心脏移植的icu护理.pptxVIP

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 GoalsTo promote adequate gas exchange and hemodynamic stability ? to ensure adequate peripheral blood flow and systemic organ perfusionTo address the concerns specific to cardiac transplantPost-OP problemsbleedinghypovolemiaCardiac tamponadeOxygenationdysrhythmiaRenal functionHypothermiaPain controlSpecific problemsEarly identification of bleedingMonitor and treatment of dysrhythmiaPrevention of right heart failureDetection of rejectionImmunosuppressionScreening of infectionInfectious disease prophylaxisEducation of the patientTask of the ICU nurseMake sense out of ChaosCritical thinkingBe alert !Be careful !Report of unusual dataTiming for call helpIntegrity of medical recordCPB (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BleedingCausePre-op status: liver functionCPB effect Surgical bleedingHypothermiaPharmaceutical effectBleedingManagement :check CBC and coagulation labMonitor vital signs closelyKeep chest tube patent and milking frequentlyComponent therapy if neededHypertension must be managedMedication: 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)Leukocyte filter許多病毒如EBV,CMV,HIV等常存在於白血球中,這些病毒可藉輸血傳染給病人,尤其在免疫功能有缺損者常引起致命的感染,另外一些輸血副作用如發燒,發冷等也常因血液中含有白血球而產生.因此如何去除減少血液中白血球成為預防病毒傳染及減少輸血副作用的重要處置.白血球過濾器又分為紅血球及血小板專用兩種 減少感染巨細胞病毒(CMV)之機率。Cardiac tamponadeCVP↑irritable, dyspnea, cyanotic ,HR↑( low C.O)chest tube drainage↓Pulsus paradoxus: 吸氣時SBP下降cardiac echo (First excluding mechanical factors)cardiac echo Pericardial effusio