心脏移植的ICU护理

1、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 tra

2、nsplantpost-op problemsvbleedingvhypovolemiavcardiac tamponade voxygenationvdysrhythmiavrenal functionvhypothermiavpain controlspecific problems early identification of bleeding monitor and treatment of dysrhythmia prevention of right heart failure detection of rejection immunosuppression screening

3、of infection infectious disease prophylaxis education of the patienttask 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 recordcpb (cardiac-pulmonary bypass)after cpb q 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

4、：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bleedingqcause pre-op status: liver function cpb effect surgical bleeding hyp

5、othermia pharmaceutical effectbleedingqmanagement : 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

6、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。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)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

7、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 filtercardiac 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)pericardial effusioncardiac echocardiac echo low cardiac outputq症狀症狀 四肢冰冷（末梢血管收縮）尿量少（ren

8、al 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 outputqcause:heart failurepericardial tamponadehypovolemiaarrthymiaprolong cpb (心肌保護不適當)bp= svr x c.oqdeterminate of c.o: hr preload contractility after loaddysrhythmiaqcause: incomplete myocardial preservation prolo

9、nged period of ischemia pulmonary hypertension cardiac edema acute rejection electrolyte imbalance drug toxicity dysrhythmiamanagementmonitor ekgkeep electrolytes balance according to lab data defibrillator（synchronize vs. unsynchronized） medication pacemakerright heart failure after htqcause: 1. pu

10、lmonary hypertension 2. chronic congestive heart failure 3. fluid overload s/s: hr, cvp u/o , svo2right heart failure after ht management: 1. use of inotropic agent 2. vasodilators: ntg, nitroprusside, pge1, primacor 3. no inhalation via ventilator (monitor bp, methemoglobin) 4. diuretics or crrt (

11、continuous renal replacement therapy )cavinfectionrejectioncav：cardiac allograft vasculopathyinfection multiple invasive central lines surgical wound: delayed wound closure nosocomial infection opportunistic infections (cmv, ebv,herpes simplex, herpes zoster, varicella zoster, ebv,hbv, hcv) malnutri

12、tioninfectionqnursing management: physical & wound assessmentat least qd protective isolation strict aseptic technique record fever curve prevent catheter infection and early line removalinfectionqnursing management: obtain cultures & infection workups routinely and prn. administer anti-micr

13、obial agent (right time & right way) patient education visitor restriction nutrition early enteral feeding as tolerate strict blood sugar control 訂餐：隔離消毒餐 tpn support *乳靡胸乳靡胸 (chylothorax)rejection-when hemodynamic compromise ivs 變厚rejectionqrelated terms: hyperacute acute chronic cellular rejec

14、tion humeral rejectionimmunosuppressants ratgqprevention of anaphylactic shock: 由cvp給藥第一次給藥時，10 c.c./1st hr premedication (solumedrol, scanol, vena) 第二個小時起才改成40 c.c./hrv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。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cyclos

15、porine 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cyclosporine會使鎂離子從尿中流失，因此移植病人常會 hypomagnesemia。tacrolimustacrolimus （ fk506，prograf ） 空腹服用空腹服用，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 hyperglycemiacellcept（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

16、cya（fk506）1/3之劑量，而仍有相同的抗排斥力。steroid solumedrol 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。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 。 emb ( endomyocardial biopsy)移植後第一個月：每週一次emb 1. 請intern先寫