糖尿病下肢血管检查.ppt
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糖尿病下肢血管检查.ppt
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,糖尿病下肢血管病变检查VascularAssessment北京迪美德尔科技有限公司医学部整理,EducationalProgramsEducatingtoperform,血管检查培训VascularAssessmentABI(臂踝指数)检查ABIAssessment多普勒波形及声音Dopplerwaveformsandsounds足趾动脉PPG检查ArterialPPG足趾血压和TBI检查TBPIusingArterialPPGPPG下肢静脉功能检查VenousPPG,ABI(踝臂指数)检查ABIAssessment,使用多普勒WhyUseDopplerVascularAssessmentTrainingSession-Introductory,足部的触诊是不充分的.Palpationoffootpulsesisnotsufficient(Moffatt1995)踝部血压用普通听诊器无法测得.BPmeasurementattheankleusingaStethoscopearedifficult(Yao1993)10%的病人缺失足背动脉的脉搏.10%ofpatientshaveabsentDorsalisPedispulses(Callam1987)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.AllpatientspresentingwithanulcershouldbescreenedforarterialdiseasebyDopplermeasurementofABIbystaffwhoaretrainedtoundertakethismeasurement.ClinicalPracticeGuidelines(RCN1998).,解释检查程序Explainandreassurepatientoftheprocedure保持室温舒适Ensureambienttemperatureoftheroomiscomfortable,(Moffatt1990)松解上下肢体衣裤Removeanytightclothingfrombotharmsandstockingssocksetc.fromlegs保护溃疡伤口Removeanydressingsfromcurrentulcersandcoverwithaclearfilm,(Kenny1997)患者保持安静休息1520分钟Restthepatientfor15-20minutes,(Yao1993;Williams1993)患者仰卧Positionthepatientsupine,(Stubbing1996),患者准备PreparationofthePatientVascularAssessmentTrainingSession-Introductory,正常静脉血流音Soundsofnormalvein,血流声音VascularAssessmentTrainingSession-Introductory,正常动脉血流声Soundofnormalartery,Theposteriortibialpulseislocatedinthehollowbehindthemedialmalleolus,andthedorsalispedispulseisfeltbetweenthefirstandsecondmetatarsals.(K.RVowden,1996),足部动脉ArteriesoftheFootVascularAssessmentTrainingSession-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AnklePressuresVascularAssessmentTrainingSession-Introductory,右足背动脉收缩压RightDPSystolicPressure,足踝血压AnklePressuresVascularAssessmentTrainingSession-Introductory,右胫后动脉收缩血压RightPTSystolicPressure,ABI检查HowtoexaminetheABIVascularAssessmentTrainingSession-Introductory,ABI计算HowtoCalculatetheABIVascularAssessmentTrainingSession-Introductory,85,80,145,150,120,115,足背動脈DorsalisPedis,後脛骨動脈PosteriorTibial,上臂Brachial,右ABIRightABI,左ABILeftABI,NormalABIratioisequalorgreaterthan0.90butnotgreaterthan1.3(checklocalpolicy),=85,150,=0.57,=120,150,=0.80,ABI計算法ABIcalculations足関節収縮期血圧最大測定値(両足)Highestanklesystolicpressure上腕収縮期血圧最大測定値Highestbrachialsystolicpressure,上臂Brachial,後脛骨動脈PosteriorTibial,ABI结果解释HowtointerprettheABIVascularAssessmentTrainingSession-Introductory,ABI0.9-1.3ABI=0.7-0.9ABI=0.4-0.7ABI1.3,动脉正常Unlikelytobearterialinorigin轻度动脉疾病Mildperipheraldisease显著动脉疾病Significantofarterialdisease严重动脉疾病Severearterialdisease检测足趾血压Measuretoepressuresorrefertospecialist,ApplycompressiontherapyApplycompressiontherapywithcautionDonotcompressrefertospecialistDonotcompressreferurgentlytovascularspecialist,mayvaryaccordingtolocalprotocols,ABI检查周期RepeatABIchecksVascularAssessmentTrainingSession-Introductory,每12周一次ItisrecommendedthattheABIischeckedevery12weeks(Simon1994)however;ifthepatientsconditionchangesduringthattimei.e.pain,theprocedureshouldberepeatedasnecessaryIfanulcerre-occurs,repeattheDopplerassessmentDonotpresumeitisofthesameorigin,影响ABI结果的因素FactorsAffectingtheAccuracyoftheABIVascularAssessmentTrainingSession-Introductory,动脉硬化AtherosclerosisHardeningofarteriescausingfalselyelevatedreadings心律不齐CardiacArrhythmias(Vowden,K.P.1996).Moredifficulttoassessthesound准备不足Inadequatepreparationi.e.roomtemperature血管收缩Vasoconstriction患者焦虑Patientandcliniciananxiousandunrelaxed血压升高Resultingintoincreasedbloodpressure患者体位不舒服IncorrectpositioningofpatientFalselyelevatedanklepressures超声耦合剂不足InappropriateGel空气气泡Interferenceduetoairbubbles血压袖带不合适Incorrectsizeofsphygcuff血压测量不准Incorrectpressuremeasurements多普勒探头不对InappropriateDopplerprobeUltrasoundcannotpenetratetodepthofvessel,探头位置不正确IncorrectpositionofDopplerprobeovervessel血压测量不正确Incorrectpressuremeasurements对血管施压过大Excessivepressureonvesselduringprocedure血管挤压Collapsesvessels血圧袖带放气过快ReleasingsphygcufftoorapidlyRiskofmissingsystolicpressurepoint血管加压时间过长Prolongedinflationofthecuff/re-inflationHyperemiceffectonlimb血管反复加压Midprocedure/repeatedinflation(VowdenK.P.1996)Hyperemiceffectonlimb检测过程中探头移动MovingDopplerduringmeasurementIncorrectpressuremeasurement检测经验不足Inexperienceoftheprocedure(Anderson1995)practicalskillrequiringassessmentbypeers,影响ABI结果的因素FactorsAffectingtheAccuracyoftheABIVascularAssessmentTrainingSession-Introductory,多普勒波形和声音Dopplerwaveformsandsounds,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DopplerWaveforms&Sounds,多普勒波形和声音DopplerWaveforms&Sounds,正常三时相波形TriphasicWaveform-Normal,VideoclipofTriphasicwaveform,单相波形异常MonophasicWaveform2-Abnormal,多普勒波形和声音DopplerWaveforms&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,Mildobstruction轻度梗阻,Moderateobstruction中度梗阻,SevereObstruction严重梗阻,波峰消失,多普勒波形和声音DopplerWaveforms&Sounds,足趾动脉PPG检查MeasuringToepressuresandTBPI,光电容积PPG原理PPGShiftExplainedVascularAssessmentTrainingSession-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FactorsaffectingAPPGmeasurements,室内温度应保持在2024摄氏度。
Theroomtemperatureshouldbebetween20-24C检查前足趾不应裸露在外。
Alwayskeeptoescovereduntiltestsarestarted患者检查局部的温度会影响波形(如凉手、凉足)Patienttemperature-coldhandsandfeetwillalterthewaveform吸烟-尼古丁会影响波形。
Smoking-nicotinewilldistortthewaveform患者肢体运动检测过程中应保持不动。
Patientmovement-patientsshouldremainstillduringtheexamination,PPG波形解释APPGWaveformInterpretation,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TBIusingArterialPPG,糖尿病患者足趾血压DiabeticsandToePressures,ABPI1.3时,需进行足趾血压测定和TBPI检查。
UndertaketoepressuresandTBPIwhenABPI1.3(Brooks,2001)血管钙化很少发生在趾端动脉Calcificationrarelyextendstodigitalarteries(Vowden,1999)足趾血压直接与足溃疡愈合相关Toepressuresdirectlyrelatetofootulcerationhealing(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。
“InpatientswithDiabetesMellitusadditionalcareshouldbetakenandfurtherarterialinvestigationsundertakensuchastoepressures”(ETRSguideline2003),糖尿病患者足趾血压DiabeticsandToePressures,动脉PPG是检查足趾血压的最佳手段。
ArterialPPGisthepreferredtechniquetomeasuretoepressures(Vowden,2002)检测脚趾血压比多普勒操作简单得多EasierthanDopplertomeasuretoepressures消除通过声音探测脉搏恢复Eliminatestheneedtoaudiblydetectthereturnofthepulse探头容易连接手指和脚趾Sensorseasilyattachtofingers&toes血压测定时,充气袖带放气速度应为23mmHg/秒Cuffsshouldbedeflatedat2-3mmHg/sec(BHS,2000),糖尿病患者足趾血压DiabeticsandToePressures,PPG检测足趾血压ToePressuresusingPPG,135,140,上臂Brachial,TBI計算法TBPIcalculations足趾収縮期血圧Toesystolicpressure上臂収縮期血圧最大測定値Highestbrachialsystolicpressure,140,140,75,115,足趾Toe,=75,=0.54,=115,=0.82,右TBIRightTBPI,左TBILeftTBI,上臂Brachial,糖尿病患者足趾血压DiabeticsandToePressures,糖尿病患者足趾血压DiabeticsandToePressures,足部伤口的预后FootLesionHealingPrognosis,愈合百分比%Percentageprobability/足趾収縮圧ToeSystolicPressure,足趾圧ToePressure糖尿病患者非糖尿病患者(mmHg)DiabeticNonDiabeticPatient,20-3030-5555,40%85%97%,73%100%100%,(Carter,1993),PPG下肢静脉功能检查UsingPPGforvenousassessment,应用红外光传感器检查微循环的静脉血流Usesinfraredlightsensortomeasurevenousbloodvolumeinthemicrocirculation检查整体的静脉循环情况Assessesoverallvenouscirculation不针对单个静脉血管Notvesselspecific通过止血袖带可以区分表浅静脉和深静脉的功能不全Candiagnosedifferencebetweensuperficialanddeepvenousincompetenceusingtourniquets可用于筛查深静脉血栓形成CanscreenfortheabsenceofDVT,应用PPG检查静脉VenousAssessmentUsingPPG,脱去鞋袜Removestockingsandfootwear将足放在绝缘板上Placefootoninsulatedmat调节高度使足部承担压力最小Adjustheighttominimiseweightonfeet肥胖患者应适当依靠以减少静脉压迫Obesepatientsshouldbereclinedtoreducevenouscompression传感器置于内踝上方10cm处(蓝线指示)Fitsensor10cmabovethemedialmalleolus(bluecable),使用ES-100V3检查时患者姿态PatientPositionusingRheoDopplex,正常静脉PPG曲线NormalPPGCurve,正常波形NormalWaveform,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VenousAssessmentUsingPPG,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.IfRefillTime(RT)isgreaterthan20seconds,thenvenousinsufficiencyisnotpresentorisnotsignificant.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AbnormalPPGCurve,异常波形AbnormalWaveform,DVT患者的VPPG曲线可以得到ACV/CFDI证实,应用PPG检查静脉VenousAssessmentUsingPPG,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.IfRefillTime(RT)islessthan20secondsthenvenousrefluxispresent.Applythetourniquetcuffattheappropriatepositionstodeterminethelevelofvenousinsufficiency,RT20S,应用PPG检查静脉VenousAssessmentUsingPPG,静脉血从动脉端再充盈Venousrefillfromarterialinflow,存在静脉功能不全Venousincompetencepresent,预示存在深静脉血栓Deepvenousobstruction/insufficiency,应用PPG检查静脉VenousAssessmentUsingPPG,使用止血袖带检查PPGVPPGassessmentusingtourniquets,第一部:
使用用UTTq(大腿)止血带,加压50-60mmHg。
阻断大隐静脉回流(浅静脉)。
进行测试:
静脉回复时间正常提示大隐静脉瓣膜功能不全。
静脉回复时间不正常提示病变部位不在大隐静脉。
第二部:
使用用AKTq(膝上)止血带,加压50-60mmHg。
阻断大隐静脉及膝上交通支静脉回流。
进行测试:
静脉回复时间正常提示膝上交通支静脉瓣膜功能不全。
静脉回复时间不正常提示病变部位不在膝上浅静脉。
第三部:
使用用BKTq(小腿)止血带,加50-60mmHg。
阻断小隐静脉回流。
进行测试:
静脉回复时间正常提示大小隐静脉瓣膜功能不全。
静脉回复时间不正常提示病变部位不在浅静脉,病人可能存在深静脉病变。
总结Summary,总结Summary,针对高危人群需进行血管检查Undertakevascularassessmentforhigherriskpatients(NICENo.10,2004)用手持式多普勒测量ABI评估下肢慢性溃疡是必要的,“MeasurementofABIbyhand-heldDopplerisessentialintheassessmentofchroniclegulcers”.(SIGN,1998)针对血管钙化的患者进行足趾血压及TBI测定Measuretoepressuresinpatientswithcalcification(Vowden1999)使用PPG整体静脉功能不全UseVPPGtodetermineoverallvenousfunction(King,2004)应用PPG筛查DVT的存在ScreenfortheabsenceofDVTusingVPPG(DaSilva,2000),ThankYou!
北京迪美德尔科技有限公司,
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- 关 键 词:
- 糖尿病 下肢 血管 检查