Ixesha lokufunda eliqikelelweyo: 10 mzuzu
Table of Contents
- Izinto ekufuneka ziqwalaselwe ngexesha loVavanyo lwaPhambi kweNkqubo
- Ulawulo lwe-Systolic Dysfunction
- Imilinganiselo kunye noKhetho lwesiXhobo ekuValweni kwePercutaneous
- Ukusetyenziswa kwe-TTE kunye ne-TEE
- UVavanyo lwasemva kokusebenza (Emva kokuvalwa kwePDA)
- Utshintsho lweHemodynamic
- Ubume beKlinikhi yesigulane
- Unyango kunye nolandelo
- Ukuhamba okushiyekileyo kunye noLawulo
- Iingxaki zasemva kotyando
UBruceBlaus, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, Nge-Wikimedia Commons
Unyango lwezonyango luyi-palliative kwaye lufanele lusetyenziswe kuphela ukuzinzisa izigulane ezinempawu ngaphambi kokungenelela okuchanekileyo okanye kwizigulane ezinokukhubazeka okukhulu kwixesha elisemva kokusebenza. Ngokuxhomekeke kubunzima kunye nohlobo lwe-pathophysiology, i-diuretics, i-vasodilators, i-positive inotropic agents, kunye ne-antiarrhythmics kufuneka isetyenziswe kwezi meko.
Unyango oluqinisekileyo lwePDA, ukuvalwa kwe-ductus arteriosusLe nkqubo ibonakaliswe kuzo zonke izilwanyana ezine-hemodynamically ephawulekayo ukusuka ekhohlo ukuya ekunene. Kwiminyaka emininzi, utyando lotyando lwalukuphela kwendlela yokuvalwa kwePDA. Xa kwenziwa ngoogqirha botyando abanamava, utyando lotyando lunezinga eliphezulu lempumelelo. kwaye izinga layo lengxaki liphantsi. Olu buchule lusasetyenziswa kumaziko angenazo izixhobo kunye nezakhono eziyimfuneko zokuvalwa kwe-percutaneous, kunye nezinja ezincinci kunye neekati kunye nezigulane ezinohlobo lwe-3 PDA ngaphandle kwe-pulmonary stenosis (iimeko ezingavumeli ukubeka isixhobo esizinzileyo).
PDA's ukuvalwa kwepercutaneous ngenxa enye I-Amplatz canine ductal occluder (ACDO) esetyenziswayo ngoku yindlela yokuqala ekhethwayo Le nkqubo ibisetyenziswa ngokubanzi ehlabathini iminyaka emininzi. Xa lwenziwa ngoogqirha botyando abanamava, olu tyando lukhawuleza, luyasebenza yaye lukhuselekile.
Imida yenkqubo ye-percutaneous imbalwa kwaye ihambelana ngokuyinhloko nobukhulu besigulane. Kwiinja ezininzi ezinobunzima obungaphantsi kwe-2 kg, i-artery femoral incinci kakhulu ukuvumela ukubekwa kwesixhobo sokufikelela kwi-vascular eyimfuneko kwinkqubo.
Utyando ligation ayifanelekanga kwizinja ezincinci kunye neekati, iiplagi ezincinci ze-vascular or Ukusetyenziswa kwe-"off-label" yeekhoyili ezilawulwayo Ezinye iinkqubo zongenelelo olungephi zinokwenzeka, ezinje: Iyakwazi ukudlula kwi-4 Fr yokuthumela i-catheter Yenziwe ngolu hlobo.
Izinto ekufuneka ziqwalaselwe ngexesha loVavanyo lwaPhambi kweNkqubo
1. Ubume beKlinikhi yesigulane:
• Ubume bempilo yesigulana ngokubanzi kunye nokuba inkqubo yaso yentliziyo izinzile na iyavavanywa.
• Inqanaba le-Pathophysiological ve iqondo le-anatomical kunye nokusebenza ngokutsha kwe-ventricle yasekhohlo (LV) kufuneka ihlalutywe.
2. Iimeko ezifuna uzinziso:
• ukungaphumeleli kwentliziyo,
• Ukungasebenzi kakuhle kweSystolic (ukuncipha kwamandla okunciphisa intliziyo),
• IiArrhythmias (i-fibrillation ye-atrial okanye i-tachyarrhythmias).
Kule meko, imeko yesigulane kufuneka izinze phambi kwenkqubo. Oku kunokufezekiswa ngonyango lweziyobisi (i-diuretics, i-inotropic agents, i-antiarrhythmic drugs).
3. IiMviwo zoMfanekiso eziyimfuneko kunye noDiagnostic:
• isifuba x-reyi: Ubukho bokwandiswa kwentliziyo (i-cardiomegaly) kunye ne-pulmonary edema ihlolwe.
• I-Electrocardiogram (ECG): Isetyenziselwa ukubona ukuphazamiseka kwesigqi sentliziyo.
• I-Transthoracic echocardiography (TTE): Kuyimfuneko ukumisela isakhiwo jikelele sentliziyo, ubungakanani bePDA kunye neqondo le-shunt.
I-edema yemiphunga ezifanelekileyo phambi kokungenelela okanye iinkqubo zotyando kwizigulane ezichongiweyo ukuzinzisa ngonyango lwe-diuretic kufuneka ibonelelwe. I-Fibrillation ye-Atrial okanye tachyarrhythmia phambi kokuvalwa kwePDA izinga lentliziyo kunye nokulawula isingqisho kufuneka ibonelelwe.
Ulawulo lwe-Systolic Dysfunction
Izigulana ezine-systolic dysfunction zifuna ukhathalelo olukhethekileyo ngezi zizathu zilandelayo:
• Inkxaso ye-Inotropic (ukwandisa amandla okunciphisa intliziyo),
• Amachiza eVasodilator (ukunciphisa uxinzelelo lwentliziyo),
• Ukubeka iliso kwi-intraoperative kunye ne-perioperative (ukubeka iliso rhoqo ngexesha nasemva kotyando).
Kwezi zigulana, umthamo we-ventricular yasekhohlo (LV). kwaye ngokukodwa umthamo we-systolic wokuphela idla ngokuba nkulu kakhulu. Iqhezu lokukhupha iyancipha. I-S' wave inesantya esiphantsi kwaye deformation longitudinal (strain) kunye nokunciphisa izinga loxinzeleloiqinisekisa ubukho bokungasebenzi kakuhle kwe-systolic.
Kwizinja ezinoMsebenzi oQhelekileyo weSystolic:
• Xa kukho iPDA kunye nomsebenzi we-systolic ogciniweyo, I-VTI (ixesha lesantya esidibeneyo) ve isantya esiphezulu se-aortic inyuka ngokulinganayo kumthamo we-shunt.
Iimpawu ze-Systolic Dysfunction:
• Ukunyuka komthamo we-systolic ekupheleni,
• I-VTI kunye ne-aortic peak velocity zihlala ziphantsi kunesiqhelo okanye eziqhelekileyo.
Imilinganiselo kunye noKhetho lwesiXhobo ekuValweni kwePercutaneous
a I-Amplatz canine ductus occluder (ACDO) Kwimeko yokuvalwa kwe-PDA nge-percutaneous:
• I-MDD (I-Minimal Ductus Diameter): Le idayimitha, inwebu zemibhobho Esi sakhiwo silinganiswa kuphela kwinqanaba le i-transthoracic echocardiography (TTE) ile probe enesisombululo esiphezulu inokuboniswa ngokuchanekileyo kusetyenziswa .
• Idayamitha ye-Distal ampulla: Lo bubanzi buyimfuneko ukuze ukhethe ubungakanani obuchanekileyo besixhobo esingenasici.
Ukusetyenziswa kwe-TTE kunye ne-TEE
TTE (transthoracic echocardiography):
• I-TTE isetyenziselwa umlinganiselo ochanekileyo we-MDD (umbhobho omncinci wedayamitha).
• Yenziwe ngeeprobes ezinesisombululo esiphezulu kunye nokulinganisa okuchanekileyo ifestile ye-acoustic ifanelekile Ufuna.
TEE (transesophageal echocardiography):
• Ukuvala iPDA ngeACDO I-TEE imaging ibaluleke kakhulu ngexesha
• I-TEE isetyenziselwa ukulinganisa ngokuchanekileyo ubukhulu be-ductus kunye nokukhokela inkqubo.
• Ixesha langempela le-3D TEE, umbhobho Umbono we-en-face we-pulmonary ostium Oku kubonelela ngomlinganiselo ochanekileyo wokukhetha isixhobo.
TEE Sebenzisa kuphela:
• Xa imifanekiso yeTEE imihle ngokwaneleyo, ngaphandle kokusebenzisa i-fluoroscopy (x-reyi) Inkqubo inokukhokelwa kuphela yi-TEE.
• Nangona kunjalo, Ukudityaniswa kwe-3D TEE kunye ne-fluoroscopylolona khetho lukhuselekileyo noluchanekileyo.
Inkqubo yokuvala iPDAinokwenziwa ngeendlela zombini zotyando kunye ne-percutaneous. Ukuvalwa kwe-ACDO yePercutaneousYindlela ekhethwayo ngenxa yezinga eliphezulu lempumelelo kunye nomngcipheko ophantsi weengxaki. Ngaphambi kokuba le nkqubo, imeko yesigulane kufuneka izinze. isifuba X-reyi, ECG, kunye transthoracic echocardiography (TTE) kufuneka yenziwe. Ukungasebenzi kakuhle kweSystolic Inkxaso ye-Inotropic kunye nokubeka iliso kwi-intraoperative ibalulekile kwizigulane ezine I-TTE kunye ne-TEE Imilinganiselo echanekileyo kufuneka ithathwe, kwaye isixhobo esikhethiweyo kufuneka simiselwe ngokufanelekileyo. Le nkqubo iphumelele ngokubanzi kwizinja ezinobunzima obungaphezu kwe-2 kg.
UVavanyo lwasemva kokusebenza (Emva kokuvalwa kwePDA)
Ukuvalwa kwePDA kuvumela isigulane ukuba utshintsho ngokukhawuleza kwibhalansi ye-hemodynamic oonobangela. Uxinzelelo lwenkqubo luyanda ngokuvalwa kwe-shunt kwaye le meko, i-reflex bradycardia ngokuvuselela ii-baroreceptors (uphawu lukaNicoladoni–Branham) Esi siphumo sikholisa ukukhokelela ekubunjweni kwe kwimibhobho emikhulu ibonakala ngakumbi kwaye inokuhlala iiyure. Ingakumbi imibhobho emikhulu ve ukungasebenzi kakuhle kwe-systolic Kwizigulane ezine-bradycardia, ukuphuma kwentliziyo kunokuncitshiswa ngakumbi.
Utshintsho lweHemodynamic
• I-ventricular yasekhohlo (LV) emva kokulayishwa iyanda, ukuhamba kwemiphunga kunye nokulayishwa kwangaphambili kwe-LV kuqheleke.
• Ngaphambili kwi-ventricle, eye yandiswa kwaye ilungelelaniswe kumthamo omkhulu wokuzalisa, ukuhla ngokukhawuleza kokulayisha kwangaphambili, Ikhubaza isiphumo se-Starling.
• Oku, Imithamo ye-diastolic kunye ne-systolic ye-LV kubangela ukuncipha kwaye ukuhla okubalulekileyo kwiqhezu lokukhupha (EF) kuyenzeka.
• Kwizinja ezincinci ve kwiintlobo ezincinci, ubukhulu be-ventricular yasekhohlo bubuyela kwisiqhelo ngokukhawuleza. Nangona kunjalo, kwizinja ezinkulu okanye kwabo benza utyando bebadala, ukulungiswa kwakhona kwenzeka ngokucothayo kwaye imiqulu ye-LV ihlala iphakanyisiwe ixesha elide inokuhlala inkulu kunesiqhelo.
Ubume beKlinikhi yesigulane
• Izigulane ezinomsebenzi ogciniweyo we-systolic, olu tshintsho lunyanyezelwa kakuhle.
• Kwizigulane ezine-systolic dysfunction Ukuba uxhulumaniso lwe-ventricle-arterial yasekhohlo luphazamisekile, uxhulumaniso lwe-ventricle-arterial yasekhohlo lunokuphazamiseka. Oku kunokukhokelela kwezi ngxaki zinzima zilandelayo:
• arrhythmias ezibulalayo,
• Ukuchithwa kwe-electromechanical (ukungaphumeleli komsebenzi wombane wentliziyo ukuguqulela kwi-contraction).
Kwizigulana ezinjalo, imeko iqhubela phambili ngenye yeendlela ezimbini:
1. Ukuzinzisa kunye nokungasebenzi kakuhle okuphakathi: Isigulana, umgangatho olungileyo wobomi kunye nexesha elilindelekileyo lokuphila ingaba.
2. Ukuwohloka ngakumbi: Kule meko, iimpawu zokungaphumeleli kwentliziyo, iingxaki ze-ventricular arrhythmias ve ukufa ngequbuliso umngcipheko uyanda.
Unyango kunye nolandelo
• Vasodilators kunye neziyobisi ezinotropic ezintle, zombini ngexesha lotyando, njengo kukhathalelo lwasemva kotyando ve kunyango lwexesha elide kufuneka isetyenziswe.
• Izigulana ezinokungasebenzi kakuhle kwe-systolic kufuneka zisoloko zibekwe esweni kwaye zixhaswe ngala machiza.
Ukuhamba okushiyekileyo kunye noLawulo
• Ukuhamba okushiyekileyoKusekho inani elincinci lokuhamba kwegazi kwi-ductus emva kokuba i-PDA ivaliwe.
• I-Doppler ultrasound ijongwe nge.
• Ukuba Umthamo we-LV awuhlehli emva kokuhlinzwa okanye ukuba ithande ukwanda, Oku, ubukho be-shunt ye-hemodynamically ebalulekileyo Kule meko, ukungenelela okwesibini kunokufuneka.
Iinketho zonyango:
• Ukuvalwa kongenelelo (Ukusetyenziswa kweAmplatz canine ductus occluder (ACDO) okanye ikhoyili)
• Utyando ligation (Ingakumbi Ubuchule bukaJackson-Henderson kunye)
Ukuhamba okushiyekileyo kuxhaphake kakhulu kwiiPDA ezivaliweyo ngeekhoyili ngelixa kubonakala, Ekuvalweni kwenziwe nge-ACDO Ukuhamba okushiyekileyo kuvamise ukubangelwa:
• Ukuma ngendlela engafanelekanga kwesixhobo (Oku kwandisa umngcipheko wokuba isixhobo sikhutshwe kamva).
• Isixhobo sinobukhulu obugqithisileyo (Kule meko, ukuhamba ngokuqhelekileyo kuyeka ngokuhamba kwexesha).
• Ukuvalwa kwePDAyinkqubo eyenza utshintsho lwe-hemodynamic.
• Izigulane ezine-systolic dysfunctionunokufumana iingxaki ezinzulu ezifana ne-arrhythmias kunye nokunciphisa ukuphuma kwentliziyo.
• I-Vasodilator kunye ne-inotropic therapy, iyimfuneko ekuzinzisweni kwezigulane ezinjalo.
• Ukuhamba okushiyekileyo kwenzeka, inkqubo yesibini ingafuneka.
• Ukuhamba okushiyekileyo kwiinkqubo zekhoyili ixhaphake kakhulu, Ekuvaleni nge-ACDO lo mngcipheko uphantsi.
Olu vavanyo, Kubaluleke kakhulu ukuqinisekisa kunye nokubeka iliso ukuzinza kwesigulane emva kokuhlinzwa..
Iingxaki zasemva kotyando
Ukuvalwa kwePDA, nokuba lutyando okanye i-percutaneous, ngokuqhelekileyo yinkqubo ekhuselekileyo nesebenzayoIzinga lobunzima liphantsi, kodwa kwezinye iimeko, iingxaki ezibalulekileyo zingenzeka.
1. ISepsis (Usulelo)
• I-sepsis yasemva kokuhlinzwa Inqabile.
• Sepsis, kwindawo yokuvala inokwenzeka kwaye le meko inokwenzeka, kwindawo yokudibanisa okanye kwindawo apho isixhobo sokuvala sibekwe khona kunokubangela usulelo.
2. I-Embolization (Ukuchithwa kwesixhobo)
• Ukwenziwa kwezixhobo ze-Amplatz canine ductus occluder (ACDO). Inqabile kakhulu.
• Le ngxaki ibonwe ngaphantsi kwe-1% yamatyala kumava ombhali.
• EmbolizationOku kuthetha ukuba isixhobo siphumile kwi-ductus kwaye sangena kwinkqubo yokujikeleza. Kule meko, inkqubo yokungenelela ingasoloko iyimfuneko.
3. Ukugqabhuka kweDuctus (Iinyembezi)
• Ukuqhekeka kwe-ductus, zombini ngexesha lotyando kwaye kunqabile ukuba kwenzeke ngexesha leenkqubo ze-percutaneous.
• Umngcipheko wokukrazulwa, ngakumbi kwimibhobho ene-ampullae evuleke kakhulu okanye ene-aneurysmal iphezulu.
• Ukuqhekeka ngexesha lotyando, Ngokubanzi kwicala lasekunene lecala le-ductus kwenzeka. Oku kuqhele ukwenzeka ngexesha lokufakwa kwemithungo kwenzeka.
Ungenelelo kwiMba yokuQhutywa kweDuctus
• Ukuyeka ukophaOogqirha abanamava basebenzisa iindlela zotyando ukunqanda ukopha Bafaka i-hemoclip (ikliphu yokunqanda ukopha).
• Ukuvalwa kwe-patent ductus eseleyoKule meko, ukuba i-ductus isahlala ivuliwe, isixhobo sokuvala (umz. ACDO) inokuvalwa nge.
• Ngokuba, Ubuchule bukaJackson-Henderson okanye indlela yongenelelo yepercutaneous, kwizakhiwo ezinjalo ze-anatomical zezona ndlela zikhethwayo.
4. I-Aortic Acute Dissection
• Le ngxaki inqabile kakhulu, kodwa yimeko ebeka ubomi esichengeni.
• Ukuqhekeka kweAortickungenzeka emva kokuvalwa kwe-ductus kwaye kunokukhokelela kwimiphumo ebulalayo.
Ukuvalwa kwePDA yinkqubo ekhuselekileyo enezinga eliphantsi lobunzima. Nangona kunjalo, ezi ngxaki zilandelayo kufuneka ziqwalaselwe:
• Usulelo (sepsis): Inqabile kwaye idla ngokuphuhla kwindawo yokudibanisa okanye yokuvala isixhobo.
• Embolization (ukukhutshwa kwesixhobo): Kubonwa ngesantya esingaphantsi kwe-1%.
• Ukugqabhuka kweductus: Inokuthi yenzeke ngokukodwa kwimibhobho ye-aneurysmal kunye nexesha lotyando kunye nexesha lokudlula i-sutures. Kule meko, isicelo hemoclip ve Ukuvala nge-ACDO ungenelelo lwenziwa ngeendlela ezinje.
• Ukuqhekeka kwe-aorta ngokukhawuleza: Yingxaki enqabileyo kodwa enokubulala.
Uninzi lwezi ngxaki, inokulawulwa ngokufanelekileyo ngoogqirha abanamava kunye neengcali zongenelelo. Ingakumbi Ubuchule bukaJackson-Henderson ve iinkqubo zokuvala i-percutaneous, yima njengeenketho ezikhuselekileyo kwizigulane ezinomngcipheko ophezulu wokuqhekeka kwe-ductal rupture.
Amanye amanqaku onokuthi ube nonomdla kuwo
"Ulonwabo kuphela kwento ephindaphindwayo xa kwabelwana ngayo."
Albert Schweitzer
