《急危重癥的監(jiān)護(hù)》PPT課件.ppt

1、急危重癥的監(jiān)護(hù) Intensive Care/Critical Care,方向韶 中山大學(xué)附屬第二醫(yī)院 急診科,1,急危重癥監(jiān)護(hù),將危重患者、先進(jìn)設(shè)備、掌握設(shè)備和技術(shù)的優(yōu)秀醫(yī)務(wù)人員同時(shí)集中于一體，充分發(fā)揮有經(jīng)驗(yàn)和專業(yè)知識(shí)的醫(yī)務(wù)人員的能力，也充分利用有限高級(jí)貴重設(shè)備，利用儀器、設(shè)備和技術(shù)方法，更加頻繁進(jìn)行快速有效的生命、器官檢查或者連續(xù)監(jiān)測(cè)，及必要的功能支持、加強(qiáng)的照料護(hù)理。目的是為迅速掌握患者病情及其變化情況，挽救患者生命和器官功能。,2,History of Critical Care,Critical care evolved from an historical recognition

2、that the needs of patients with acute, life-threatening illness or injury could be better treated if they were grouped into specific areas of the hospital. Nurses have long recognized that very sick patients receive more attention if they are located near the nursing station.,3,History of Critical C

3、are,Florence Nightingale wrote about the advantages of establishing a separate area of the hospital for patients recovering from surgery,4,In 1927, the first hospital premature-born infant care center was established at the Sarah Morris Hospital in Chicago During World War II, shock wards were estab

4、lished to resuscitate and care for soldiers injured in battle or undergoing surgery The nursing shortage, which followed World War II, forced the grouping of postoperative patients in recovery rooms to ensure attentive care,5,In 1947-1948, the polio (poliomyelitis) epidemic raged through Europe and

5、the United States, resulting in a breakthrough in the treatment of patients dying from respiratory paralysis. Patients with respiratory paralysis and/or suffering from acute circulatory failure required intensive nursing care Bjorn Aage Ibsen (1915-2007) became involved in the poliomyelitis outbreak

6、 in Denmark; Patients were managed in 3 special 35 bed areas; In this fashion, mortality declined from 90% to around 25%.,6,During the 1950s, the development of mechanical ventilation led to the organization of respiratory intensive care units (ICUs) in many European and American hospitals. Created

7、in 1958, Johns Hopkins Bayview Medical Centerbecame the first multidisciplinary intensive care unit (ICU) in the United States.,7,By the late 1960s, most United States hospitals had at least one ICU. In 1970, an organization committed to meeting the needs of critical care patients: the Society of Cr

8、itical Care Medicine (SCCM). Between 1990 and the present, critical care significantly reduced in-hospital time as well as costs incurred by patients with diseases such as cerebrovascular insufficiency and respiratory failure.,8,Landmark of History of Critical Care,1950 iron lungs (polio and brain s

9、tem paralysis) 1958 Peter Safar: the first multidisciplinary first Intensive Care Unit at Baltimore City Hospital 1970 Swan Ganz catheter Transplantation,9,Landmark of History of Critical Care,World War II, shock wards,10,Landmark of History of Critical Care,1950 iron lungs (polio and brain stem par

10、alysis),11,Polio Survivors in Iron Lung,12,Landmark of History of Critical Care,1958 Peter Safar: the first multidisciplinary intensive care unit first Intensive Care Unit at Baltimore City Hospital Father of CPR: combined the A (Airway) and the B (Breathing) of CPR with the C (chest compressions),1

11、3,Landmark of History of Critical Care,1970 Jeremy Swan and William Ganz: Swan-Ganz catheter (pulmonary artery catheterization ),14,ICU of the Second affiliated hospital,15,ICU of the Second affiliated hospital,16,急診危重癥監(jiān)護(hù)地位的爭(zhēng)議,17,Specialized types of ICUs include,Emergency Intensive Care Unit，EICU C

12、oronary Care Unit (CCU) for heart disease Medical Intensive Care Unit (MICU) Surgical Intensive Care Unit (SICU) Pediatric Intensive Care Unit (PICU) for children Neuroscience Critical Care Unit (NCCU) Shock/Trauma Intensive Care Unit (STICU) Neonatal Intensive Care Unit (NICU) for babies,18,急診重癥監(jiān)護(hù)室

13、的定位和發(fā)展前景爭(zhēng)議和困惑 與“危重醫(yī)學(xué)”學(xué)科間的關(guān)系 ：“短期醫(yī)療行為” 還是“全程治療 ” EICU也不同于急診搶救室,19,EICU的位置和基本設(shè)置要求,EICU應(yīng)該位于急診的搶救區(qū)附近，與急診搶救區(qū)直接相通連，要相對(duì)安靜和獨(dú)立。 EICU內(nèi)部環(huán)境的設(shè)計(jì)和布局應(yīng)該兼顧患者和工作人員的需要，常常將一個(gè)封閉的大房間劃分為病床監(jiān)護(hù)區(qū)、護(hù)士站、治療室和工作室，留置一定空間放置備用的搶救、監(jiān)護(hù)設(shè)備和設(shè)施。,20,EICU的主要設(shè)備,分為監(jiān)測(cè)設(shè)備和治療設(shè)備兩種： 常用的監(jiān)測(cè)設(shè)備有:各種監(jiān)護(hù)儀、心電圖機(jī)、心臟血液動(dòng)力學(xué)監(jiān)測(cè)設(shè)備以及血糖儀、快速血?dú)夂蜕治鰞x等。 常用治療設(shè)備有：輸液泵、注射泵、無(wú)創(chuàng)和

14、有創(chuàng)呼吸機(jī)、除顫器、搶救車、搶救藥品和各種護(hù)理用具等。,21,multi-parameter monitors,22,Pulse oximeter,23,Blood gas analyzer,24,Medical Ventilator,25,Laryngoscope (Tracheal intubation ),26,27,Hemofiltration,28,Continuous veno-venous hemofiltration (CVVHF),29,Defibrillator,Manual external defibrillator,Automated external defibri

15、llator (AED),30,Intensive Care Monitoring,31,EICU的收治對(duì)象,通常主要收治急性中毒、急性危重病、嚴(yán)重慢性病急性發(fā)作、嚴(yán)重創(chuàng)傷以及未確診但有高危因素的患者等幾大類。 有時(shí)EICU還會(huì)接受部分不能馬上入院的危重患者先進(jìn)行搶救和部分?？浦委?，當(dāng)然也難以推辭臨終患者和晚期腫瘤患者。,32,EICU的管理要求,封閉式病房 ：優(yōu)點(diǎn)和缺點(diǎn) EICU醫(yī)師 工作制度：三級(jí)查房制度和值班制度 護(hù)理制度：對(duì)護(hù)士的技術(shù)和應(yīng)變能力要求高 EICU治療水準(zhǔn)的標(biāo)準(zhǔn)化和規(guī)范化,33,四點(diǎn)關(guān)鍵,采用規(guī)范的治療流程； 有一個(gè)具有相當(dāng)權(quán)威的、可以處理各種政策和協(xié)調(diào)各個(gè)醫(yī)務(wù)人員工作的有

16、能力領(lǐng)導(dǎo)者； 護(hù)士要有相當(dāng)高的專業(yè)水平并掌握重癥監(jiān)護(hù)技術(shù)和熟練各種醫(yī)療設(shè)備的使用； 醫(yī)生和護(hù)士有十分精強(qiáng)的協(xié)調(diào)關(guān)系。,34,合理使用監(jiān)護(hù)和支持技術(shù),認(rèn)識(shí)和避免監(jiān)護(hù)設(shè)備存在的負(fù)面問(wèn)題 合理掌握監(jiān)護(hù)的指征和使用設(shè)備,35,危重癥的生命與器官功能監(jiān)護(hù)策略,36,1. 心電參數(shù)監(jiān)護(hù),Detection of arrhythmias Permits monitoring of heart rate Evaluation of pacemaker function Detect myocardial ischemia Electrolyte abnormalities,37,Locations of th

17、e unipolar precordial leads on the body surface,38,Electrocardiography (ECG),39,40,Reminders,Consider potassium derangements in any arrhythmia in the ICU Focus on treating the underlying electrolyte disturbance promptly,41,Torsade de pointes,The ECG reading demonstrates a rapid, polymorphic ventricu

18、lar tachycardia with a characteristic twist of the QRS complex around the isoelectric baseline. It is also associated with a fall in arterial blood pressure, which can produce fainting.,42,Characteristic tracing showing the twisting (blue line) of a torsade de pointes,43,Lead II electrocardiogram sh

19、owing Torsades being shocked by an Implantable cardioverter-defibrillator back to the patients baseline cardiac rhythm.,44,Acute Myocardial Infarction,45,2. 血壓監(jiān)護(hù)（ Blood Pressure monitoring ）,Related to both cardiac function and the peripheral circulation Standard and universal for critically ill pat

20、ients BP does not reflect cardiac output (CO) BP can be high with a low CO if vasoconstriction occurs and vice versa,46,Can be measured intermittently with a cuff or continuously with an arterial line An additional use of arterial catheterization is to provide access for arterial blood sampling. Thi

21、s is often indicated in patients who require frequent sampling of blood for arterial blood gases or other blood tests.,47,中心靜脈壓（central venous pressure ）,Be inserted via the subclavian, internal jugular provide estimates of central venous pressure (CVP) and measurement of central venous oxygen satur

22、ation (ScvO2) CVP reflects the balance between systemic venous return and cardiac output Have difficulty to assess left-sided preload (only secondarily reflects changes in pulmonary venous and left-sided pressures ),48,鎖骨下靜脈穿刺示意圖,49,頸內(nèi)靜脈穿刺示意圖,50,視頻1,51,中心靜脈壓與血壓之間關(guān)系,52,3. 血氧飽和度（ Pulse oximetry ）,Affo

23、rds a noninvasive estimate of arterial oxygen saturation A standard of care in many institutions The reliability of this method may be limited in patients with severe hypoxemia, abnormal arterial pulsations, and hypoperfusion of the site of measurement,53,Clinical Applications,Adjusting inspired oxy

24、gen, during weaning from mechanical ventilation Testing different levels of PEEP, inverse I:E ratio, or other mechanical ventilator adjustments Monitoring during procedures such as bronchoscopy, gastrointestinal endoscopy, cardioversion, hemodialysis,54,4. 肺動(dòng)脈插管Pulmonary Artery Catheterization,Monit

25、oring CVP Provides information related to left heart filling pressures Allows sampling of pulmonary artery blood for determination of mixed venous oxygen saturation. Thermodilution cardiac output measurements are made using a thermistor-tipped catheter.,55,56,57,pulmonary capillary wedge pressure (P

26、CWP),Estimates left ventricular end-diastolic pressure and thus serves as an estimate of left ventricular preload,58,Clinical Applications,Pressure MeasurementsIn most instances, PCWP is an accurate indicator of left ventricular end-diastolic pressure Mixed Venous Oxygen is an indicator of systemic

27、oxygen utilization. Measuring cardiac output (CO) by thermodilution,視頻2,3,59,漂浮導(dǎo)管的進(jìn)展,混合靜脈血氧飽和度（ Svo2）的監(jiān)測(cè)： Svo2是通過(guò)改良的7.5或8F 熱稀釋肺動(dòng)脈導(dǎo)管作連續(xù)靜脈血氧飽和度監(jiān)測(cè)。 該導(dǎo)管的主要特點(diǎn)是含有光學(xué)纖維，能將光線傳至血流，也能將來(lái)自血流的光線傳出。光源由三個(gè)二極管組成，通過(guò)其中一根光纖可發(fā)射出三種不同波長(zhǎng)的紅光可變光束，這種光被血流血紅蛋白成分吸收、折射，并從第二根光纖反射到光源探測(cè)器上，然后轉(zhuǎn)換成電信號(hào)，輸送到資料處理機(jī)上。所計(jì)算出的血氧飽和度是5秒內(nèi)的平均值，每12秒測(cè)量一

28、次,60,漂浮導(dǎo)管的進(jìn)展,連續(xù)測(cè)定CO： 美國(guó)Baxter公司生產(chǎn)的VigilanceVGS1型連續(xù)心排血量監(jiān)測(cè)儀，連接其專用的美國(guó)Baxter公司生產(chǎn)的744H型六腔Swan-Ganz CCO/Svo2導(dǎo)管。 其原理是從導(dǎo)管熱電阻絲向心腔內(nèi)脈沖式釋放一已知的正性熱量，在其下游部位即肺動(dòng)脈內(nèi)借助熱敏電極記錄到反應(yīng)血液溫度差的溫度-時(shí)間變化曲線，根據(jù)熱稀釋原理計(jì)算出心輸出量。 優(yōu)點(diǎn)：每隔30-60秒自動(dòng)測(cè)量并顯示數(shù)據(jù)，免去了常用的注射冰鹽水的麻煩和由于注射操作不易嚴(yán)格掌握帶來(lái)的重復(fù)性差等缺點(diǎn)。,61,5. 組織灌注的評(píng)估,通過(guò)對(duì)皮膚、溫度、尿量、酸中毒、胃粘膜內(nèi)PH值的改變等監(jiān)測(cè)進(jìn)行,62,循環(huán)

29、與心臟功能支持,對(duì)于所有的循環(huán)功能不全的患者，治療的目的是在糾正基礎(chǔ)病的同時(shí)(如外科止血或消除感染)，盡早恢復(fù)向組織輸送氧。 循環(huán)支持的幾個(gè)決定因素：前負(fù)荷、心肌收縮力和后負(fù)荷，以及心率。其措施包括呼吸支持、心臟負(fù)荷控制、血容量補(bǔ)充或控制、血管活性藥物及正性肌力藥物、心輸出量管理（如主動(dòng)脈內(nèi)球囊反搏術(shù)）等。,63,呼吸系統(tǒng)功能監(jiān)護(hù),64,1. 臨床癥狀體征與呼吸功能基本參數(shù)監(jiān)測(cè),呼吸相關(guān)臨床癥狀體征 呼吸頻率和深度 呼吸力學(xué)監(jiān)測(cè) 呼吸波形及呼吸功監(jiān)測(cè) 肺功能監(jiān)測(cè) 彌散功能監(jiān)測(cè) 呼氣末二氧化碳分壓,65,2.血?dú)夥治?氧分壓(PO2)：血漿中物理溶解的氧分子產(chǎn)生的分壓力；正常值80-100mmH

30、g。 血氧飽和度(SO2)：血紅蛋白實(shí)際結(jié)合氧量(氧含量)與應(yīng)結(jié)合氧量(氧容量)之比；正常值95-100%。 氧含量：血液實(shí)際結(jié)合的氧量；等于1.34血紅蛋白量氧飽和度,66,二氧化碳分壓(PCO2)：血漿中溶解的二氧化碳產(chǎn)生的壓力；正常值35-45mmHg。 酸堿度(PH值)：溶液內(nèi)氫離子濃度的負(fù)對(duì)數(shù)；正常值7.35-7.45。 氧合指數(shù)（PaO2/FiO2）：是監(jiān)測(cè)肺換氣功能的主要指標(biāo)，當(dāng)PaO2/FiO2300mmHg時(shí)，為急性呼吸衰竭。,67,碳酸氫離子(HCO3-)：每毫升血漿中含有的HCO3-濃度，即為實(shí)際碳酸氫鹽(AB)；正常值242mmol/L。受呼吸性、代謝性因素影響。 標(biāo)準(zhǔn)

31、碳酸氫鹽(SB)：正常值253mmol/L；反映代謝性因素。,68,緩沖堿(BB)：血液中起緩沖作用的全部堿量；正常值45-55mmol/L。 堿剩余(BE)：正常值3mmol/L；測(cè)定代謝性酸堿紊亂的指標(biāo)。 二氧化碳結(jié)合力(CO2CP)：受代謝性、呼吸性兩方面影響；正常值22-31mmol/L。,69,3. 胸部影像學(xué)檢查,胸部X線 超聲波檢查 胸部CT,70,呼吸功能支持與氣道管理,氣道管理：開放和暢通呼吸道、祛除氣道分泌物和異物、氣道濕化 氧氣療法：PaO2保持在8Kpa或者血氧飽和度90 無(wú)創(chuàng)呼吸支持：持續(xù)正壓氣道通氣(CPAP),71,機(jī)械通氣支持：,緊急氣管插管機(jī)械通氣：在積極的氧

32、氣療法前提下，仍存在低氧血癥(PaO28kPa或SaO290)、存在高碳酸血癥甚至意識(shí)不清、由于神經(jīng)肌肉疾患導(dǎo)致肺活量下降等。 通氣模式：容量控制通氣方式、壓力控制通氣方式 通氣策略：潮氣量、呼吸頻率、呼氣末正壓、吸呼氣時(shí)間比,72,撤機(jī)的指征,患者氧合良好，在吸氧濃度8kPa； 能維持CO2分壓在正常范圍內(nèi)；可滿足斷開呼吸機(jī)后的呼吸功耗； 神志清楚，反應(yīng)良好。 撤機(jī)方法包括嚴(yán)密監(jiān)護(hù)患者病情下，逐漸增加患者自主呼吸的時(shí)間或逐漸降低通氣支持的水平。,73,腎功能監(jiān)護(hù),尿量：監(jiān)測(cè)腎功能最基本、直接的指標(biāo)，通常記錄每小時(shí)及24小時(shí)尿量 尿液常規(guī)檢查：尿比重1.020提示腎灌注不足，為腎前性腎功能衰竭

33、；比重1.010的低比重尿則為腎性腎功能衰竭。 血、尿腎臟生化學(xué)監(jiān)測(cè)：評(píng)價(jià)腎小球?yàn)V過(guò)功能和腎小管重吸收功能 。,74,腎臟支持,評(píng)估和糾正呼吸或循環(huán)障礙； 處理腎臟功能不全引起的任何威脅生命的情況； 排除尿道梗阻； 確定病因和明確腎功能不全的原因，并立即開始治療； 了解用藥史，適當(dāng)更改醫(yī)囑； 有適應(yīng)證的患者應(yīng)及早使用腎臟替代療法。,75,腎臟替代療法,無(wú)法控制的高血鉀癥； 對(duì)利尿劑無(wú)反應(yīng)的嚴(yán)重水鈉潴留； 嚴(yán)重的尿毒癥； 嚴(yán)重酸中毒。,76,肝功能監(jiān)護(hù),血清膽紅素：評(píng)估肝臟排泄功能。 血清白蛋白：評(píng)估肝臟合成功能。 谷丙轉(zhuǎn)氨酶（ALT）、谷草轉(zhuǎn)氨酶（AST）：評(píng)估肝實(shí)質(zhì)細(xì)胞有否損傷。 凝血酶原時(shí)

34、間（PT）：評(píng)估肝臟合成功能。凝血酶原時(shí)間和凝血因子、和有關(guān)，而這些因子也均在肝臟合成。特別是因子，是肝臟合成的半衰期短的凝血因子，半衰期46h，是肝功能受損時(shí)最早減少的凝血因子。,78,胃腸道功能的監(jiān)護(hù),危重患者出現(xiàn)消化道應(yīng)激性潰瘍的比例較高 不能進(jìn)食者，除給予全腸道外營(yíng)養(yǎng)外，盡早予腸道內(nèi)營(yíng)養(yǎng),79,腦功能的監(jiān)護(hù),重癥監(jiān)護(hù)治療的目的是通過(guò)保證正常的動(dòng)脈血氧含量及維持腦灌注壓在70mmHg以上，以免產(chǎn)生繼發(fā)性損害，并使大腦獲得最佳的氧合。 Glasgow昏迷評(píng)分標(biāo)準(zhǔn)，顱內(nèi)壓監(jiān)測(cè)，頸靜脈球部氧飽和度、腦組織氧合壓監(jiān)測(cè)，腦多普勒超聲，腦電圖。,80,神經(jīng)系統(tǒng)重癥監(jiān)護(hù)治療,應(yīng)保護(hù)氣道通暢，常用的措施

35、是氣管內(nèi)插管或氣管切開，必要時(shí)用機(jī)械通氣維持正常的氣體交換。 控制顱內(nèi)壓和腦灌注壓 抗驚厥治療等,81,凝血功能的監(jiān)護(hù),對(duì)臨床上出現(xiàn)：嚴(yán)重或多發(fā)性出血傾向；不易用原發(fā)病解釋的微循環(huán)衰竭或休克；多發(fā)性微循環(huán)栓塞的癥狀和體征，如廣泛性皮膚、粘膜栓塞、灶性缺血性壞死、脫落及潰瘍形成，或伴有早期的不明原因的肺、腎、腦等臟器功能不全；抗凝治療有效等情況，要注意是否有DIC的可能。,82,營(yíng)養(yǎng)檢測(cè)和支持,危重癥患者營(yíng)養(yǎng)支持目的在于供給細(xì)胞代謝所需要的能量與營(yíng)養(yǎng)底物，維持組織器官結(jié)構(gòu)與功能； 通過(guò)營(yíng)養(yǎng)素的藥理作用調(diào)理代謝紊亂，調(diào)節(jié)免疫功能，增強(qiáng)機(jī)體抗病能力，從而影響疾病的發(fā)展與轉(zhuǎn)歸，這是實(shí)現(xiàn)重癥患者營(yíng)養(yǎng)支持

36、的總目標(biāo)。,83,General Principles of Critical Care,84,Early Identification of Problems,Critically ill patients are at high risk for developing complications ICU practitioner must remain alert to early manifestations of organ system dysfunction, complications of therapy, potential drug interactions, and other premonitory data Early identifying and acting on new problems demands frequent and regular review of all information available,85,86,87,Effective Use of the Problem-Oriented Medical Record,The special importance of finding, tracking