(dǎo)致波形嚴(yán)重失真有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 管路預(yù)沖管路預(yù)沖首先利用袖帶產(chǎn)生的壓力排除沖洗液中的空氣然后, 沖洗整個(gè)管路系統(tǒng)常見的空氣存留部位n三通, 各種接頭以及傳感

7、器n在預(yù)沖及導(dǎo)管使用過程中需特別注意有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 防止管路進(jìn)氣防止管路進(jìn)氣開放管路進(jìn)行取血或調(diào)零后, 應(yīng)當(dāng)立即快速?zèng)_洗整個(gè)管路系統(tǒng), 包括取血或調(diào)零所使用的三通將所有連接處旋緊, 確?？諝獠粫?huì)進(jìn)入避免增加三通或延長(zhǎng)管保持沖洗液袋中液體不會(huì)走空, 并保持袖帶壓力為300 mmHg定期輕彈并沖洗管路和三通有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 參考平面與調(diào)零參考平面與調(diào)零動(dòng)脈壓監(jiān)測(cè)系統(tǒng)必須n以左心房水平作為參考平面(leveling)n將大氣壓設(shè)置為0(zeroing)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 參考平面參考平面將監(jiān)測(cè)系統(tǒng)的氣液平面(通常為傳感器頂端的三通)與心臟的體表標(biāo)志點(diǎn)對(duì)齊心臟

8、的體表標(biāo)志點(diǎn)(phlebostatic axis)n第四肋間線與腋中線交點(diǎn)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 調(diào)零調(diào)零操作:n氣液平面與大氣相通n按動(dòng)監(jiān)護(hù)儀的調(diào)零功能鍵作用:n將大氣壓作為零點(diǎn)n將氣液平面作為零點(diǎn)n消除零點(diǎn)漂移(zerodrift)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 傳感器校準(zhǔn)傳感器校準(zhǔn)傳感器校準(zhǔn) 調(diào)零(zeroing)n消除外界大氣壓和靜水壓的影響“根據(jù)現(xiàn)有證據(jù), 僅需要進(jìn)行一次調(diào)零, 除非傳感器與監(jiān)護(hù)儀脫開”Ahrens T, 1994很多護(hù)理研究人員建議每班護(hù)士都應(yīng)對(duì)傳感器進(jìn)行調(diào)零以確保傳感器讀數(shù)準(zhǔn)確Darovic, G., Vanriper, J., & Vanriper, S

9、. (1995). Arterial pressure monitoring. In Darovic, G. (Ed.), Hemodynamic Monitoring: Invasive and noninvasive clinical application. (pp.177-210). Philadelphia: W.B. Saunders Company.Ahrens, T (1994). Ask the Experts. Critical Care Nurse,14 (6), 98-99.Chulay, M (1995). Ask the experts. Critical Care

10、 Nurse, 15 (2), 108.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 傳感器位置傳感器位置傳感器的位置n接近動(dòng)脈插管部位, 或n固定在患者床頭傳感器應(yīng)當(dāng)固定在導(dǎo)管尖端水平n留置導(dǎo)管的肢體應(yīng)與右心房位于同一水平nphlebostatic axisCampbell, B (1997). Arterial waveforms: Monitoring changes in configuration. Heart and Lung, 26 (3), 205-215.Chulay, M (1995). Ask the experts. Critical Care Nurse, 15 (2), 108.

11、Chulay, M., & Holland, S (1997). Ask the experts. Critical Care Nurse, 17 (3), 14-16.Daily, E., & Schroeder, J. (1995). Techniques in bedside hemodynamic monitoring. (5th ed). St Louis: Mosby.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 傳感器位置傳感器位置傳感器低于右心房血壓讀數(shù)升高傳感器高于右心房血壓讀數(shù)降低Daily, E., & Schroeder, J. (1995). Techniques in bedsi

12、de hemodynamic monitoring. (5th ed). St Louis: Mosby.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 傳感器位置傳感器位置護(hù)士必須了解傳感器位置的重要性不準(zhǔn)確的讀數(shù)可以導(dǎo)致錯(cuò)誤的治療對(duì)患者造成危害有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 參考平面與調(diào)零參考平面與調(diào)零準(zhǔn)確性n每當(dāng)氣液平面與參考點(diǎn)的相對(duì)位置改變時(shí), 均應(yīng)重新確定參考平面并調(diào)零n消除靜水壓的影響一致性n體表標(biāo)志點(diǎn)應(yīng)當(dāng)特殊標(biāo)明有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 管路管路傳感器與動(dòng)脈插管間的管路長(zhǎng)度影響監(jiān)護(hù)儀讀數(shù)n順應(yīng)性差n長(zhǎng)度 120 cmn半徑足夠大管路需要傳導(dǎo)來自插管尖端的液體搏動(dòng)n管路過長(zhǎng)或過短, 過硬或過

13、軟都會(huì)影響讀數(shù)的準(zhǔn)確性Daily, E., & Schroeder, J. (1995). Techniques in bedside hemodynamic monitoring. (5th ed). St Louis: Mosby.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)態(tài)反應(yīng)試驗(yàn)動(dòng)態(tài)反應(yīng)試驗(yàn)血流動(dòng)力學(xué)監(jiān)測(cè)系統(tǒng)的動(dòng)態(tài)反應(yīng)(dynamic response)自然頻率(natural frequency)n動(dòng)脈血壓搏動(dòng)或快速?zèng)_洗試驗(yàn)的壓力信號(hào)引起壓力監(jiān)測(cè)系統(tǒng)振蕩的速度衰減系數(shù)(damping coefficient)n系統(tǒng)振蕩衰減直至最終靜止的速度有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)態(tài)反應(yīng)試驗(yàn)動(dòng)態(tài)反應(yīng)

14、試驗(yàn)第一步: 確定自然頻率進(jìn)行快速?zèng)_洗操作n方波試驗(yàn)在記錄紙上記錄方波及隨后振蕩波形測(cè)定兩個(gè)連續(xù)振蕩波之間的距離(t, mm)計(jì)算自然頻率(Fn)nFn = 走紙速度(mm/s) / t有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)態(tài)反應(yīng)試驗(yàn)動(dòng)態(tài)反應(yīng)試驗(yàn)第二步: 確定波幅比值測(cè)定兩個(gè)連續(xù)振蕩波形的波幅(A1, A2)計(jì)算波幅比值(A2/A1)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)態(tài)反應(yīng)試驗(yàn)動(dòng)態(tài)反應(yīng)試驗(yàn)第三步: 確定動(dòng)態(tài)反應(yīng)特性將自然頻率作為X軸將波幅比值作為Y軸確定圖中兩條直線的交點(diǎn)位置有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 動(dòng)態(tài)反應(yīng)試驗(yàn)動(dòng)態(tài)反應(yīng)試驗(yàn)自然頻率越高(間距越小), 系統(tǒng)的動(dòng)態(tài)反應(yīng)特性越好n如果兩個(gè)連續(xù)振蕩

15、波之間的距離 2個(gè)小格n無論波幅如何, 系統(tǒng)缺乏準(zhǔn)確性衰減舉例衰減舉例適當(dāng)?shù)乃p適當(dāng)?shù)乃p臨床例證臨床例證衰減不足反跳波間距 2個(gè)小格第二個(gè)反跳波與第一個(gè)高度相同系統(tǒng)衰減不足, 壓力不準(zhǔn)確(過高)衰減過度沒有反跳波逐漸降低到基線水平系統(tǒng)過度衰減, 壓力不準(zhǔn)確(低估)與收縮壓及舒張壓相比, 平均壓不受影響影響波形準(zhǔn)確性的因素影響波形準(zhǔn)確性的因素降低波形的因素(衰減過度)n空氣n血液/纖維蛋白n管路打折n管路過軟放大波形的因素(衰減不足)n管路過長(zhǎng)n三通過多有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 護(hù)理要點(diǎn)護(hù)理要點(diǎn)有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 血壓讀數(shù)血壓讀數(shù)選擇正確的導(dǎo)管傳感器調(diào)零參考平面正確有創(chuàng)動(dòng)脈壓

16、監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 血壓讀數(shù)血壓讀數(shù)護(hù)士往往不相信有創(chuàng)動(dòng)脈壓監(jiān)測(cè)結(jié)果, 轉(zhuǎn)而測(cè)定無創(chuàng)血壓“只要管路通暢, 傳感器系統(tǒng)設(shè)置及功能正常, 有創(chuàng)動(dòng)脈血壓測(cè)定應(yīng)當(dāng)最為準(zhǔn)確”Chulay, M., & Holland, S (1997). Ask the experts. Critical Care Nurse, 17 (3), 14-16.有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 血壓讀數(shù)血壓讀數(shù)有創(chuàng)動(dòng)脈壓與無創(chuàng)血壓的區(qū)別測(cè)定循環(huán)血容量的不同成分有創(chuàng)動(dòng)脈血壓測(cè)定壓強(qiáng)n即單位面積上循環(huán)血液所產(chǎn)生的壓力袖帶血壓測(cè)定血流n單位時(shí)間內(nèi)流過的血液量有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 血壓讀數(shù)血壓讀數(shù)健康人有創(chuàng)及無創(chuàng)血壓測(cè)定

17、MAP相差不超過10 mmHg高血壓患者n無創(chuàng)血壓低估實(shí)際血壓低血壓患者n無創(chuàng)血壓高估實(shí)際血壓有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 壓力波形壓力波形當(dāng)對(duì)有創(chuàng)血壓讀數(shù)有懷疑時(shí), 應(yīng)當(dāng)觀察動(dòng)脈壓力波形有創(chuàng)動(dòng)脈壓監(jiān)測(cè)有創(chuàng)動(dòng)脈壓監(jiān)測(cè): 壓力波形壓力波形The initial steep up swing is called the anacrotic rise and occurs during early systole with the opening of the aortic valve and left ventricular contraction. The rounded peak of th

18、e waveform is due to the continued stroke volume ejection from the left ventricular contraction and is therefore still in systole. The other side of the waveform is the downward slope which, represents the peripheral run off following the cessation of the contraction. The notch on the downward slope represents the closure of the aortic valve and i