糖尿病下肢血管检查.ppt

糖尿病下肢血管病变检查 Vascular Assessment 北京迪美德尔科技有限公司 医学部整理 Educational Programs Educating to perform 血管检查培训 Vascular Assessment ABI(臂踝指数)检查 ABI Assessment 多普勒波形及声音 Doppler waveforms and sounds 足趾动脉PPG检查 Arterial PPG 足趾血压和TBI检查 TBPI using Arterial PPG PPG下肢静脉功能检查 Venous PPG ABI (踝臂指数) 检查 ABI Assessment 使用多普勒 Why Use Doppler Vascular Assessment Training Session - Introductory 足部的触诊是不充分的.Palpation of foot pulses is not sufficient (Moffatt 1995) 踝部血压用普通听诊器无法测得.BP measurement at the ankle using a Stethoscope are difficult (Yao 1993) 10%的病人缺失足背动脉的脉搏.10% of patients have absent Dorsalis Pedis pulses (Callam 1987) 所有存在溃疡的病人都需要有一个受过专业培训的人员使用多普勒 进行ABI检测来监测动脉病变的情况.All patients presenting with an ulcer should be screened for arterial disease by Doppler measurement of ABI by staff who are trained to undertake this measurement. Clinical Practice Guidelines (RCN 1998). 解释检查程序 Explain and reassure patient of the procedure 保持室温舒适 Ensure ambient temperature of the room is comfortable, (Moffatt 1990) 松解上下肢体衣裤 Remove any tight clothing from both arms and stockings socks etc. from legs 保护溃疡伤口 Remove any dressings from current ulcers and cover with a clear film, (Kenny 1997) 患者保持安静休息1520分钟 Rest the patient for 15-20 minutes, (Yao 1993; Williams 1993) 患者仰卧 Position the patient supine, (Stubbing 1996) 患者准备 Preparation of the Patient Vascular Assessment Training Session - Introductory 正常静脉血流音 Sounds of normal vein 血流声音 Vascular Assessment Training Session - Introductory 正常动脉血流声 Sound of normal artery The posterior tibial pulse is located in the hollow behind the medial malleolus, and the dorsalis pedis pulse is felt between the first and second metatarsals. (K.R Vowden, 1996) 足部动脉 Arteries of the Foot Vascular Assessment Training Session - Introductory 足動脈 前面 後脛骨動脈 後腓骨動脈貫通枝 腓骨動脈 前脛骨動脈 弓状動脈 外側内側足根動脈 足背動脈 外側内側足底動脈 足底動脈弓 貫通枝（深足底枝） 後脛骨動脈内果後方部流、触診検査行適 前腓骨動脈貫通枝 足踝血压 Ankle Pressures Vascular Assessment Training Session - Introductory 右足背动脉收缩压 Right DP Systolic Pressure 足踝血压 Ankle Pressures Vascular Assessment Training Session - Introductory 右胫后动脉收缩血压 Right PT Systolic Pressure ABI检查 How to examine the ABI Vascular Assessment Training Session - Introductory ABI计算 How to Calculate the ABI Vascular Assessment Training Session - Introductory 85 80 145150 120 115 足背動脈 Dorsalis Pedis 後脛骨動脈 Posterior Tibial 上臂 Brachial 右ABI Right ABI 左ABI Left ABI Normal ABI ratio is equal or greater than 0.90 but not greater than 1.3(check local policy) = 85 150 = 0.57 = 120 150 = 0.80 ABI計算法 ABI calculations 足関節収縮期血圧最大測定値(両足) Highest ankle systolic pressure 上腕収縮期血圧最大測定値 Highest brachial systolic pressure 上臂 Brachial 後脛骨動脈 Posterior Tibial ABI结果解释 How to interpret the ABI Vascular Assessment Training Session - Introductory ABI 0.9 - 1.3 ABI = 0.7 - 0.9 ABI = 0.4 - 0.7 ABI 1.3 动脉正常 Unlikely to be arterial in origin 轻度动脉疾病 Mild peripheral disease 显著动脉疾病 Significant of arterial disease 严重动脉疾病 Severe arterial disease 检测足趾血压 Measure toe pressures or refer to specialist Apply compression therapy Apply compression therapy with caution Do not compress refer to specialist Do not compress refer urgently to vascular specialist may vary according to local protocols ABI检查周期 Repeat ABI checks Vascular Assessment Training Session - Introductory 每12周一次 It is recommended that the ABI is checked every 12 weeks (Simon 1994) however; if the patients condition changes during that time i.e. pain, the procedure should be repeated as necessary If an ulcer re-occurs, repeat the Doppler assessment Do not presume it is of the same origin 影响ABI结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Session - Introductory 动脉硬化 Atherosclerosis Hardening of arteries causing falsely elevated readings 心律不齐 Cardiac Arrhythmias (Vowden, K.P. 1996). More difficult to assess the sound 准备不足 Inadequate preparation i.e. room temperature 血管收缩 Vaso constriction 患者焦虑 Patient and clinician anxious and unrelaxed 血压升高 Resulting into increased blood pressure 患者体位不舒服 Incorrect positioning of patient Falsely elevated ankle pressures 超声耦合剂不足 Inappropriate Gel 空气气泡 Interference due to air bubbles 血压袖带不合适 Incorrect size of sphyg cuff 血压测量不准 Incorrect pressure measurements 多普勒探头不对 Inappropriate Doppler probe Ultrasound cannot penetrate to depth of vessel 探头位置不正确 Incorrect position of Doppler probe over vessel 血压测量不正确 Incorrect pressure measurements 对血管施压过大 Excessive pressure on vessel during procedure 血管挤压 Collapses vessels 血圧袖带放气过快 Releasing sphyg cuff too rapidly Risk of missing systolic pressure point 血管加压时间过长 Prolonged inflation of the cuff/re-inflation Hyperemic effect on limb 血管反复加压 Mid procedure/repeated inflation (Vowden K. P. 1996) Hyperemic effect on limb 检测过程中探头移动 Moving Doppler during measurement Incorrect pressure measurement 检测经验不足 Inexperience of the procedure (Anderson 1995) practical skill requiring assessment by peers 影响ABI结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Session - Introductory 多普勒波形和声音 Doppler waveforms and sounds 心脏收缩期 迅速升高的 血流速 心脏舒张期前期 血液回流 心脏舒张期后期 血液顺流 下肢动脉血流波形图 多普勒波形和声音 Doppler Waveforms & Sounds 多普勒波形和声音 Doppler Waveforms & Sounds 正常三时相波形 Triphasic Waveform - Normal Video clip of Triphasic waveform 单相波形 异常 Monophasic Waveform2 - Abnormal 多普勒波形和声音 Doppler Waveforms & Sounds 失去多相波单 元 单向波 波峰圆钝 Normal 正常 坚锐的上升支 三相波单元 Mild obstruction 轻度梗阻 Moderate obstruction 中度梗阻 Severe Obstruction 严重梗阻 波峰消失 多普勒波形和声音 Doppler Waveforms & Sounds 足趾动脉PPG检查 Measuring Toe pressures and TBPI 光电容积PPG原理 PPG Shift Explained Vascular Assessment Training Session - Introductory 光电容积描记仪发射并接收红外线，红外线遇 到组织时出现散射，遇到红细胞时则被其吸收 。 肢体的皮下微循环内血容量增加时被反射的红 外线密度减少；反之则增大。 影响PPG检查的因素 Factors affecting APPG measurements 室内温度应保持在2024摄氏度。The room temperature should be between 20 - 24C 检查前足趾不应裸露在外。 Always keep toes covered until tests are started 患者检查局部的温度会影响波形（如凉手、凉足） Patient temperature - cold hands and feet will alter the waveform 吸烟-尼古丁会影响波形。 Smoking - nicotine will distort the waveform 患者肢体运动检测过程中应保持不动。 Patient movement - patients should remain still during the examination PPG波形解释 APPG Waveform Interpretation 正常 Normal 异常 Abnormal 下降坡 重搏切迹尖峰 基线 重搏切迹消失，下降支轻度上弓 上升支轻度下弓 上升支延迟 波峰园钝 波幅减小 足趾血压和TBI检查 TBI using Arterial PPG 糖尿病患者足趾血压 Diabetics and Toe Pressures ABPI1.3时，需进行足趾血压测定和TBPI检查。 Undertake toe pressures and TBPI when ABPI1.3 (Brooks, 2001) 血管钙化很少发生在趾端动脉 Calcification rarely extends to digital arteries (Vowden, 1999) 足趾血压直接与足溃疡愈合相关 Toe pressures directly relate to foot ulceration healing (Carter, 1993) 对于糖尿病患者应给予更加关注，需进行特殊的动脉检查，如足趾血压检查。 “In patients with Diabetes Mellitus additional care should be taken and further arterial investigations undertaken such as toe pressures” (ETRS guideline 2003) 糖尿病患者足趾血压 Diabetics and Toe Pressures 动脉PPG是检查足趾血压的最佳手段。Arterial PPG is the preferred technique to measure toe pressures (Vowden, 2002) 检测脚趾血压比多普勒操作简单得多 Easier than Doppler to measure toe pressures 消除通过声音探测脉搏恢复 Eliminates the need to audibly detect the return of the pulse 探头容易连接手指和脚趾 Sensors easily attach to fingers & toes 血压测定时，充气袖带放气速度应为23mmHg/秒 Cuffs should be deflated at 2-3mmHg/sec (BHS, 2000) 糖尿病患者足趾血压 Diabetics and Toe Pressures PPG检测足趾血压 Toe Pressures using PPG 135140 上臂 Brachial TBI計算法 TBPI calculations 足趾収縮期血圧 Toe systolic pressure 上臂収縮期血圧最大測定値Highest brachial systolic pressure 140 140 75 115 足趾 Toe = 75 = 0.54 = 115 = 0.82 右TBI Right TBPI 左TBI Left TBI 上臂 Brachial 糖尿病患者足趾血压 Diabetics and Toe Pressures 糖尿病患者足趾血压 Diabetics and Toe Pressures 正常TBI 0.7 临界值TBI 0.65-0.7 病变TBI 55 40% 85% 97% 73% 100% 100% (Carter, 1993) PPG下肢静脉功能检查 Using PPG for venous assessment 应用红外光传感器检查微循环的静脉血流 Uses infrared light sensor to measure venous blood volume in the microcirculation 检查整体的静脉循环情况 Assesses overall venous circulation 不针对单个静脉血管 Not vessel specific 通过止血袖带可以区分表浅静脉和深静脉的功能不全 Can diagnose difference between superficial and deep venous incompetence using tourniquets 可用于筛查深静脉血栓形成 Can screen for the absence of DVT 应用PPG检查静脉 Venous Assessment Using PPG 脱去鞋袜 Remove stockings and footwear 将足放在绝缘板上 Place foot on insulated mat 调节高度使足部承担压力最小 Adjust height to minimise weight on feet 肥胖患者应适当依靠以减少静脉压迫 Obese patients should be reclined to reduce venous compression 传感器置于内踝上方10cm处（蓝线指示） Fit sensor 10cm above the medial malleolus (blue cable) 使用ES-100V3检查时患者姿态 Patient Position using Rheo Dopplex 正常静脉PPG曲线 Normal PPG Curve 正常波形 Normal Waveform 正常患者的静脉PPG曲线应有正常的静脉再充盈时间（RT） 应用PPG检查静脉 Venous Assessment Using PPG 如果在5次足部背曲运动后, 静脉回复时间20秒则提示下肢静脉瓣膜正常. If Refill Time (RT) is greater than 20 seconds, then venous insufficiency is not present or is not significant. RT20s 静脈再充満期（休憩中）静脉排空时相（运动时） 异常静脉PPG波形 Abnormal PPG Curve 异常波形 Abnormal Waveform DVT患者的VPPG曲线可以得到ACV/CFDI证实 应用PPG检查静脉 Venous Assessment Using PPG 如果在5次足部背曲运动后, 静脉回复时间20秒则提示下肢静脉瓣膜功能 不全, 可使用止血带法鉴别病变部位. If Refill Time (RT) is less than 20 seconds then venous reflux is present. Apply the tourniquet cuff at the appropriate positions to determine the level of venous insufficiency, RT20S 应用PPG检查静脉 Venous Assessment Using PPG 静脉血从动脉端再充盈 Venous refill from arte