先天性心脏病患者术后护理.pptVIP

Postoperative Care in the Patient With Congenital Heart Disease General Principles Patient homeostasis Early – declining trends do not correct themselves Late – time can be important diagnostic tool “The enemy of good is better” Specific Approaches Cardiovascular principles Approach to respiratory management Pain control/sedation Metabolic/electrolytes Infection Effects of surgical interventions on these parameters NO PARAMETER EXISTS IN ISOLATION Cardiovascular Principles Maximize O2 delivery/ O2consumption ratio Oxygen delivery: Cardiac Output Ventilation/Oxygenation Hemoglobin Maximizing Oxygen Delivery Metabolic acidosis is the hallmark of poor oxygen delivery Maximizing Oxygen Delivery Maximizing Oxygen DeliveryCardiac Output O2 Content = Saturation(O2 Capacity)+(PaO2)0.003 Oxygen Capacity = Hgb (10) (1.34) So . . Hemoglobin and saturations are determinants of O2 delivery Maximizing Oxygen DeliveryCardiac Output Gidding SS et al 1988 y=-0.26(x)+38 R=0.77 S.E.E.=1.6 Maximizing Oxygen DeliveryCardiac Output Stroke Volume Contractility Diastolic Filling Afterload Heart rate Physiologic Response Non-physiologic Response Sinus vs. junctional vs. paced ventricular rhythm Maximizing Oxygen Oxygen consumption Decreasing metabolic demands Sedation/ paralysis Thermoregulation Ventilator Strategies Respiratory acidosis/hypercarbia Oxygenation Physiology of single ventricle/shunt lesions Oxygen delivery! Atelectasis – 15-20 cc/kg tidal volumes. PEEP, inspiratory times Ventilator Strategies:Pulmonary Hypertension Sedation/neuromuscular blockade High FiO2 – no less than 60% FiO2 Mild respiratory alkalosis pH 7.50-7.60 pCO2 – 30-35 mm Hg Nitric Oxide Ventilator Strategies: Pulmonary Hypertension Pain Control/Sedation Stress response attenuation Limited myocardial reserve – decreasing metabolic demands Labile pulmonary hypertension Analgesia/anxiolysis Pain Control/Sedation Opioids MSO4 – Gold standard: better sedative effects than synthetic opioids Cardioactive –