台大医院心脏外科专科护理师.ppt

ICU care for heart transplantation 台大醫院心臟外科專科護理師 李秋慧 接獲移植命令 病床調整（單人房、遠離感染床….） 病室清潔與消毒（紫外線燈消毒2小時） 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 transplant Post-OP problems Specific problems Early identification of bleeding Monitor and treatment of dysrhythmia Prevention of right heart failure Detection of rejection Immunosuppression Screening of infection Infectious disease prophylaxis Education of the patient Task 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 record CPB (Cardiac-Pulmonary Bypass) After CPB … 體液分布改變：血液稀釋，水腫 腎功能改變：腎血管灌注不足 血壓改變：術後25小時變化大 心臟功能改變：既存功能缺損，心跳停止時間過長 血液功能改變：肝素，血小板功能缺損, 抗凝血功能 肺功能改變：肺無血流灌注，低溫 電解質改變：血液稀釋，細胞內外液、內分泌改變，酸檢平衡 高血糖：低溫抑制胰島素釋放，肝醣分解 神經功能改變：栓塞，腦血流灌注減少，麻醉 免疫功能改變：免疫反應活化 護理目標 維持心臟血管功能，組織灌流，穩定生命徵象 促進呼吸功能及氧氣交換 維持體液電解質平衡及營養給予 舒適及止痛 神經功能評估 預防術後合併症 Bleeding Cause Pre-op status: liver function CPB effect Surgical bleeding Hypothermia Pharmaceutical effect Bleeding Management : check CBC and coagulation lab Monitor vital signs closely Keep chest tube patent and milking frequently Component therapy if needed Hypertension must be managed Medication: Transamin, Vit K1 , DDAVP, factor VII(NovoSeven?) Component therapy in HTX 照放射線血品（γ -Irradiated Blood）: 可以抑制Ｔ淋巴球活性，而能防止輸血所引起之移植物抗宿主反應(GVHD)，但會影響紅血球、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)去除儲存時所產生的微凝體(Microaggregate) 一般輸血套(170um) Cardiac tamponade CVP↑ irritable, dyspnea, cyanotic ,HR↑( low C.O) chest tube drainage↓ Pulsus paradoxus: 吸氣時SBP下降 cardiac echo (First excluding mechanical factors) Low cardiac output 症狀 四肢冰冷（末梢血管收縮） 尿量少（renal blood blow↓） 皮膚潮濕（交感神經刺激汗腺分泌） 脈壓狹窄 irritable（腦部血流不足） Acidosis (組織缺氧產生過多乳酸) Low cardiac output Cause: Heart failure pericardial Tamponade hypovolemia Arrthymia Prolong CPB (心肌