nqkk58 发表于 2024-6-5 17:24:16

右心衰竭的症状和管理


    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPxziaJTOFCVpaXJEVbYezjkIA6Cl1cwtwGcs6mqwN8hribdgoFuF42DrA/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p><span style="color: black;">右心功能不全<span style="color: black;">指的是</span>任何<span style="color: black;">原由</span><span style="color: black;">引起</span>的心血管结构或功能<span style="color: black;">反常</span>，损害右心室充盈或射血功能的临床<span style="color: black;">综合症</span>。<span style="color: black;">按照</span>右心功能不全及其发展的时间，分为慢性和急性右心衰竭（图1）。急性右心衰竭<span style="color: black;">平常</span>于急性肺栓塞</span><span style="color: black;">（</span><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPOGcsuz7ibCvE9Rfyqdic10vKIe4DdicQ40P7JaSxJhADKGHCIACEMGYRg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"><a style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">认识肺动脉栓塞</span></strong></span></a><span style="color: black;">）</span><span style="color: black;">、右室心肌梗死、<span style="color: black;">各样</span>诱因<span style="color: black;">引起</span>的慢性右心衰竭急性加重等<span style="color: black;">状况</span></span><span style="color: black;">（</span><span style="color: black;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPOGcsuz7ibCvE9Rfyqdic10vKIe4DdicQ40P7JaSxJhADKGHCIACEMGYRg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span><a style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">心力<span style="color: black;">衰</span>竭</span></strong></span></a><span style="color: black;">）</span><span style="color: black;">。右心功能不全的病残率和死亡率均高于左心衰竭。</span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPqSHibw0SWoPWic7Xru7UdJeGmhD1jPxsWb1ia0K9kqodEdialaVicmOQtLQ/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">图1 心衰病因<span style="color: black;">归类</span></span></p><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPTvuHD355XFEjzl3OldjBLhgz4OXEOJgbwGuAfuM3TrzqqneGwst6Aw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">1.右心衰竭的症状</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">急性右心衰竭<span style="color: black;">通常</span>以急性右心室扩张、左心室充盈<span style="color: black;">阻碍</span>、右心室前向血流减少和全身静脉压<span style="color: black;">上升</span>为特征，此类<span style="color: black;">病人</span><span style="color: black;">一般</span>有低灌注的表现如出汗、精神不振、发绀、四肢阙冷、低血压和心动过速，<span style="color: black;">另外</span>还会有气促、房性或室性<span style="color: black;">心率</span>失常等。可见颈静脉压<span style="color: black;">上升</span>、心前区抬举性搏动，当慢性右心衰竭急性加重时，还可<span style="color: black;">显现</span>肝大、腹腔积液和外周水肿。<span style="color: black;">因为</span>肝包膜受到肝脏淤血的牵拉可<span style="color: black;">导致</span>右上腹不适。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">慢性右心衰最<span style="color: black;">明显</span>的临床表现是外周水肿，<span style="color: black;">初期</span>可能症状轻微，当右心室功能<span style="color: black;">逐步</span>恶化时，心搏出量降低，可<span style="color: black;">显现</span>进行性活动耐量下降。房性和室性快速性<span style="color: black;">心率</span>失常、传导阻滞<span style="color: black;">亦</span>是<span style="color: black;">平常</span>并发症，是慢性右心衰竭<span style="color: black;">病人</span>心源性猝死的<span style="color: black;">原由</span>。<span style="color: black;">长时间</span>体循环淤血还可<span style="color: black;">引起</span>肝肾功能和胃肠功能损害。（图2）</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPBPapnKJfVlfveyKlniaK6mD60FyAtLAGH2gcQxtGx4SA97hRRq4Hvibg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">图2 左心衰与右心衰临床表现比较</span></span></p><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPTvuHD355XFEjzl3OldjBLhgz4OXEOJgbwGuAfuM3TrzqqneGwst6Aw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.<span style="color: black;">关联</span><span style="color: black;">检测</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">N末端脑钠肽前体（NT-proBNP）可用于右心衰竭的诊断，但特异度较差，<span style="color: black;">亦</span><span style="color: black;">没</span>法区别左、右心室功能不全的水平。但NT-proBNP能<span style="color: black;">供给</span>肺动脉高压伴右心衰竭<span style="color: black;">病人</span>的预后信息。超声心动图可<span style="color: black;">经过</span>下腔静脉直径和<span style="color: black;">呼气</span>塌陷<span style="color: black;">评定</span>容量状态，估计右房压力。肝静脉倒流<span style="color: black;">显示</span>重度右房室瓣反流，而房间隔向左偏移提示右房压高或容量超负荷。有<span style="color: black;">前提</span>的中心还可<span style="color: black;">运用</span>三维超声<span style="color: black;">评定</span>右心室<span style="color: black;">体积</span>和收缩力，与心脏磁共振<span style="color: black;">关联</span>性更强。</span>&nbsp;</span></p><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPTvuHD355XFEjzl3OldjBLhgz4OXEOJgbwGuAfuM3TrzqqneGwst6Aw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;">3.右心衰竭的管理</strong></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">容量管理是急性右心衰竭管理最<span style="color: black;">要紧</span>的一环，如<span style="color: black;">没</span>外周水肿，仔细观察静脉搏动<span style="color: black;">状况</span>，可<span style="color: black;">认识</span>中心静脉压有<span style="color: black;">没</span><span style="color: black;">上升</span>，必要时可用有创<span style="color: black;">办法</span>如中心静脉导管或肺动脉导管<span style="color: black;">评定</span>血流动力学状态。右心衰竭<span style="color: black;">病人</span>常需<span style="color: black;">海量</span>补液保持较高的循环血液量，但容量不是越高越好，<span style="color: black;">必须</span><span style="color: black;">大夫</span><span style="color: black;">按照</span><span style="color: black;">病人</span><span style="color: black;">详细</span><span style="color: black;">状况</span>进行判断和处理，保持适当的容量。在利尿剂方面，右心衰竭的<span style="color: black;">病人</span><span style="color: black;">因为</span>静脉淤血等<span style="color: black;">原由</span>，<span style="color: black;">必须</span>多种利尿剂联合应用，严重的<span style="color: black;">病人</span><span style="color: black;">针对</span>利尿治疗<span style="color: black;">没</span>反应，<span style="color: black;">乃至</span>会行肾脏替代治疗</span><span style="color: black;">（</span><span style="color: black;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPOGcsuz7ibCvE9Rfyqdic10vKIe4DdicQ40P7JaSxJhADKGHCIACEMGYRg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span><a style="color: black;"><strong style="color: blue;"><span style="color: black;">心外科<span style="color: black;">平常</span>利尿剂</span></strong></a><span style="color: black;">）</span><span style="color: black;">。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">针对</span>有充血症状的慢性右心衰竭<span style="color: black;">病人</span>，利尿与适度限钠是<span style="color: black;">恰当</span>的。慢性右心衰竭的<span style="color: black;">病人</span>可能常常<span style="color: black;">必须</span><span style="color: black;">吃下</span>肺血管扩张剂，例如静脉用依前列醇等。合并肺动脉高压等<span style="color: black;">疾患</span>的<span style="color: black;">病人</span>可能还<span style="color: black;">必须</span><span style="color: black;">吃下</span>西地那非等进行原发病治疗。</span></p><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPTvuHD355XFEjzl3OldjBLhgz4OXEOJgbwGuAfuM3TrzqqneGwst6Aw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;">4.机械循环支持（MCS）和姑息治疗</strong></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">急性或慢性右心衰竭经优化<span style="color: black;">药品</span>治疗<span style="color: black;">没</span>效的<span style="color: black;">病人</span>，<span style="color: black;">或</span>用于心脏或心肺移植前的桥接治疗，应<span style="color: black;">思虑</span><span style="color: black;">按照</span>发病机制<span style="color: black;">选取</span>合适的MCS<span style="color: black;">安装</span>。<span style="color: black;">一般</span>继发于肺动脉梗阻性病变的右心衰竭<span style="color: black;">病人</span>，会体外膜肺氧合（ECMO）</span><span style="color: black;">（</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPOGcsuz7ibCvE9Rfyqdic10vKIe4DdicQ40P7JaSxJhADKGHCIACEMGYRg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></strong><a style="color: black;"><strong style="color: blue;"><span style="color: black;">续命利器-ECMO</span></strong></a></span><span style="color: black;">）</span><span style="color: black;"><span style="color: black;">，其他类型的右心衰竭会<span style="color: black;">按照</span><span style="color: black;">状况</span><span style="color: black;">选取</span>合适的MCS<span style="color: black;">安装</span>（图3）。<span style="color: black;">针对</span>晚期难治性右心衰竭<span style="color: black;">病人</span>，应<span style="color: black;">思虑</span>心脏移植，因严重肺血管疾病<span style="color: black;">导致</span>慢性右心衰竭<span style="color: black;">病人</span>，可<span style="color: black;">思虑</span>行心-肺或双肺移植。</span>&nbsp;</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPmxC6qPian451L9FJsv0OAqIFwd5Xp01KPmJtPttlZZsW7b3gALVEApA/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">图3 ECMO<span style="color: black;">功效</span>示意图</span></p><span style="color: black;">总而言之，右心衰竭在心衰<span style="color: black;">病人</span>中致残率和死亡率都<span style="color: black;">明显</span>高于左心衰竭，其管理和治疗<span style="color: black;">必须</span>医患<span style="color: black;">一起</span><span style="color: black;">奋斗</span>。愿<span style="color: black;">咱们</span><span style="color: black;">一块</span><span style="color: black;">奋斗</span>，<span style="color: black;">初期</span>识别右心衰竭，还您一个健康的身体。</span><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPTvuHD355XFEjzl3OldjBLhgz4OXEOJgbwGuAfuM3TrzqqneGwst6Aw/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">End</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">作者|周小宇</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">编辑|罗宾</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">审校|郭震</span></p><span style="color: black;">往期</span><span style="color: black;">推</span><span style="color: black;">荐</span><span style="color: black;">：</span><span style="color: black;"><a style="color: black;">心肺复苏——你<span style="color: black;">必定</span>要会的技能</a></span><span style="color: black;"><a style="color: black;">糖</a>尿病合并严重冠心病该<span style="color: black;">怎样</span>处理</span><a style="color: black;">【<span style="color: black;">恢复</span>】高血压科普</a><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPBNRfkaIWI7SaSnqqWYn3Z5qQ4ThEm73vFLibVSz7MyLtOo9MQ5YOiaIg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPU1etBXb0Mcgbx65Vth1a6ib7cicYxHibgxOkhHKSBDhHjmUoOWqiafytibg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">科室介绍<img src="https://mmbiz.qpic.cn/mmbiz_png/RxbYDXJVwaOP0W2eeiao8rnic0u15J4PdPapBV2fuzB342HIr8ibQAdaujpVZcrUFUt85fT08INn0vHCUscEibeDEg/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">上海市胸科医院是在我国著名心脏外科专家顾恺时倡议下<span style="color: black;">创立</span>，以治疗心胸<span style="color: black;">疾患</span>为主的三级甲等专科医院，1957年3月研制出我国<span style="color: black;">第1</span>台国产鼓泡式人工心肺机，并由顾恺时主刀完<span style="color: black;">成为了</span>我国<span style="color: black;">第1</span>例国产心肺机辅助的心脏外科直视手术，对我国心血管外科的发展产生了深远的影响。在我国最早被卫生部指定为全国心胸外科进修基地，迄今为全国培养的心胸外科<span style="color: black;">大夫</span>超过千人。1997年成功完成上海<span style="color: black;">第1</span>例存活同种异体心脏原位移植手术。2013年，心脏大血管外科被正式授予国家级临床重点专科，<span style="color: black;">日前</span>已形成瓣膜外科、冠脉血管外科、微创外科、房颤心衰外科，小儿心脏外科和体外循环与生命辅助六大亚学科的规模，诊治范围全方位覆盖心脏大血管的各类<span style="color: black;">疾患</span>，手术成功率居全国领先水平，为来自全国各地的<span style="color: black;">病人</span><span style="color: black;">供给</span><span style="color: black;">优秀</span>的服务。</span></p>




wrjc1hod 发表于 2024-10-1 02:01:55

期待更新、坐等、迫不及待等。

wrjc1hod 发表于 2024-11-1 10:42:09

交流如星光璀璨，点亮思想夜空。
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