IABP护理查房课件ppt

一例心跳呼吸骤停使用IABP患者的护理查房主动脉内球囊反搏泵Intra-AorticBalloonPump————简称IABP主动脉内球囊反搏泵ACAT1PLUS

AUTOCAT2AUTOCAT2WAVE反搏的原理心脏收缩前一瞬间（主动脉开放时），球囊放气，降低主动脉内舒张末压，减少左心室做功，降低后负荷，减少心肌耗氧心脏舒张前一瞬间（主动脉关闭时），球囊充气，增加舒张期冠脉灌注压力，增加心肌供氧冠脉分布示意图使用科室应用指征术前---国外：42-72%国内：5%左右危重状态或血液动力学不稳，争取时间手术---PTCA，旋切，支架等失败，或难以控制心律失常---心梗后并发症---MI合并左室功能低下，低心排---心衰状态的术前病人

心脏外科（冠脉搭桥术、心脏瓣膜置换术）心脏内科（急诊PTCA）急诊科（急性心梗合并心源性休克）适应症一、各种原因引起的心泵衰竭急性原因引起的心泵衰竭围手术期发生的心肌梗塞体外循环后低心排综合症心脏挫伤中毒性休克病毒性心肌炎二、急性心肌梗塞后发生的机械性并发症室间隔穿孔乳头肌断裂致二尖瓣关闭不全大室壁瘤三、内科治疗无效的不稳定型心绞痛四、心肌缺血而致的室性心律失常五、进展性心肌梗塞六、围手术期对重症病人的支持和保护措施严重心肌缺血病人作冠脉造影、PTCA、溶栓术、麻醉诱导高危重症病人作心导管检查、心脏手术、普外手术七、心脏移植前后的辅助治疗八、人工心脏的过渡治疗九、手术中产生搏动性血流IABP使用禁忌症主动脉瓣关闭不全主动脉瘤或主动脉血管性的疾病动脉粥样硬化与严重的周围血管疾病脑死亡患者疾病末期如癌症转移IABP并发症下肢缺血：由于经皮穿刺，损伤小，无鞘导管的应用，这类并发症已属少见血栓形成：应保持ACT(激活全血凝固时间)在150-180秒主动脉内膜损伤，动脉破裂血小板减少气栓感染，败血症IABP停用指征多巴酚丁胺＜5ug/kg/min心脏指数＞2.5L/min／m2平均动脉压＞90mmHg尿量＞4ml/kg/小时手足暖，末稍循环好减慢反搏频率时，上述指标稳定一般不超过3天CompanyLogoIABP球囊的位置位置:左锁骨动脉以下2-3cm（第二肋间）和肾动脉开口之间的降主动脉内.确定位置:

可通过胸部X光片观察导管尖端是否位于第2-3肋间.接IABP机器IABP球囊的位置异常●放置位置过高

气囊可能阻塞左锁骨下动脉的开口左上肢灌注不足●放置位置过低气囊可能阻塞肾动脉的开口肾动脉灌注不足尿量减少阻断主动脉截面积：球囊充气后的大小应该是主动脉直径的80-90%。如果球囊的太大，会损伤主动脉；而球囊的体积太小，反搏会无效。IABP导管阻塞面积DiastoleSystole<162cm<5’4”<182cm<6’0”>182cm>6’0”30cc40cc50ccIABP导管型号选择IABP导管

BalloonMembraneProximalMarkerUniversalSheathSealSTAT-GARDSleeveY-fittingExtracorporealTubingDistalMarkerCatheterShaftSuturePadsInnerLumenPort远端标记球囊膜近段标记延长管延伸管导管轴通用鞘STAT-GARD轴中心管内腔Y型接口球囊导管耗材的组成

2.连接压力传感器中心腔血压监护的连接示意Y接头加压盐水袋保持300mmHg压力连续冲洗装置测压管路长度不超过8Ft或240cm连接至球囊反搏泵的鲁尔接头处导管连接显示面板H-----HELIUM（氦气）E-----ECG（心电图）A-----AP（动脉血压）R-----RESET（球囊气量设置）

RATIO（反搏比率）T-----TRIGGER（触发模式）TIMING（充放气时机）

I.PowerOn打开电源

II.PatientConnect病人连接

III.PumpOn启动泵IABP操作快速上路安装氦气瓶；打开减压阀；如左图屏幕右下方显示氦气余量。氦气供应在反搏中更换氦气时无需中断反搏，即可自动填充开机后，自动执行排气动作ECG导线ECG信号传输线ECG信号的输入接口

连接心电图导线心电图是绿色波，以白色部分突出充放气时间动脉压是红色波，以白色部分突出充放气时间球囊压是蓝色波,以mmHg为单位波形显示PSP、PDP、EDP、MAP压力测量线（游标），可测量血压和球囊压力上的任一点的压力值压力信号自动校正，可分段显示提供AP输入、输出接口触发时机图同步显示在血压图上，以白色标识显示血压信号充气量调节球囊充气量球囊压力波形123456789零基线球囊压力基线快速充气充气机械波充气后的稳定压力快速放气放气机械波回复基线球囊充/放气周期时间CompanyLogo球囊压力波形球囊充气气量的设置保证PDP与球囊的平台压力在25mmHg之间反搏比率1:1，1:2，1:4，1:8反搏频率

1:1

1:2

1:3触发模式ACTA1PLUS规范型（PATTERN）峰型（PEAK）自动房颤（AFIB）心室起搏触发（VPACE）心房起搏触发（APACE）血压触发（AP）最低3-5mmHg触发内触发（INT）触发模式AUTOCAT2触发时机图示充、放气时间在R-R间期的标识R波-R波间期表示在R-R间期的35%充气、90%放气ECG和AP信号的自动识别，选择，转换触发模式的自动选择充放气时间的自动选择触发模式AUTOCAT2ECG导联间的转换监护仪和病人经皮采集信号间的转换在必要时在ECG和AP触发间转换持续ECG增益自动缩放AP波形比例自动选择ECG/AP信号来源从6种触发模式中自动选择合适的触发模式根据ECG信号情况自动在ECG和AP触发间转换自动触发模式的选择根据信号选择模式自动选择合适充放气点在心律不规则时R波自动放气早搏后长间歇自动补偿充放气时机的自动调整IABP的护理保证充足氦气供应

术前注意拧开氦气瓶总开关和小开关，并检查氦气表。IABP使用期间，要随时检查压力表，当指针指向红线时要更换氦气瓶。

CompanyLogoIABP的护理确保球囊位置正确

①术前预测量待置入球囊的长度。②术后立即拍床边胸片，确保球囊位置正确。

CompanyLogoIABP的护理采取正确舒适的卧位，避免导管曲折

①严格卧床休息，适当限制术肢的活动，病情允许者床头摇高不超过30°，侧卧位是不超过40°，术肢伸直，避免屈曲。②下肢做被动功能锻炼，即肢体按摩、拍打。加强皮肤护理，预防褥疮。CompanyLogoIABP的护理密切观察病情①注意病人心率、心律、有创动脉压、反搏压的变化，如出现心律失常而致反搏比例不当时，及时报告医生。在医生指导下，适当调整反搏比或球囊充气放气时间。②术后患者需要达到全身肝素化（ACT250～300秒，凝血酶原时间18±2秒），防止血栓形成。注意伤口出血情况及皮肤粘膜、尿液等有无出血。③注意观察IABP并发症的临床表现。如每小时尿量、24小时出入量、双侧足背动脉搏动情况。CompanyLogoIABP的护理保证管道通畅及密闭性

①注意导管各连接处有无松动、脱开及血液返流等情况出现。各接口紧密衔接。妥善固定有创动脉导管并保持其通畅。每小时用肝素盐水（NS500ml+肝素5000u）冲管。②保证压力换能器位置始终处于心脏水平。注意定时校正零位，确保测压值正确反映患者情况及IABP使用效果。③注意保护导管。严禁经导管抽血或进行其他治疗，以免损伤球囊导管。

CompanyLogoIABP的护理确保反搏触发信号清晰

确保心电图信号清晰做到以下几点：①固定好电极片。②心电图导联选用标准肢导联中R波高尖，T波低平的导联。③操作时要注意心电图情况，防止心电导联及电极脱落。必要时在操作时将心电图触发改为压力触发，同时注意反搏波形。IABP使用期间，密切观察反搏波形及其振幅、球囊充气、放弃时间是否正确。CompanyLogoIABP的护理正常的球囊压力波形球囊压力波形的变化CompanyLogo

正常的球囊压力波形

心率慢时心率快时心率的影响球囊压力波形的变化

血压高时血压低时血压的影响球囊压力波形的变化

正常波形充气受限充气受限球囊压力波形的变化

正常波形排气受限排气受限球囊压力波形的变化

导管扭曲球囊压力波形的变化

漏气球囊压力波形的变化

持续充盈球囊压力波形的变化舒张期切迹（DN）平均压收缩压PulsePressure舒张压12010080收缩期舒张期mmHg如何确定正确的充放气时机通过动脉压力波形来判断及调节动脉压力波形图WithoutIABPWithIABPassist1:2EKG动脉压力波形图充放气时机的调整主要是观察机器以1:2比率反搏时的血压波形

1。PDP点是否高于PSP点10mmHg的压力值以上。（虚线①）

2。PSP点是否略高于APSP点。（虚线②）

3。PAEDP点是否略高于BAEDP点。（虚线③）PSPAPSP反搏辅助后的收缩压BAEDP球囊在主动脉内的末期舒张压PAEDP病患的主动脉末期舒张压PDP①②③动脉压力波形图PDP应大于PSP（PDP>PSP）除非: 1.病人每搏量远远大于球囊容量 2.导管位置太低 3.严重低血容量 4.球囊充气量太小 5.体循环阻力太低

PSPPDP动脉压力波形图时相错位-充气过早有反搏收缩压反搏压有反搏舒张压末尾没反搏收缩压

球囊于主瓣关闭前充气波形特点:球囊在V型切口前充气舒张压侵占收缩期(可能难以分辨）生理效应:主动脉瓣提前关闭每搏量/心输出量减少前负荷增加增加加心肌耗氧时相错位-充气过晚有反搏收缩压反搏压

V型切口有反搏舒张压末尾

没反搏收缩压球囊于主瓣关闭后较晚充气波形特点: • 球囊在V型切口后充气 • 缺乏尖V • 反搏压不足生理效应: • 冠脉灌注不足时相错位-放气过早有反搏收缩压反搏压有反搏舒张压末尾没反搏舒张压末尾球囊于舒张期内过早放期波形特点: • 反搏压出现后马上看到其急降 • 反搏压不足 • 有反搏舒张压末尾可能等于或小于没反搏舒张压 • 有反搏收缩压可能提高生理效应: • 反搏压不足 • 可能出现冠脉和颈动脉逆流 • 由于冠脉血液逆流可引起心绞疼

• 没足够后负荷降低效果 • 增加心肌耗氧时相错位-放气过晚反搏压有反搏舒张压末压没反搏收缩压外观加宽有反搏收缩压上升时间延长当主瓣开始打开时球囊才放气波形特点:

• 有反搏舒张压末压可能等于没反搏舒张压末压

• 有反搏收缩压上升时间延长

• 反搏压外观看来加宽生理效应:

• 完全没有减低后负荷

• 由于是左心室射血的阻力增加和等容收缩期延长而增加心肌耗氧

• 球囊阻挡左室心排血而增加后负荷充放气时机三部曲CompanyLogo

1. 在DN前充气

如果在DN前>40ms–充气过早

如果可见DN–充气过晚

APSPPDPPSPPAEDPPAEDPBAEDPDN705580HypotheticalBP=90/70充放气时机三部曲CompanyLogo2. BAEDP<PAEDP

如果BAEDP≥PAEDP–放气过晚

3. APSP<PSP

如果APSP=PSP–放气过早

CompanyLogoAPSPPDPPSPPAEDPPAEDPBAEDPDN705580CompanyLogo患者信息姓名苗XX性别女年龄21岁民族汉族职业学生入院日期2013-05-15主诉呼吸心跳骤停25分钟，心肺复苏术后6小时病史05-15凌晨1:40左右，同学发现其在床上翻动后，出现双上肢抽搐，当时脸色、口唇苍白，呼之不应，诉触颈动脉搏动减弱，立即送至我院急诊。2:05到达我院急诊室，当时患者处于昏迷状态，呼之不应，颈动脉搏动未扪及，立即行心肺复苏术及气管插管、“胺碘酮300mg”静推、电除颤4次等抢救措施后患者于2:15恢复自主心率，心率167次/分，再次出现室颤，立即予电除颤、心肺复苏术，于2:21恢复自主心率，当时心率123次/分，血氧饱和度91%。2:56查心电图示窦性心率，频发室早。9点复查电解质示钾3.43mmol/l，钙1.85mmol/l，现为求进一步治疗，转入EICU治疗。CompanyLogo病史既往史：2006年4月在当地医院诊断为“频发室早”，入院治疗后好转。2009年2月因“频发室早”在外院行“射频消融术”，2012年11月先后有两次晕厥病史，每次时间短，可自行恢复。2013年3月开始服用“普罗帕酮”，100mg，每天3次。近一月反复出现心悸。家族史：其父亲有“二尖瓣关闭不全”。CompanyLogo入室评估T36.5℃P148次/分R18次/分Bp92/46mmHg神志处于镇静状态，Ramsay评分5分。双侧瞳孔等大等圆，直径约2.0mm，对光反射迟钝。带入气管插管在位，两肺呼吸音稍粗，未闻及明显干、湿啰音。心律齐，未及明显病理性杂音。脊柱、四肢无畸形。四肢肌张力不高。CompanyLogo实验室及辅助检查血气分析（2013-5-1502:26本院）PH7.333，PCO237.0mmHg，PO2612mmHg，HCO319.6mmol/l，BE-6mmol/l，SpO2100%。

电解质（2013-5-153:31本院）钾3.43mmol/l，钙1.85mmol/l。

心肌酶谱（2013-5-153:49本院）肌酸激酶同工酶48.80umol/l。

血气分析（2013-5-1508:52本院）PH7.456，PCO231.5mmHg，PO2118mmHg，HCO322.1mmol/l，BE-2mmol/l，SpO299%，Lac2.48mmol/l。

CompanyLogo24小时动态心电图（2013-3-26南京市第一医院）1、窦性心率；2偶发房性早搏；3频发室性早搏，短暂性室性心动过速；4、T波改变。

心电图（2013-5-152:56本院）窦性心率，频发室早。

床旁胸片（2013-5-154:06本院）右肺胸腔少量积液，两肺纹理增多。CompanyLogo实验室及辅助检查护理问题心输出量减少与心泵功能降低有关（05-15）组织灌注量改变与有效循环血量减少有关（05-15）不能维持自主呼吸与镇静药，肌松药使用有关（05-15）有感染的危险与低温治疗及各种导管留置有关（05-15）有皮肤完整性受损的危险与卧床，IABP治疗移动减少有关（05-15）CompanyLogo护理问题营养失调低于机体需要量与不能进食，疾病消耗有关（05-15）潜在并发症心跳呼吸骤停﹑出血﹑坠积性肺炎﹑心律失常﹑血栓﹑动脉破裂（05-15）CompanyLogo护理目标患者能维持足够的心输出量，生命体征平稳及尿量正常患者组织灌注量能得到改善患者能渐渐恢复自主呼吸直至完全脱机患者导管留置及低温治疗阶段无感染发生患者住院期间皮肤能维持完整，无压疮发生患者能得到机体所需的能量供应住院期间防治各种并发症的发生CompanyLogo护理措施24h心电监护，密切观察患者神志，瞳孔，意识，皮肤温度，有无出血倾向。记录24h生命体征及出入量。做好IABP的护理遵医嘱按时准确使用各种药物，并注意观察疗效及不良反应。遵医嘱控制输液速度。做好各项基础护理。保持皮肤的完整性，防止冻伤。定时翻身。做好各种导管的护理，标示清晰，严格无菌操作。保持呼吸道通畅，按需吸痰。CompanyLogo备好抢救车除颤仪，随时准备配合医生抢救。定时检测血糖。遵医嘱留取血标本，及时查看结果。做好床边交接班。班班调节心电监护呼吸机等的报警线。肺部听诊。做好患者家属的解释沟通工作。CompanyLogo护理措施05-1612点开始复温。偶见室早，05-1701:29至01:30可见频发室早。呼吸机模式改为A/C新护理问题复温并发症（心律失常）与亚低温复温治疗有关目标患者复温阶段未发生休克，心律失常次数减少措施做好复温阶段的护理。遵医嘱用药，密切监测体温变化，生命体征，记录24出入量，CVP；监测血糖防止体温上升过快，由于血管扩张，回心血量减少，血压下降而发生低血容量休克；如体温不升，可增加盖被等。CompanyLogo05-1709点停万可松，10:30球囊反搏调为1:2。15:45拔出球囊反搏置管。停亚低温治疗。停静安？停去甲肾？患者可睁眼，能明白言语，神志清。痰液呈黄白色。停亚低温治疗。右下肢肿胀，皮温高。新护理问题有发生血栓的危险与IABP治疗有关目标患者住院期间溶栓成功或血栓未脱落措施定时测量双侧下肢大腿围，观察下肢皮温，足背动脉搏动情况。防止右下肢肢体动作过大。CompanyLogo05-1808:20试停呼吸机，08:30遵医嘱拔出气管导管，给予双腔鼻导管吸氧5L/分。18点T38.7x℃。17日血常规示白细胞计数14.44×10^9/L，中性粒细胞91.20%，中性粒细胞计数13.17×10^9/L，淋巴细胞4.60%。新护理问题体温过高与感染有关目标患者3天内体温下降至正常措施遵医嘱使用物理降温，1小时后复测体温。做好降温护理CompanyLogo05-1909点停多巴胺。发生肛周失禁性皮炎。新护理问题肛周失禁性皮炎目标患者一周内皮炎恢复措施使用液体敷料喷涂。增加翻身次数。保持局部清洁干燥。CompanyLogo05-20右下肢肿胀好转05-21肛周失禁性皮炎好转,右下肢肿胀消退。CompanyLogo护理评价（05-23）患者生命体征平稳，尿量正常，但仍有心衰的可能患者完全恢复自主呼吸患者有感染发生，体温暂正常患者住院期间无压疮发生患者能得到机体所需的能量供应患者有室早的发生患者皮炎好转，右下肢肿胀消退CompanyLogoYourcompanysloganThankYou!8686赠送2套亮丽色表格可一键删除折线图/表格/数据关系Trending

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