心脏移植的ICU护理优秀

1、ICU care for heart transplantation台大醫院心臟外科專科護理師心脏移植的ICU护理优秀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）心脏移植的ICU护理优秀Immediate post-op.心脏移植的ICU护理优秀Primary GoalsTo promote adequate gas exchange and hemodynamic stability to ensure adequate peripheral blood flow and systemic organ perfusionTo address the con

2、cerns specific to cardiac transplant心脏移植的ICU护理优秀Post-OP problemsbleedinghypovolemiaCardiac tamponadeOxygenationdysrhythmiaRenal functionHypothermiaPain control心脏移植的ICU护理优秀Specific problemsEarly identification of bleedingMonitor and treatment of dysrhythmiaPrevention of right heart failureDetection o

3、f rejectionImmunosuppressionScreening of infectionInfectious disease prophylaxisEducation of the patient心脏移植的ICU护理优秀Task of the ICU nurseMake sense out of ChaosCritical thinkingBe alert !Be careful !Report of unusual dataTiming for call helpIntegrity of medical record心脏移植的ICU护理优秀CPB (Cardiac-Pulmona

4、ry Bypass)心脏移植的ICU护理优秀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：免疫反應活化心脏移植的ICU护理优秀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心脏移植的ICU

5、护理优秀BleedingCausePre-op status: liver functionCPB effect Surgical bleedingHypothermiaPharmaceutical effect心脏移植的ICU护理优秀BleedingManagement :check CBC and coagulation labMonitor vital signs closelyKeep chest tube patent and milking frequentlyComponent therapy if neededHypertension must be managedMedica

6、tion: Transamin, Vit K1 , DDAVP, factor VII(NovoSeven)心脏移植的ICU护理优秀Component therapy in HTX照放射線血品（ -Irradiated Blood）: 可以抑制淋巴球活性，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。心脏移植的ICU护理优秀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)心脏移植的ICU护理优秀許多病毒如EBV,CMV,HIV等常

7、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。Leukocyte filter心脏移植的ICU护理优秀Cardiac tamponadeCVPirritable, dyspnea, cyanotic ,HR( low C.O)chest tube drainagePulsus paradoxus: 吸氣時SBP下降cardiac echo (Fir

8、st excluding mechanical factors)心脏移植的ICU护理优秀心脏移植的ICU护理优秀Pericardial effusioncardiac echo 心脏移植的ICU护理优秀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)心脏移植的ICU护理优秀Low cardiac outputCause:Heart failurepericardial TamponadehypovolemiaArrthy

9、miaProlong CPB (心肌保護不適當)心脏移植的ICU护理优秀BP= SVR X C.ODeterminate of C.O:HRPreloadContractilityAfter load心脏移植的ICU护理优秀DysrhythmiaCause:Incomplete myocardial preservationProlonged period of ischemiaPulmonary hypertensionCardiac edemaAcute rejectionElectrolyte imbalanceDrug toxicity 心脏移植的ICU护理优秀DysrhythmiaM

10、anagementMonitor EKGKeep electrolytes balance according to Lab dataDefibrillator（synchronize vs. unsynchronized）MedicationPacemaker心脏移植的ICU护理优秀Right heart failure after HTCause: 1. Pulmonary hypertension 2. Chronic congestive heart failure 3. Fluid overloadS/S: HR, CVP U/O , SVO2心脏移植的ICU护理优秀Right he

11、art failure after HTManagement: 1. Use of inotropic agent 2. Vasodilators: NTG, Nitroprusside, PGE1, Primacor 3. NO inhalation via ventilator (monitor BP, methemoglobin) 4. Diuretics or CRRT ( Continuous Renal Replacement Therapy )心脏移植的ICU护理优秀CAVInfectionRejectionCAV：Cardiac allograft vasculopathy心脏

12、移植的ICU护理优秀InfectionMultiple invasive central linesSurgical wound: delayed wound closureNosocomial infectionOpportunistic infections (CMV, EBV,Herpes simplex, Herpes Zoster, Varicella Zoster, EBV,HBV, HCV)Malnutrition心脏移植的ICU护理优秀InfectionNursing management:Physical & wound assessmentat least QDProtec

13、tive isolationStrict aseptic techniqueRecord fever curvePrevent catheter infection and early line removal心脏移植的ICU护理优秀InfectionNursing management:Obtain cultures & infection workups routinely and prn.Administer anti-microbial agent (right time & right way)Patient educationVisitor restriction 心脏移植的ICU

14、护理优秀NutritionEarly enteral feeding as tolerateStrict blood sugar control訂餐：隔離消毒餐TPN support*乳靡胸 (chylothorax)心脏移植的ICU护理优秀Rejection-when hemodynamic compromise IVS 變厚心脏移植的ICU护理优秀RejectionRelated terms:HyperacuteAcuteChronicCellular rejectionHumeral rejection心脏移植的ICU护理优秀Immunosuppressants RATGPreventi

15、on of anaphylactic shock: 由CVP給藥第一次給藥時，10 c.c./1st hrpremedication (solumedrol, scanol, vena)第二個小時起才改成40 c.c./hr通常只用於前35天，除非術後有急性腎衰竭，常見副作用有:發燒白血球和血小板減少。心脏移植的ICU护理优秀Cyclosporine ( Sandimmune, Neoral)給藥劑量是依照最低血中濃度(C0)來調整劑量，所以抽血一定要在給藥之前，以免判讀困難。(C2: 給予cyclosporine 2 hrs 後測血中濃度)病人若長期使用利尿劑，使鎂離子流失。加上cyclos

16、porine會使鎂離子從尿中流失，因此移植病人常會 hypomagnesemia。心脏移植的ICU护理优秀Tacrolimus （ FK506，Prograf ）空腹服用，給藥時間為飯前一小時或飯後兩小時，因食物會影響其吸收依給藥前血中濃度調整劑量Hyperglycemia心脏移植的ICU护理优秀Cellcept（MMF Mycophenolate mofetil）沒有腎毒性。多使用在有高度排斥免疫風險的個案，價錢較imuran貴很多。為減少cyclosporine（or FK506）之劑量，使用全量MMF後，約可減CyA（FK506）1/3之劑量，而仍有相同的抗排斥力。心脏移植的ICU护理优

17、秀SteroidSolumedrol 120 mg IV, q8hr X 1 day口服prednisolone 0.5 mg/kg/day，每次biopsy，視排斥狀況逐漸減量。心脏移植的ICU护理优秀Azathioprine（ Imuran ）目標是WBC : 4000 6000，手術後可以開始口服即開始給藥。因會骨髓抑制，造成WBC and Plat，所以每日check CBC，視WBC調整劑量。如果有infection的S/S，暫停imuran 。心脏移植的ICU护理优秀心脏移植的ICU护理优秀 EMB ( endomyocardial biopsy)移植後第一個月：每週一次心脏移植的ICU护理优秀EMB1. 請Intern先寫好病理單(Lev