Coronary artery bypass grafting (CABG) - SlideShare

四、手術步驟四、手術步驟- 2- 2.. 取血管. SlideShareusescookiestoimprovefunctionalityandperformance,andtoprovideyouwithrelevantadvertising.Ifyoucontinuebrowsingthesite,youagreetotheuseofcookiesonthiswebsite.SeeourUserAgreementandPrivacyPolicy. SlideShareusescookiestoimprovefunctionalityandperformance,andtoprovideyouwithrelevantadvertising.Ifyoucontinuebrowsingthesite,youagreetotheuseofcookiesonthiswebsite.SeeourPrivacyPolicyandUserAgreementfordetails. Upload Home Explore Login Signup Successfullyreportedthisslideshow. Activateyour14dayfreetrial tounlockunlimitedreading. Coronaryarterybypassgrafting(CABG) 8 Share RobertChen • May.02,2015 • 8likes • 4,079views DownloadNow Download NextSlideShares Youarereadingapreview. Activateyour14dayfreetrial tocontinuereading. ContinueforFree UpcomingSlideShare M&MforbowelischemiaafterEVAR Loadingin…3 × Facebook Twitter LinkedIn Size(px) Starton ShowrelatedSlideSharesatend Share Email     Topclippedslide 1 1of53 1of53 Coronaryarterybypassgrafting(CABG) May.02,2015 • 8likes • 4,079views 8 Share DownloadNow Download Downloadtoreadoffline Health&Medicine AnintroductionforoperatingroomstaffwhoarenotfamiliarwithCABG Readmore RobertChen Follow AttendingSurgeon,ClinicalAssistantProfessor,CardiovascularSurgeryatTaipeiTzuChiHospital AnintroductionforoperatingroomstaffwhoarenotfamiliarwithCABG Readmore Health&Medicine M&MforbowelischemiaafterEVAR RobertChen M&MforVV-ECMOforARDS RobertChen Aorticdissection--IntroductiontoORstaff RobertChen Organdonationbydeathprisoners RobertChen Organdonationbydeathprisoners RobertChen RiskScoresinCardiacSurgery RobertChen ResearchMethdologyinCardiovascularSurgery RobertChen ClinicalDatabase RobertChen Influenza-likeillnessbyNationalHealthInsurancedatabases RobertChen DataScienceinCardiacSciences RobertChen M&MforbowelischemiaafterEVAR RobertChen M&MforVV-ECMOforARDS RobertChen Aorticdissection--IntroductiontoORstaff RobertChen Organdonationbydeathprisoners RobertChen Organdonationbydeathprisoners RobertChen RiskScoresinCardiacSurgery RobertChen ResearchMethdologyinCardiovascularSurgery RobertChen ClinicalDatabase RobertChen Influenza-likeillnessbyNationalHealthInsurancedatabases RobertChen DataScienceinCardiacSciences RobertChen MoreRelatedContent Featured WhattoUploadtoSlideShare SlideShare BeAGreatProductLeader(Amplify,Oct2019) AdamNash TrillionDollarCoachBook(BillCampbell) EricSchmidt APIdaysParis2019-Innovation@scale,APIsasDigitalFactories'NewMachi... apidays Afewthoughtsonworklife-balance WimVanderbauwhede Isvcstillathingfinal MarkSuster TheGaryVeeContentModel GaryVaynerchuk MammalianBrainChemistryExplainsEverything LorettaBreuning,PhD Blockchain+AI+CryptoEconomicsAreWeCreatingaCodeTsunami? 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CABGCABG (CoronaryArteryBypassGrafting)(CoronaryArteryBypassGrafting) Dr.Dr.陳勁辰陳勁辰 2014.8.132014.8.13 2. 一、器械一、器械 PCV01PCV01開心基本包開心基本包 PCV04PCV04冠狀動脈輔助包冠狀動脈輔助包 PCV01(PCV01(附件附件)-)-開胸器、開胸器、wirecutterwirecutter、鋼線持針器、鋼線持針器 PCV09ByPassPCV09ByPass包包--TubingClampTubingClamp、、TubingTubing固定板固定板 ICV01ICV01骨鋸骨鋸 RCV01IMAretractorRCV01IMAretractor PCV11PCV11顯微器械包顯微器械包--MicroForcepsMicroForceps、、PottsPotts ScissorsScissors 3. PottsScissorsPottsScissors 4. 二、醫材（刀片、空針、針二、醫材（刀片、空針、針 頭頭)) 1.1.刀片：刀片：20×215×111×169×120×215×111×169×1 2.2.空針：空針：1cc×1→1cc×1→紫藥水紫藥水 10cc×1→Adenosine(3vial)10cc×1→Adenosine(3vial) 5cc5cc×1×1→→固定固定RetrogradeRetrograde 20cc×2→Heparin20cc×2→Heparin水水(1ccHeparin150~200ccN/S)﹕(1ccHeparin150~200ccN/S)﹕、、N/SN/S沖水用沖水用 ☆☆50cc+20cc+1950cc+20cc+19號針頭號針頭 →→NTG(NTG(避光避光)=Nitroglycerin(millisrol)10cc+20ccN/S)=Nitroglycerin(millisrol)10cc+20ccN/S 3.3.針頭：針頭：2424號號cathcath、、2727號針頭。

號針頭。

5. 二、醫材（縫線、其他二、醫材（縫線、其他)) 4.4.縫線縫線︰︰11號號Silk×12/0Silk×13/0Silk×13/0C003D×1Silk×12/0Silk×13/0Silk×13/0C003D×1 2/0Ticon(2839-51)×12/0Ticon(2839-51)×1、、2/0Ticon(3369-51)×1→forA-cannular2/0Ticon(3369-51)×1→forA-cannular 3/0Prolene(8522)×1→forV-cannular3/0Prolene(8522)×1→forV-cannular 4/0Prolene(8557)×2→forRetrograde4/0Prolene(8557)×2→forRetrograde、、AorticrootAorticroot。

。

7/0Prolene(8702)×1→forstatsuture7/0Prolene(8702)×1→forstatsuture 7/0Prolene(8702)×3→for7/0Prolene(8702)×3→for心壁血管心壁血管 5/0Prolene(8310)×1→foraorta5/0Prolene(8310)×1→foraorta 5.5.其他其他︰︰手控電刀手控電刀×2×2、、SuctiontubeSuctiontube、電刀括座、開刀巾、電刀括座、開刀巾(6648(6648、、 6650×2)6650×2) IVsetIVset、、RetrogradeRetrograde延長線延長線 NylonTape×1→forAortaNylonTape×1→forAorta PlegetPleget、、RubbershuntRubbershunt、、束帶、束帶、BoneWax×2BoneWax×2、、clip(s)clip(s) ☆☆心臟穩定器→心臟穩定器→TissueStabilizerTissueStabilizer(350-400mmHg)(350-400mmHg) ☆☆二氧化碳霧化噴槍二氧化碳霧化噴槍++IVset(4-8L/min)IVset(4-8L/min) ☆☆OcculderOcculder：常用：常用1.5mm1.5mm、、2.0mm(2.0mm(庫房庫房))。

。

6. 三、手術前準備三、手術前準備((儀器、包布、儀器、包布、 器械器械)) 1.儀器(由麻醉機後面依序排 列)： (1)溫毯機→suction→電機燒→ 電擊器→電鋸主機→ (2)頭燈→溫毯墊→平版墊→ (3)電極片×2×2→精密尿袋→肛溫 2.包布、器械(由左至右依序 排)： (1)臉盆架→碎花包→碎花包→ 開心包→ (2)PCV01→PCV04→醫材盒 →其他必上器械放在腳控椅上。

7. 四、手術步驟四、手術步驟 1.1.打開胸腔打開胸腔 2.2.取血管取血管 3.3.建立體外循環建立體外循環 4.4.接血管接血管 5.5.脫離體外循環脫離體外循環 6.6.關閉胸腔關閉胸腔 8. 四、手術步驟四、手術步驟--1.1.打開胸腔打開胸腔 1.由胸骨正中劃刀 . 2.鋸開胸骨 3.打開心包膜後,就能看到 整 個跳動的心臟。

。

9. 四、手術步驟四、手術步驟-2-2..取血管取血管 (1a)從病患的腿部取出大隱靜脈,, 作 為繞道手術用的血管。

。

(1b)檢查血管品質 。

。

(2)若要取內乳動脈(LIMA)作為手 術 用血管,,則是在開胸後進行剝離 。

。

10. 四、手術步驟四、手術步驟-3-3..建立體外循建立體外循 環環 (1)3/0Ethibond→束帶→蚊鉗→ 11號尖刀→動脈導管→ (2)用1號silk固定動脈導管和束帶 。

。

11. 四、手術步驟四、手術步驟-3-3..建立體外循建立體外循 環環 - 4 1 2 3 備註： 1.動脈導管-升主動脈根 部 2.靜脈導管-右心房 3.Retrograde–冠狀竇 4.Antegrade-升主動脈根部 12. 四、手術步驟四、手術步驟-3-3..心肌保護心肌保護 1.主動脈鉗 3.灌注心臟保護液 2.Adenosine 體外循環 在體外循環管路建立完成後,心臟保護液將被灌入心臟,而心臟 會慢慢地停止跳動。

在進行血管繞道的過程中,病患的血液循環就由人 工心肺體外循環機來運作,一直到繞道的步驟完成為止。

13. 四、手術步驟四、手術步驟-4-4..接血管接血管 14. 四、手術步驟四、手術步驟-4-4..接血管接血管 2.前彎剪→後彎剪→ 1.69號刀片→11號刀片→ 3.(1)心壁﹕7/0prolene(w8702) (2)主動脈：5/0prolene (w8310) 4.完成圖 。

15. 四、手術步驟四、手術步驟-4-4..接血管接血管 16. 五、脫離體外循環五、脫離體外循環 血管遠端吻合完畢血管遠端吻合完畢,,可放開主動脈鉗可放開主動脈鉗,,使心臟開始復跳。

使心臟開始復跳。

隨隨 著心肌收縮力的恢復和溫度的回升著心肌收縮力的恢復和溫度的回升,,當灌注壓持續穩定在當灌注壓持續穩定在 60~80mmHg60~80mmHg時時,,應逐漸減少動脈灌注量應逐漸減少動脈灌注量,,當流量降至當流量降至 20ml/kg/min20ml/kg/min 且具備下列指標時可考慮停止體外循環。

且具備下列指標時可考慮停止體外循環。

1.EKG1.EKG波形正常。

波形正常。

2.2.心肌收縮有力、心臟充盈適度。

心肌收縮有力、心臟充盈適度。

3.3.肛溫達肛溫達34~35,℃34~35,℃鼻咽鼻咽37~38,℃37~38,℃末稍溫暖。

末稍溫暖。

4.Hemoglobin(Hb)9g/dl4.Hemoglobin(Hb)9g/dl左右。

左右。

5.Bloodgas5.Bloodgas、、ElectrolyteElectrolyte正常。

正常。

17. 準備收工準備收工 每個心臟和大血管的洞都沒流血每個心臟和大血管的洞都沒流血 每個有縫血管的地方都沒流血每個有縫血管的地方都沒流血 每個每個GraftGraft整條都沒流血整條都沒流血 難看到的地方一定要在有體循能翻心時檢查難看到的地方一定要在有體循能翻心時檢查 IMABedIMABed沒流血沒流血 心跳慢心跳慢RVRV要縫要縫PacingwirePacingwire注意流血注意流血 18. 關閉胸腔結束關閉胸腔結束 量量FlowsFlows小心翻心臟小心翻心臟 穿過鋼絲處都沒流血穿過鋼絲處都沒流血 不可傷到不可傷到GraftsGrafts 放胸管小心黏到放胸管小心黏到GraftsGrafts PleuraPleura若有破抽乾積血若有破抽乾積血 19. THANKYOU~THANKYOU~ 8likes × 淑惠謝 Oct.11,2020 AngelTsao Aug.09,2020 MuoCihn Aug.22,2018 DaniellePhillips Jul.10,2018 淑惠洪 Apr.14,2017 ShowMore Views × Totalviews 4,079 OnSlideShare 0 FromEmbeds 0 NumberofEmbeds 7 Youhavenowunlockedunlimitedaccessto20M+documents! × UnlimitedReading Learnfasterandsmarterfromtopexperts UnlimitedDownloading Downloadtotakeyourlearningsofflineandonthego YoualsogetfreeaccesstoScribd! Instantaccesstomillionsofebooks,audiobooks,magazines,podcastsandmore. Readandlistenofflinewithanydevice. FreeaccesstopremiumserviceslikeTuneln,Mubiandmore. DiscoverMoreOnScribd × ShareClipboard × Facebook Twitter LinkedIn Link Publicclipboardsfeaturingthisslide × Nopublicclipboardsfoundforthisslide Selectanotherclipboard × Lookslikeyou’veclippedthisslidetoalready. Createaclipboard Youjustclippedyourfirstslide! Clippingisahandywaytocollectimportantslidesyouwanttogobacktolater.Nowcustomizethenameofaclipboardtostoreyourclips. Name* Description Visibility OtherscanseemyClipboard Cancel Save SharethisSlideShare SpecialOffertoSlideShareReaders × TheSlideSharefamilyjustgotbigger.Enjoyaccesstomillionsofebooks,audiobooks,magazines,andmorefromScribd. Readfreefor60days Cancelanytime.