《血管通路》ppt课件

1、如何加强血液透析患者血管通路的管理和维护如何加强血液透析患者血管通路的管理和维护血管通路血管通路血液透析患者的生命线血液透析胜利施行的必要条件第一个问题第一个问题 血管通路的开展进程血管通路的开展进程动静脉外瘘Quinton-Scribner shunt血管通路开展史上的第一个里程碑1960年自体动静脉內瘘Arteriovenous Fistula血管通路开展史上的第二个里程碑1962年移植血管內瘘 Arteriovenous Graft中心静脉留置导管central venous catheter充足的血流量操作简单，可反复运用平安稳定，并发症少理想的血管通路第二个问题第二个问题 对几种血管

2、通路的初步认识对几种血管通路的初步认识AVF是什么？AVF是运用血管外科技术人为的建立一条动静脉之间的短路是目前国际上公认的最正确的血管通路AVG是什么？AVG就是移植血管内瘘 AVG用一根人工血管将动静脉衔接起来CVC是什么 The catheter is placed in the right internal jugular vein with a smooth curve in the subcutaneous tunnel.The tip of the catheter is placed in the right atrium to achieve adequate blood f

3、low during hemodialysis.AVF的并发症血管狭窄急性血栓构成静脉高压征动脉瘤高输出量心力衰竭通路相关性缺血综合征感染血管狭窄 fistulogram showing a long inflow segment stenosis which was successfully balloon angioplastied. A: Pre-angioplasty. B: Waist on the balloon. C: Post-angioplasty image.ABC静脉高压征 Massively swollen right upper extremity from comp

4、letely occluded right subclavian vein. The transposed basilic vein arteriovenous fistula is patentExtensive network of collateralveins over the right shoulderand chest area.动脉瘤通路相关性缺血综合征87-year-old female with a brachiocephalic fistula created approximately 9 months prior to photograph who complaine

5、d of pain and numbness over her right hand during dialysis.On examination the fingers were blue and cold (A). Panel Bcompares the color of her hand to a normal pink color.ABAVG的并发症血管狭窄感染血栓构成静脉高压征假性动脉瘤高输出量心力衰竭血清肿血管狭窄Forty-five-year-old male with a right forearm loop AVG placed in 2003 has marked cent

6、ral vein stenosis. The collateral veins are visualized on his shoulder and chest (arrowheads).The patient has a right subclavian vein stent with recurrent stenosis as shown in next image.假性动脉瘤假性动脉瘤CVC的并发症感染导管功能不良纤维蛋白鞘、血栓构成导管出口感染Purulent fluid collection under the dressing suggestive of infectionPuru

7、lent secretion, erythema over the tunnel and skin changes secondary to infection in the subcutaneous tunnel.导管功能不良An intact fibrin sheath pulled out along with the catheter.A fibrin sheath is a flimsy fibroepithelial tissue that extends from the cuff (A) to the tip of the catheter (B).纤维蛋白鞘AB血栓第三个问题

8、第三个问题 血管通路的长期管理和维护血管通路的长期管理和维护每次穿刺前对内瘘的情况的评价望诊用眼睛看触诊经过触摸来觉得内瘘的震颤和搏动听诊用听诊器听内瘘的杂音normal-AVF-bruitAVF-whistleNormal-AV-Graftgraft-whistleAVF的功能监测瘘管血流量的测定超声稀释法病症检查：举臂实验,Augmentation test超声检查再循环测定非尿素法静态静脉压测定AVF的血流量测定每个月丈量一次丈量要在透析前一个半小时内完成每次检查要丈量三次，取平均值血流量缺乏时，做血管造影检查确定能否有狭窄举臂实验 将内瘘侧手臂抬高，与身体呈90度，察看内瘘静脉段能否塌

9、陷再循环测定葡萄糖测定法建议每 3 个月 1 次。透析后30min，血流量在300ml/min,停超滤，动脉端取血A，4s内从静脉端注入50%的葡萄糖2ml，开场计时，至第13秒，于动脉端同一部位取血B，测定两次血糖浓度，带入公式计算结果：R%=0.046B-A+ 0.07静态静脉压测定*每一到二周测定一次静态静脉压测定直接丈量法间接测定法：当封锁血泵时，外部压力传感器与输液壶压力传感器之间的压力差等于瘘管与输液壶血液面之间的高度差，详细方法： 先校正静脉壶及动脉壶的压力P0 在非瘘管肢体丈量平均动脉压MAP 停血泵，夹闭静脉壶上游管路，30s压力稳定后，读取结果P 丈量瘘管与输液壶血液面的间

10、隔H 计算偏移压力：Ph=0.35xH+3.6 计算瘘管内压力：Pia=P+Ph-P0 得出瘘管内压力和平均动脉压比值Pia/MAP RatioAVG的功能监测血流量测定静态静脉压测定超声检查物理检查关于CVC的维护管理导管感染的维护管理导管功能不良的维护管理导管感染分类出口感染隧道感染导管相关血流感染Exit site erythema with crusting suggestive of infection or allergic reaction to topical ointment or tape. The exit site should be evaluated prior t

11、o every dialysis therapy for early signs of infection.The exit site infection can spread through the subcutaneous tunnel causing bacteremia, sepsis and worsening morbidity and mortality。导管感染预防减少或防止运用导管应严厉遵守无菌技术去除鼻腔葡萄球菌等的携带形状防止导管用于非血液净化用途导管功能不良的缘由导管功能不良的处置导管功能不良的预防Left internal jugular catheter with

12、kink in the subcutaneous tunnel (arrow). The tip is placed in the left innominate (brachiocephalic) vein. The catheter is unlikely to provide adequate blood flows for dialysis.血管通路的安康宣教AVF和AVG的安康宣教CVC的安康宣教患者的术前安康宣教AVF的术后的自我管理内瘘术后的功能锻炼动静脉内瘘成形术后，制止在内瘘侧测血压、抽血、输液、 输血。手术侧衣袖不可过紧。术后当日内瘘侧肢体抬高30度，坚持其血流通畅，防止受压，站立时可用三角巾托起，术肢手腕超越心界；卧床时可用软枕垫高，制止向手术侧侧卧。术肢保暖，坚持术侧血液循环通畅，防止指端肿胀。术后24小时，可做握拳及腕关节动作，防血栓。术后3-7天，开场内瘘强化护理用手握拳或挤压橡皮球10秒放松，每次做10-15分钟，3-4次/日伤口拆线以后