糖尿病下肢血管检查

nullnull糖尿病下肢血管病变检查　　　　　　　　　　　　　　　　　　　　　Vascular Assessment nullEducational Programs Educating to perform 　血管检查 Vascular Assessment ABI(臂踝指数)检查　ABI Assessment 多普勒波形及声音 Doppler waveforms and sounds 足趾动脉PPG检查 Arterial PPG 足趾血压和TBI检查 　TBPI using Arterial PPG PPG下肢静脉功能检查　Venous PPGnullABI (踝臂指数) 检查 ABI Assessmentnull使用多普勒　Why Use Doppler 　Vascular Assessment Training Session - Introductory 足部的触诊是不充分的.Palpation of foot pulses is not sufficient (Moffatt 1995) 踝部血压用普通听诊器无法测得.BP measurement at the ankle using a Stethoscope are difficult (Yao 1993) 10%的病人缺失足背动脉的脉搏.10% of patients have absent Dorsalis Pedis pulses (Callam 1987) 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.All patients presenting with an ulcer should be screened for arterial disease by Doppler measurement of ABI by staff who are trained to undertake this measurement. Clinical Practice Guidelines (RCN 1998).null解释检查程序 Explain and reassure patient of the procedure 保持室温舒适　Ensure ambient temperature of the room is comfortable, (Moffatt 1990) 松解上下肢体衣裤 Remove any tight clothing from both arms and stockings socks etc. from legs 保护溃疡伤口 Remove any dressings from current ulcers and cover with a clear film, (Kenny 1997) 患者保持安静休息15－20分钟　Rest the patient for 15-20 minutes, (Yao 1993; Williams 1993) 患者仰卧 Position the patient supine,　(Stubbing 1996)患者准备 Preparation of the Patient 　Vascular Assessment Training Session - Introductorynull正常静脉血流音 Sounds of normal vein血流声音 Vascular Assessment Training Session - Introductory正常动脉血流声 Sound of normal arterynullThe posterior tibial pulse is located in the hollow behind the medial malleolus, and the dorsalis pedis pulse is felt between the first and second metatarsals. (K.R Vowden, 1996)足部动脉　Arteries of the Foot 　Vascular Assessment Training Session - Introductory足の動脈　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）後脛骨動脈が内果後方部を流れているため、触診や検査を行うのに適している前腓骨動脈貫通枝null足踝血压 Ankle Pressures 　Vascular Assessment Training Session - Introductory 右足背动脉收缩压 Right DP Systolic Pressurenull足踝血压 Ankle Pressures 　Vascular Assessment Training Session - Introductory 右胫后动脉收缩血压 Right PT Systolic PressurenullABI检查 How to examine the ABI 　Vascular Assessment Training Session - IntroductorynullABI计算 How to Calculate the ABI 　Vascular Assessment Training Session - Introductory8580145150120115足背動脈 Dorsalis Pedis後脛骨動脈 Posterior Tibial上臂 Brachial右ABI Right ABI左ABI Left ABI Normal ABI ratio is equal or greater than 0.90 but not greater than 1.3(check local policy)= 85150= 0.57= 120150= 0.80ABI計算法 ABI calculations 足関節収縮期血圧最大測定値(両足) Highest ankle systolic pressure 上腕収縮期血圧最大測定値 Highest brachial systolic pressure上臂 Brachial後脛骨動脈 Posterior TibialnullABI结果解释 How to interpret the ABI 　Vascular Assessment Training Session - IntroductoryABI > 1.0 - 1.3 ABI = 0.8 – 1.0 ABI = 0.5 - 0.8 ABI < 0.5 ABI > 1.3  动脉正常 Unlikely to be arterial in origin 轻度动脉疾病 Mild peripheral disease 显著动脉疾病 Significant of arterial disease 严重动脉疾病 Severe arterial disease 血管钙化需检测足趾血压　Measure toe pressures or refer to specialist Apply compression therapy Apply compression therapy with caution Do not compress – refer to specialist Do not compress – refer urgently to vascular specialist  　may vary according to local protocolsnullABI检查周期　Repeat ABI checks 　Vascular Assessment Training Session - Introductory每12周一次 It is recommended that the ABI is checked every 12 weeks (Simon 1994) however; if the patients condition changes during that time i.e. pain, the procedure should be repeated as necessary If an ulcer re-occurs, repeat the Doppler assessment Do not presume it is of the same originnull影响ABI结果的因素 Factors Affecting the Accuracy of the ABI 　Vascular Assessment Training Session - Introductory 动脉硬化 Atherosclerosis Hardening of arteries causing falsely elevated readings 心律不齐 Cardiac Arrhythmias (Vowden, K.P. 1996). More difficult to assess the sound 准备不足 Inadequate preparation i.e. room temperature 血管收缩 Vaso constriction 患者焦虑 Patient and clinician anxious and unrelaxed 血压升高 Resulting into increased blood pressure 患者体位不舒服 Incorrect positioning of patient Falsely elevated ankle pressures 超声耦合剂不足 Inappropriate Gel 空气气泡 Interference due to air bubbles 血压袖带不合适　Incorrect size of sphyg cuff 血压测量不准 Incorrect pressure measurements 多普勒探头不对 Inappropriate Doppler probe Ultrasound cannot penetrate to depth of vesselnull 探头位置不正确 Incorrect position of Doppler probe over vessel 血压测量不正确 Incorrect pressure measurements 对血管施压过大 Excessive pressure on vessel during procedure 血管挤压　Collapses vessels 血圧袖带放气过快　Releasing sphyg cuff too rapidly 　Risk of missing systolic pressure point 血管加压时间过长　Prolonged inflation of the cuff/re-inflation 　Hyperemic effect on limb 血管反复加压　Mid procedure/repeated inflation (Vowden K. P. 1996) Hyperemic effect on limb 检测过程中探头移动　Moving Doppler during measurement Incorrect pressure measurement 检测经验不足　Inexperience of the procedure　(Anderson 1995) practical skill requiring assessment by peers影响ABI结果的因素 Factors Affecting the Accuracy of the ABI 　Vascular Assessment Training Session - Introductorynull多普勒波形和声音 Doppler waveforms and soundsnull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　Doppler Waveforms & Soundsnull多普勒波形和声音　Doppler Waveforms & Sounds 正常三时相波形　Triphasic Waveform - Normal Video clip of Triphasic waveformnull 单相波形　－　异常　Monophasic Waveform2 - Abnormal 多普勒波形和声音　Doppler Waveforms & Sounds null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Mild obstruction 轻度梗阻Moderate obstruction 中度梗阻Severe Obstruction 严重梗阻波峰消失多普勒波形和声音　Doppler Waveforms & Soundsnull足趾动脉PPG检查 Measuring Toe pressures and TBPI null光电容积PPG原理　PPG Shift Explained 　Vascular Assessment Training Session - 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。null影响PPG检查的因素　Factors affecting APPG measurements 室内温度应保持在20－24摄氏度。The room temperature should be between 20 - 24C 检查前足趾不应裸露在外。　Always keep toes covered until tests are started 患者检查局部的温度会影响波形（如凉手、凉足） Patient temperature - cold hands and feet will alter the waveform 吸烟-尼古丁会影响波形。　Smoking - nicotine will distort the waveform 患者肢体运动－检测过程中应保持不动。 Patient movement - patients should remain still during the examinationnullPPG波形解释　APPG Waveform Interpretation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null足趾血压和TBI检查 TBI using Arterial PPGnull糖尿病患者足趾血压　Diabetics and Toe Pressures ABPI>1.3时，需进行足趾血压测定和TBPI检查。 　Undertake toe pressures and TBPI when ABPI>1.3 (Brooks, 2001) 血管钙化很少发生在趾端动脉　 Calcification rarely extends to digital arteries (Vowden, 1999) 足趾血压直接与足溃疡愈合相关 Toe pressures directly relate to foot ulceration healing (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。 “In patients with Diabetes Mellitus additional care should be taken and further arterial investigations undertaken such as toe pressures” (ETRS guideline 2003) null糖尿病患者足趾血压　Diabetics and Toe Pressures 动脉PPG是检查足趾血压的最佳手段。Arterial PPG is the preferred technique to measure toe pressures (Vowden, 2002) 检测脚趾血压比多普勒操作简单得多　Easier than Doppler to measure toe pressures 消除通过声音探测脉搏恢复　Eliminates the need to audibly detect the return of the pulse 探头容易连接手指和脚趾　Sensors easily attach to fingers & toes 血压测定时，充气袖带放气速度应为2－3mmHg/秒 　Cuffs should be deflated at 2-3mmHg/sec (BHS, 2000)null糖尿病患者足趾血压　Diabetics and Toe Pressures PPG检测足趾血压　Toe Pressures using PPGnull135140上臂BrachialTBI計算法 TBPI calculations 足趾収縮期血圧　Toe systolic pressure 上臂収縮期血圧最大測定値Highest brachial systolic pressure14014075115足趾　Toe= 75= 0.54= 115= 0.82右TBI Right TBPI左TBI Left TBI 上臂Brachial糖尿病患者足趾血压　Diabetics and Toe Pressuresnull糖尿病患者足趾血压　Diabetics and Toe Pressuresnull足部伤口的预后　Foot Lesion Healing Prognosis 愈合百分比%　Percentage probability / 足趾収縮圧　Toe Systolic Pressure 足趾圧　Toe Pressure 糖尿病患者　　 非糖尿病患者 (mmHg) 　　 Diabetic Non Diabetic Patient20-30 30-55 >5540% 85% 97%73% 100% 100%(Carter, 1993)nullPPG下肢静脉功能检查 Using PPG for venous assessmentnull 应用红外光传感器检查微循环的静脉血流　　　　　　　　　　　　　　　　　　　　　　Uses infrared light sensor to measure venous blood volume in the microcirculation 检查整体的静脉循环情况　Assesses overall venous circulation 不针对单个静脉血管　Not vessel specific 通过止血袖带可以区分表浅静脉和深静脉的功能不全　　　　　　　　　　　　　　Can diagnose difference between superficial and deep venous incompetence using tourniquets 可用于筛查深静脉血栓形成　Can screen for the absence of DVT应用PPG检查静脉　Venous Assessment Using PPG null 脱去鞋袜　Remove stockings and footwear 将足放在绝缘板上　Place foot on insulated mat 调节高度使足部承担压力最小 　Adjust height to minimise weight on feet 肥胖患者应适当依靠以减少静脉压迫 　Obese patients should be reclined to reduce venous compression 传感器置于内踝上方10cm处（蓝线指示） 　Fit sensor 10cm above the medial malleolus (blue cable)使用ES-100V3检查时患者姿态 Patient Position using Rheo Dopplexnull正常静脉PPG曲线　Normal PPG Curve 正常波形　Normal Waveform 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　Venous Assessment Using PPG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. If Refill Time (RT) is greater than 20 seconds, then venous insufficiency is not present or is not significant. RT>20s 静脈再充満期（休憩中）静脉排空时相（运动时）null异常静脉PPG波形　Abnormal PPG Curve 异常波形　Abnormal Waveform DVT患者的VPPG曲线可以得到ACV/CFDI证实应用PPG检查静脉　Venous Assessment Using PPG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. If Refill Time (RT) is less than 20 seconds then venous reflux is present. Apply the tourniquet cuff at the appropriate positions to determine the level of venous insufficiency, RT<20Snull应用PPG检查静脉　Venous Assessment Using PPG静脉血从动脉端再充盈 Venous refill from arterial inflow存在静脉功能不全 Venous incompetence present预示存在深静脉血栓 Deep venous obstruction/ insufficiency null应用PPG检查静脉　Venous Assessment Using PPG 使用止血袖带检查PPG　 VPPG assessment using tourniquets 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。null Summarynull总结　Summary 针对高危人群需进行血管检查　　　　　　　　　　　　　　　　　Undertake vascular assessment for higher risk patients (NICE No. 10, 2004) 用手持式多普勒测量ABI评估下肢慢性溃疡是必要的,“Measurement of ABI by hand-held Doppler is essential in　the assessment of chronic leg ulcers”. (SIGN, 1998) 针对血管钙化的患者进行足趾血压及TBI测定　　　　　　　　　　Measure toe pressures in patients with calcification (Vowden 1999) 使用PPG整体静脉功能不全　　　　　　　　　　　　　　　　　　　　　　　　　　Use VPPG to determine overall venous function (King, 2004) 应用PPG筛查DVT的存在　　　　　　　　　　　　　　　　　　　　　　　　　　　　Screen for the absence of DVT using VPPG (Da Silva, 2000) null北京迪美德尔科技有限公司