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脑血管造影术武警总医院神经血管外科高天课件

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脑血管 造影 武警总医院 神经 血管 外科 课件
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 1 脑血管造影术脑血管造影术 武警总医院神经血管外科武警总医院神经血管外科 高天高天 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 术前查看病人 询问过敏史 滞留的血块 凝血块及气栓是脑血 管造影的主要敌人 忠 告 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 所有进入体内介入器材均为一次性 医疗器械 禁止重复使用 忠 告 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 常备药物 肝素 鱼精蛋白 硝普钠 尿激酶 罂 粟碱 尼膜同 肾上腺素 地塞米松 麻 醉及抗癫痫药物 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 适应证 颅内血管性病变 如出血性或闭塞性 脑血管性病变 自发性脑内血肿 SAH的出血原因检查 富血运肿瘤术前了解血供 血管性病变治疗后复查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 禁忌证 对碘过敏 严重出血倾向或出血性疾病 严重心肝肾功能不全 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 操作前准备 病人准备 脑血管造影并无绝对禁忌 症 重要的是确定非创伤技术是否足 以解决问题 是否接触过造影剂及过 敏史 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 操作前准备 实验室检查 凝血酶时间 PT 部分 凝血活酶时间 APTT 及血小板计数 以除外出血素质 BUN及Cr以排除肾功 不全或肾衰竭 注意是否正在接受肝素 治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 操作前准备 1 常规术前检查 血尿常规 出凝血 时间 肝肾功能 心电图及胸片 2 术前6小时禁饮食 急诊酌情 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 操作前准备 3 碘过敏试验 拟使用的造影剂1ml 静脉推注 无心慌 气短 荨 x n 麻疹及球结膜充血等 过敏体征 注射前后测量血压波动低于10 20mmHg者为阴性 碘过敏试验阳性必须造影者 术前3天进行激素 治疗 并尽量使用非离子碘水溶液造影剂 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 碘过敏或严重肾功能不全 5 12 的人群碘过敏 0 05 是威胁生命的严重 过敏 磁共振对比剂 钆 g 喷匍胺 欧乃影 钆元素在X线下特别是DSA中良好显影能力 不良反 应0 0003 0 01 万分之一 恶心 呕吐 皮肤 刺激症状 磁共振检查时0 1 0 3mmol kg 肾功不全用到 0 4mmol kg 0 8ml kg 也是安全的 所以成人总量 40 70ml 难以多角度反复投照 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 操作前准备 4 双侧腹股沟及会阴区备皮 操作时间长者留置 导尿管 5 术前30分钟肌注鲁米那钠 全麻者肌注阿托品 6 酌情术前24小时静脉持续给予钙离子拮抗剂 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病人教育 简明扼要逐个步骤介绍操作过程 腹股沟部麻 醉 穿刺股动脉 插入导管 以及造影剂注入 时病人可能体验到的感受 发热感 减影时病人动作 屏息不做吞咽动作 深吸一 口气 呼出去 再吸半口气 然后屏气 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 手术知情同意书 过分强调危险性是不适宜的 因这可 能使病人过度恐惧以致不敢作造影 从而影响病人的最大利益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 全脑脑血管造影术术知情同意书书 1 CT 证实蛛网膜下腔出血 疑为动脉瘤破裂出血 为明确诊断 指导治疗 拟行全脑血管造影术 但患者一般 情况差 手术耐受性差 2 如系动脉瘤或其他血管性疾病 造影前后随时可能破裂出血 导致病情迅速恶化甚至死亡 即使急症手术也 不一定能挽救生命 3 麻醉意外 造影剂或其他药物引起的过敏 异物反应或毒性反应 严重者出现脏器功能衰竭 死亡 4 穿刺部位血肿 导管途经血管损伤造成动脉夹层 血管破裂出血 腹膜后血肿可以致休克 5 导管 导丝断裂 打结 被迫置于血管内 途经血管壁上的动脉硬化斑块及血栓栓子脱落 导管内形成的凝 血块或栓子脱落 导管内进入气体 进而进入血管 这些情况都可以造成脑或脊髓的梗死和缺血 6 以上情况均可以造成神经系统功能障碍如瘫痪 失语 感觉障碍 全盲 偏盲 癫痫 眩晕 脑干功能衰竭 严重时危及生命 7 术中因机器障碍或其他原因 如穿刺 插管困难等 终止治疗 8 局部或全身感染 放射损伤 9 由于疾病和医疗上不可确定的因素可能导致无法达到预期目的和效果 围手术过程中可能出现未预先告知的 术前难以预料的特殊情况 患者或代理人应同意医生根据具体病情和原则 实施相应的治疗 10 11 经医生仔细讲解 患者或代理人已经完全理解 听懂或看懂 上述说明 经过慎重考虑 明确表示自愿 接受手术 如出现上述情况将完全谅解 并接受因上述情况造成的一切后果 特签字为证 12 13 患者或代理人签字 签字时间 年 月 日 14 代理人与患者关系 谈话医生签字 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病人准备 病人安置及监视 检 查台上适当摆位 固 定头颈部及双上肢 连接左手静脉通道 心电血氧监护 必要 时吸氧 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 器械准备 造影手术包1 压力袋2 软包装500ml生 理盐水4袋 Y筏1 三通接头2 5 6F穿 刺针 成人16或18G 儿童18或20G 导 管鞘1 30cm 160cm导丝各1 造影导管 1 高压注射器及连接管 100 200ml造 影剂 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 器械准备 工具盘的准备 肝素生理盐水 导管导丝的准备 表层涂有亲水化合 物 使用前首先彻底湿润 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 消毒 刷手 铺单 暴露双腹股沟部 连接2套高压滴注系统 一个与导管鞘 连接 另一个备用或接Y筏导丝 接高 压注射器并抽吸造影剂 要求所有连接 装置无气泡 肝素盐水冲洗造影导管 导管鞘 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 穿刺点 腹股沟韧带下1 5 2cm股动脉搏动最明显处 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Seldinger穿刺技术 1953年 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 进针角度30 45度 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 穿刺成功后 在短导丝辅助下 置血管鞘 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 接高压冲洗 调节持续滴速 滴数为15 30滴 分钟 全身肝素化 控制APTT大于120秒或ACT大 于250秒 肝素化方法 首剂2 3mg kg静脉注 射 1小时后给半量 2小时后再加1 4量 以 后每隔1小时追加半量 若减到10mg 每隔1 小时给10mg Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 透视下行全脑血管造影 包括双侧颈内 颈 外 双侧椎动脉 必要时行甲状颈干 颈肋 干造影 血管迂曲可用导丝辅助 对缺血性病变 或老年人 应自下而上分段 行主动脉弓造影和弓上各级血管造影 造影结束 酌情给予鱼精蛋白中和肝素 1 1 5mg可对抗1mg肝素钠 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 预防气栓 注射器中无气泡 注射器尖端向下 可使气泡升至针栓侧 高压注射器针筒朝下 三通要在注射中期转动活栓至关闭位 半月 半月技术 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 导管选择的原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 导管选择的原则 A B1 D区 Vertebral Hunterhead MPA B2区 Hunterhead Simmons C区 Simmon Cobra Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 当难以选择适宜导管时 多孔猪尾巴行主动脉弓 造影常有帮助 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 主动脉弓变异 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 弓上血管扭曲 导丝弹回主动脉弓 让病人深 吸气后屏住呼吸 近侧大血管常可变直变长 颈部最大限度的转向插管对侧 复合弯曲导管 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 自动注射器 可调项目 1 每秒钟造影剂注射量 2 造影剂全量 3 线形速率上升 造影剂在第1秒内进行性加速 至达到设定速度的时间 4 每平方英寸压力 磅值 注射时注射器产 生的最大压力 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 建议的造影剂注射率与量 血 管 线线性上升 注射率 ml s 总总量 ml 颈总动 脉 0 0 2 4 5 8 10 颈内动脉 0 0 5 3 4 6 8 颈外动脉 近侧 0 0 5 2 3 4 6 远侧 0 0 5 2 3 3 4 分支 0 0 5 1 2 2 4 椎 动 脉 0 0 5 4 5 8 10 主动脉弓 15 20 30 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 压迫并加压包扎穿刺点 卧床24小时 保持 穿刺侧下肢伸直 测穿刺肢体足背动脉搏动 每半小时一次 适当给予抗生素与激素 术后处理 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管造影术并发症 1 穿刺部位血肿 原因 凝血机制障碍 患者躁动 过早运动下肢 预防 术后肝素中和后10 20分钟拔鞘 三指压迫15 20 分钟 松开后观察5分钟 无出血后加压包扎 处理 小血肿 直径小于10cm 一般观察 观察不 是不处理 大血肿 直径大于10 cm 24小 时后热敷或理疗 造成压迫者可切开 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 血管痉挛 原因 导管导丝对血管内皮细胞的刺激 预防 操作轻柔 避免导丝对血管壁的反复刺激 导管 位置不能太高 尤其是椎动脉造影 术前用钙离 子拮抗剂 处理 导管内缓慢推注罂粟碱 15mg加10ml生理盐水 脑血管造影术并发症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 内膜下通道 原因 凝血机制障碍 患者躁动 过早运动下肢 穿刺 针与皮肤角度过大 导管或导丝进入内膜下 注 射造影剂压力过大 预防 透视下监视导管或导丝的方向和位置 遇到阻力 时不可强行插入 处理 股动脉处多为顺行夹层 可自愈 弓上多为逆行 夹层 严重者需放置支架或抗凝 主动脉夹层应 控制性降压并请心外科 介入科会诊 脑血管造影术并发症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 4 血栓形成 原因 高凝状态 斑块脱落 预防 术前检查导管或导丝有无损伤 操作轻柔 正规 肝素化 导管90 120秒冲洗一次 处理 保持镇静 全面造影 找出栓子位置 行溶栓治 疗 尿激酶快速5 10万 以后每分钟1万 总量 20 70万 给药时间0 5 2 小时 或者 前循环尿激酶75万 后循环100万 每分钟 1万 rTPA20mg 1mg 分钟 脑血管造影术并发症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 血栓性静脉炎 原因 造影剂之内皮细胞损伤 静脉血淤滞 高凝 预防 严格抗凝 处理 抬高患肢 减少疼痛 脑血管造影术并发症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 6 血管穿孔或血管壁撕裂 7 穿刺部位假性动脉瘤或动静脉瘘 8 脑内气栓 脑血管造影术并发症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 谢 谢
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