先天性心脏病患者术后护理

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1、PostoperativeCareinthePatientWithCongenitalHeartDiseaseUTHSCSAPediatricResidentCurriculumforthePICUGeneralPrinciplesPatienthomeostasisEarly–decliningtrendsdonotcorrectthemselvesLate–timecanbeimportantdiagnostictool“Theenemyofgoodisbetter”SpecificApproachesCardiovascularprinciplesAp

2、proachtorespiratorymanagementPaincontrol/sedationMetabolic/electrolytesInfectionEffectsofsurgicalinterventionsontheseparametersNOPARAMETEREXISTSINISOLATIONCardiovascularPrinciplesMaximizeO2delivery/O2consumptionratioOxygendelivery:CardiacOutputVentilation/OxygenationHemoglobinMaxim

3、izingOxygenDeliveryMetabolicacidosisisthehallmarkofpooroxygendeliveryMaximizingOxygenDeliveryOXYGENDELIVERYOXYGENCONTENTCARDIACOUTPUTX=O2Content=Saturation(O2Capacity)+(PaO2)0.003OxygenCapacity=Hgb(10)(1.34)So..HemoglobinandsaturationsaredeterminantsofO2deliveryMaximizingOxygenDeli

4、veryCardiacOutputGiddingSSetal1988y=-0.26(x)+38R=0.77S.E.E.=1.6MaximizingOxygenDeliveryCardiacOutputMaximizingOxygenDeliveryCardiacOutputStrokeVolumeContractilityDiastolicFillingAfterloadHeartratePhysiologicResponseNon-physiologicResponseSinusvs.junctionalvs.pacedventricularrhyt

5、hmCardiacOutputStrokeVolumeHeartRate=XMaximizingOxygenOxygenconsumptionDecreasingmetabolicdemandsSedation/paralysisThermoregulationVentilatorStrategiesRespiratoryacidosis/hypercarbiaOxygenationPhysiologyofsingleventricle/shuntlesionsOxygendelivery!Atelectasis–15-20cc/kgtidalvolumes

6、.PEEP,inspiratorytimesVentilatorStrategies:PulmonaryHypertensionSedation/neuromuscularblockadeHighFiO2–nolessthan60%FiO2MildrespiratoryalkalosispH7.50-7.60pCO2–30-35mmHgNitricOxideVentilatorStrategies:PulmonaryHypertensionThevisciouscycleofPHTNPrecipitatingEvent-Coldstress-Suctio

7、ning-AcidosisMetabolicAcidosisHypercapniaIncreasedPVRDecreasedPulmonaryBloodFlowDecreasedLVpreloadRVdysfunctionCentralVenousHypertensionHypoxemiaLowoutputIschemiaPainControl/SedationStressresponseattenuationLimitedmyocardialreserve–decreasingmetabolicdemandsLabilepulmonaryhypertens

8、ionAnalgesia/anxiolysisPai