I. Nursing measures
1.Maintain the normal whistling function of the patient
(1) Observe the condition Pay attention to the frequency, rhythm, mode of inspiration, cyanosis, and monitor the patient’s blood gas, especially oxygen saturation, partial pressure of oxygen and partial pressure of carbon dioxide. Because of the increased frequency of pulmonary hypertension patients, hyperventilation is likely to occur, so that the partial pressure of carbon dioxide decreases and whistling alkalosis occurs.
(2) Improve the hypoxic condition Assist patients to adopt a semi-recumbent position and continuous oxygenation. Oxygen therapy, which can improve blood oxygen saturation, correct hypoxemia, improve chest tightness, breath-holding, and whistling difficulty symptoms. Instruct effective whistling, control the frequency of whistling, deep whistling and slow whistling, and switch to mask oxygenation if necessary to maintain oxygen saturation above 90%.
(3) Meet the needs of the patient’s life Frequent patient rounds, reduce unnecessary speech and activity, keep bowel movements unobstructed, reduce muscle oxygen consumption.
(4) Centralize treatment and care Reduce patient handling, use wheelchairs or flat carts when going out for examination, have sufficient oxygen available, accompanied by a person if necessary, and pay attention to changes in vital signs on the way.
(5) Give cardiac monitoring to critically ill patients Monitor the patient’s heart rate and rhythm, give symptomatic treatment if there is any abnormality, and prepare first aid items.
2.Prevent the occurrence of syncope to prevent accidents
(1) Patients with advanced pulmonary hypertension are accompanied by changes in right heart function to varying degrees. Therefore, patients should be instructed to perform moderate physical activities, and the intensity of activities should be limited to what the patient can tolerate, so as not to aggravate the disease.
(2) Patients with pulmonary arterial hypertension may experience upright hypotension and syncope when applying vasodilators, especially 1 to 2 hours after taking the drug. Therefore, patients should be asked to rest in bed within 2 hours after taking the drug, and to sit on the bed for a few minutes when getting up 2 hours after taking the drug, without any discomfort before slowly getting out of bed and using bed gear if necessary. Pay attention to monitoring the patient’s blood pressure before and after taking the medication.
(3) Patients with pulmonary hypertension usually have low blood pressure, and syncope is a common complication. Patients should be instructed to move moderately, reduce the degree of bending, avoid standing for a long time, and try to rest in a sitting position. Once vertigo and blackness appear, rest in sitting or lying position should be adopted immediately.
3.Prevent the occurrence of asphyxia
Have suction devices and hemostatic drugs, such as posterior pituitary gland, aminoglutethimide and vitamin K, ready when hemoptysis is detected in a timely manner. Pay attention to the patient’s body position when hemoptysis occurs, with the head tilted to the side in a semi-sitting position.
The purpose of pharmacological treatment is to inhibit pulmonary vascular remodeling, reduce pulmonary vascular resistance, reduce pulmonary artery pressure, improve cardiac function, increase cardiac blood volume, and prolong survival time and quality.
1.Commonly used drugs and methods
(1) calcium ion antagonist Representative drug: Heshinshang, suitable for acute drug test with vasodilator response, only a few patients by long-term use effective.
(2) inhaled nitric oxide NO is the active component of endothelial diastolic factor, is an inhaled human selective pulmonary vasodilator.
NO binds rapidly to hemoglobin and then loses its activity, and does not dilate the blood vessels of the body circulation when inhaled. Inhaled N0 can be used for the treatment of perioperative pulmonary hypertension and persistent pulmonary hypertension in neonates.
(3) Endothelin antagonists Representative drug: bosentan. Elevated plasma endothelin levels in pulmonary hypertension – vasoconstrict and proliferate. Endothelin acts on two types of receptors: endothelin-A receptor, vasoconstriction, smooth muscle growth; endothelin-β receptor, nitric oxide production, vasodilation.
(4) phosphodiesterase inhibitors Representative drug: sildenafil, a powerful selective pulmonary vasodilator, maintains or even improves pulmonary ventilation/perfusion ratio and oxygenation.
(5) Epoprostenol and its analogues Epoprostenol (PGI2) is a physiological product of arachidonic acid metabolism, mainly synthesized by vascular endothelium, which dilates pulmonary vessels and inhibits pulmonary vascular remodeling. It plays an important role in the treatment of pulmonary arterial hypertension. At present, nebulizer (Vantave) is available in China.
(6) Anticoagulant drugs The small internal pulmonary arteries of patients with pulmonary hypertension often have in situ thrombosis, and the application of anticoagulation therapy can reduce in situ thrombosis. Representative drug: warfarin. When applied, attention should be paid to monitoring the change of INR and adjusting the drug dosage to avoid bleeding. Generally INR is kept at 2 to 3.
(7) Oxygen therapy (oxygen saturation of less than 90%, 14 to 16 hours of oxygen daily) can dilate the pulmonary vasculature, improve the overall organ function and improve the difficulty of whistling.
2.Application of Vantave nebulized inhalation precautions
(1) The drug should be kept in the refrigerator.
(2) Usage Vantave 10μg plus saline to 2ml, 6 to 9 times/day.
(3) Pay attention to blood pressure changes and measure blood pressure before and after administration.
(4) Syncope is more common in patients with inhaled Vantavir, so pay attention to not getting out of bed during the inhalation period and adopt a sitting or semi-sitting position.
(5) Pay attention to the side effects of the drug such as headache, hot flashes, cough, diarrhea and nausea.
(6) Because it is expensive, it should be prepared accurately and not wasted.
Third, the special examination of the right heart catheter care
1, the purpose of right heart catheterization
(1) To determine pulmonary artery pressure, pulmonary capillary wedge pressure, calculate pulmonary artery vascular resistance and cardiac blood volume.
(2) To clarify the cause of pulmonary hypertension (especially to clarify the presence of congenital heart disease).
(3) Preoperative examination and evaluation of congenital heart disease.
(4) Perform acute pulmonary vascular drug response test.
2.Preoperative preparation
(1) Give preoperative education. Inform the patient of the purpose, precautions and eliminate patient tension.
(2) Prepare the skin, do iodine allergy test, and give sedation as appropriate before bedtime on the day before surgery.
(3) Patients who are receiving anticoagulants should be discontinued or reduced in advance, and INR should not be greater than 1.5.
(4) Establish intravenous access. Antimicrobial drugs are given once 0, 5 to 2 hours before puncture, and a second dose may be given intraoperatively if the operation lasts more than 3 hours.
3.Postoperative care
(1) When the patient returns to the ward, if the femoral vein is punctured, local sandbag compression is applied for 2 to 4 hours, while those with arterial puncture have sandbag compression for 4 to 6 hours and are bedridden for 12 hours; if the jugular vein is punctured, local compression is not needed and strict bed rest is not necessary.
(2) Closely observe the vital signs and the bleeding, hematoma and murmur of the puncture site.
(3) Cardiac monitoring for 24 hours.
(4) If pulmonary angiography is performed, rehydration may be given as appropriate, and diuretics may be given to show the status of cardiac function in order to drain the contrast agent as soon as possible and to retain the urine specimen. Residual contrast agent may increase pulmonary artery pressure and aggravate heart failure.
(5) Observe the vital signs according to the status of cardiac function, whether the patient has low blood pressure, increased heart rate, normal urine output, and listen to the patient’s complaints promptly and give symptomatic treatment.
4.Acute pulmonary vascular reactivity test
Patients with pulmonary hypertension, if possible in the determination of long-term application of vasodilators, to the pulmonary vascular response to drugs to select the type of drug.
(1) Whether there is pulmonary vasoconstriction.
(2) Presence of fixed structural changes in the pulmonary vasculature.
(3) Prognosis determination.
(4) Assessment of the safety and efficacy of the application of vasodilators.