ICU(英文).ppt

1、Intensive care外科重癥監(jiān)測治療,2,What is ICU?,An intensive care unit (ICU) is a specially staffed and equipped hospital ward dedicated to the management of patients with life-threatening illnesses,injuries or complications. 重癥監(jiān)護(hù)病房(intensive care unit, ICU)是將疑難危重患者集中監(jiān)測治療的單位。,3,History of ICU,ICU developed fr

2、om the poliomyelitis脊髓灰質(zhì)炎epidemic in the early 1950s,when the use of long-term artificial ventilation resulted in reduced mortality. Mortality of polio epidemic 87% Dropped to 27% by the use of anesthesia machines for ventilation of pts 1952年夏，丹麥哥本哈根脊灰流行，造成延髓性呼吸麻痹，多死于呼吸衰竭。病人被集中，通過氣管切開保持呼吸道暢通并進(jìn)行肺部人工通

3、氣，使死亡率顯著下降。治療效果的改善，使有關(guān)醫(yī)生認(rèn)識(shí)到加強(qiáng)監(jiān)護(hù)和治療的重要性。,4,Category of ICU,綜合性ICU (general ICU)、?？艻CU SICU 外科ICU(surgery ICU) CICU，冠心病ICU(coronary intensive care unit, CCU) RICU，呼吸系統(tǒng)疾病ICU(respiratory intensive care unit, RCU) EICU，急診ICU(emergency care unit) NICU，新生兒ICU(neonatalICU) 心肺重癥監(jiān)護(hù)治療病房(CPICU) 心臟外科重癥監(jiān)護(hù)治療病房(CSI

4、CU) 神經(jīng)外科重癥監(jiān)護(hù)治療病房(NSICU) 危重腎病重癥監(jiān)護(hù)治療病房(UICU),5,Type of ICU patients,Intensive care is usually only offered to those whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Patients requiring intensive care usually require support for hemodynamic i

5、nstability (hypertension/hypotension) airway or respiratory compromise (such as ventilator support) acute renal failure potentially lethal cardiac dysrhythmias, frequently the cumulative effects of multiple organ system failure,6,Type of ICU patients,Terminal illness or irreversible Terminal cancer

6、Permanent brain damage Infectious disease? SARS -management of mechanically ventilated severe acute respiratory syndrome (SARS) patients in the isolation intensive care unit (ICU)-successful,7,cost,ICU is generally the most expensive, technologically advanced and resource intensive area of medical c

7、are. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion accounting for about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004).,8,Gerneral ICU ward,9,ICU equipment,監(jiān)測設(shè)備monitoring equipment :多功能生命體征監(jiān)測儀、呼吸功能監(jiān)測儀、心臟血

8、流動(dòng)力學(xué)監(jiān)測儀、脈搏血氧飽和度儀、血?dú)夥治鰞x、心電圖機(jī)。 監(jiān)護(hù)儀器按系統(tǒng)或器官功能參數(shù)分門排列，左列顯示功能參數(shù)，右列為治療參數(shù)。 治療設(shè)備:呼吸機(jī)、除顫器、輸液泵、注射泵、起搏器、主動(dòng)脈內(nèi)球囊反搏器、血液凈化儀、麻醉機(jī)、中心供氧、中心吸引裝置、體外膜式肺氧合(ECMO)裝 。,10,監(jiān)護(hù)儀,心功能監(jiān)測系統(tǒng),11,心電圖機(jī),12,便攜式血?dú)怆娊赓|(zhì)腎功檢驗(yàn)儀,13,鐵肺重癥監(jiān)護(hù)病房的最早嘗試,14,呼吸機(jī),15,Defibrillator 除顫器,16,制氧機(jī),Pulse Oxymetry 血氧飽和儀,17,ICU收治對(duì)象-外科重危病人,創(chuàng)傷、大手術(shù) 器官移植后監(jiān)測 循環(huán)失代償者 有呼吸衰竭可能

9、，需呼吸器治療者 嚴(yán)重水電解質(zhì)紊亂，酸堿平衡失調(diào)者 麻醉意外、心肺復(fù)蘇后病人 單個(gè)或多個(gè)器官功能不全者 嚴(yán)重代謝障礙性疾病(甲亢、腎上腺、垂體危象),18,What do we do in ICU?,monitoring ECG heart rate, rhythm, ischemia Blood pressure non-invasive invasive arterial,central venous, pulmonary artery Hemodynamic measurement cardiac output Pulse oxymetry and capnography Intracr

10、anial,intraabdominal pressure Many others electrolyte, CNS,19,What do we do in ICU?-Treatment,Hemodynamic support -inotrope and vasoactive medication Mechanical ventilation Organ support (eg.dialysis) Sedation and analgesia Treatment of underlying illnesses Enteral/parenteral nutrition,20,Why are sc

11、oring systems needed?,Scoring systems can provide: -Defining population of critically ill pts A tool for comparative audit A mechanism to decide resource allocation An aid for the clinical management of patients,21,“Its more important to know what sort of person this disease has, than what sort of d

12、isease this person has.”William Osler 1849-1919,22,History,1953 Virginia Apgar 1974 Glasgow Coma Scale APACHE vital signs; assessments of respiratory, renal, and neurologic function; and an evaluation of chronic medical illnesses,24,APACHE,William Knaus Initially 34 physiological variables 1985 APAC

13、HE II 12 variables APACHE II allows probability of death before hospital discharge to be estimated Standardised mortality ratio,25,Assessment of Severity of Illness-History,APACHE 24 hours; 72 hours Series of true/false questions Weighted according to their individual contribution to mortality,36,Mo

14、nitoring of Respiratory function,床旁觀察既簡單又實(shí)用。 general: Consciousness Respiratory movements， Respiratory rate、apnea 呼吸音。 mucous,37,呼吸運(yùn)動(dòng)的觀察,呼吸頻率(RR) Adult RR 10-18 beat/min 每分鐘肺泡通氣量(minute ventilation,MV MV)=tidal volume(VT)dead volume(VD)RR,38,呼吸功能測定,肺容量監(jiān)測反映靜態(tài)通氣功能 潮氣量(tidal volume,VT) 補(bǔ)吸氣量(inspiratory

15、 reserve volume,IRV) 深吸氣量(inspiratory capacity,IC) 補(bǔ)呼氣量(expiratory reserve volume,ERV) 殘氣量(residual volume,RV) 功能殘氣量(functional residual capacity,FRC) 肺活量(vital capacity,VC) 肺總量(total lung capacity,TLC) Normal- 80% predicted value,39,Oxygen therapy 氧治療,Oxygen therapy is the administration of oxygen

16、as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care. 氧治療是通過吸入不同濃度的氧，使吸入氧濃度(F1O2)和肺泡氣的氧分壓(PAO2)升高，以升高動(dòng)脈血氧分壓(PaO2)，達(dá)到緩解或糾正低氧血癥的目的。 Indication: Cardiac and resp arrest Resp failure type,type Cardiac failure or MI Shock Increase metabolic demands Post

17、-operative states Carbon monoxide poisoning,40,Oxygen therapy,氧療方法:高流量系統(tǒng)，如文圖里(Venturi)面罩(F1O2穩(wěn)定)。低流量系統(tǒng)，如鼻導(dǎo)管吸氧、面罩吸氧、帶貯氣囊面罩吸氧等(F1O2不穩(wěn)定) 。 氧療護(hù)理:加強(qiáng)監(jiān)測、預(yù)防交叉感染、濕化吸入氣體、注意防火和安全。,41,Mechanical Ventilation 機(jī)械通氣:人工氣道,In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous b

18、reathing Artificial airway: endotracheal intubation or tracheostomy氣管插管或氣管切開。,42,Indication of mechanical ventilation,Acute lung injury (including ARDS, trauma) Apnea with respiratory arrest Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxi

19、de (pCO2) 50 mmHg and pH 7.25, which may be due to paralysis of the diaphragm due to Guillain-Barr syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs Increased work of breathing as evidenced by significant tachypnea, retractions, and other physica

20、l signs of respiratory distress Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of inspired oxygen (FiO2) 55mm Hg Hypotension including sepsis, shock, congestive heart failure Neurological diseases,43,Types of ventilators,Ventilation can be delivered via: Hand-co

21、ntrolled ventilation such as: Bag valve mask Continuous-flow or Anaesthesia (or T-piece) bag A mechanical ventilator. Types of mechanical ventilators include: Transport ventilators. These ventilators are small, more rugged, and can be powered pneumatically or via AC or DC power sources. ICU ventilat

22、ors. NICU ventilators. Designed with the preterm neonate in mind,. PAP ventilators. these ventilators are specifically designed for non-invasive ventilation. this includes ventilators for use at home, in order to treat sleep apnea,44,Mechanical Ventilation: modes,Control mode ventilation (CMV):控制通氣

23、Asist/control mode ventilation (A/CMV):輔助/控制通氣 Intermittent mandatory ventilation (IMV): 間歇指令通氣 Synchronized Intermittent mandatory ventilation (SIMV):同步間歇指令通氣 Pressure support ventilation (PSV):壓力支持通氣 Positive end respiratory pressure (PEEP):呼氣末正壓通氣 Weaning from Mechanical Ventilat呼吸機(jī)的撤離:臨床綜合判斷、撤機(jī)生

24、理參數(shù)、撤機(jī)觀察呼吸頻率、節(jié)律、深度、呼吸方式；監(jiān)測心率、血壓、有無出汗、紫紺、呼吸窘迫。,45,arterial blood-gas analysis (ABG),Evaluation of respiratory gas exchange is routine in critical illness. The gold standard remains arterial blood-gas analysis, where pH, partial pressures of O2 and CO2, and O2 saturation are measured directly. With ar

25、terial blood-gas analysis, the two main functions of the lungoxygenation of arterial blood and elimination of CO2can be directly assessed. Importantly, the blood pH, which has a profound effect on the drive to breathe, can be assessed only by sampling of arterial blood. Though sampling of arterial b

26、lood is generally safe, it may be painful and cannot provide continuous information for clinicians routinely. Given these limitations, noninvasive monitoring of respiratory function is often employed in the critical care setting.,46,Arterial blood-gas analysis,pH:7.357.45 PaO2 :1213.3kPa(90100mmHg)

27、PaCO2:4.76kPa(3545mmHg) SaO2(SAT):正常值96100% CaO2(動(dòng)脈血O2含量):正常值1620ml/dl 實(shí)際HCO-3 (AB)和標(biāo)準(zhǔn)HCO-3(SB):2227mmol/L(24) ABSB:呼酸 ABSB:呼堿:AB=SB 正常。兩者均增加:失代償性代堿；兩者均降低:失代償性代酸 堿剩余(BE):-3+3mmol/L 緩沖液(BB):包括HCO-3和P-r。正常值4555mmol/L。 血漿陰離子間隙(AGp):正常值7-16mmol/L TCO2(CO2總量)正常值28-35 3mmol/L,47,Pulse Oximetry脈搏血氧飽和度 (SpO

28、2),Pulse Oximetry is the most commonly utilized noninvasive monitor of respiratory function. This technique takes advantage of differences in the absorptive properties of oxygenated and deoxygenated hemoglobin. 脈搏血氧飽和度是通過脈搏血氧監(jiān)測儀(pulse oximeter ，POM)利用紅外線測定末梢組織中氧合血紅蛋白含量，間接測得SpO2。正常值95100%。 SpO2監(jiān)測的影響因

29、素 正鐵血紅蛋白(MetHb)與碳氧血紅蛋白(COHb)愈高其SpO2測值愈低。 體溫因素:低體溫致SpO2降低。 低血壓肢端末梢循環(huán)不良:當(dāng)50mmHg，SpO2下降。 測定部位:測定部位其皮膚組織愈厚，精確度愈低。 皮膚色素:色素沉著、指甲染料SpO2偏低。 血管收縮劑:使SpO2測值下降。,48,expiratory C02 monitoring，PETC02 呼氣末C02監(jiān)測,PETC02 end-tidal CO2 呼氣末C02監(jiān)測 主要根據(jù)紅外線原理、質(zhì)譜原理、拉曼散射原理和圖聲分光原理而設(shè)計(jì)，主要測定呼氣末二氧化碳。 noninvasive 呼氣末二氧化碳濃度(EtC02) 呼出

30、氣二氧化碳濃度在呼氣末最高，接近肺泡氣水平(約3.55)，其與PaC02的相關(guān)性良好，可據(jù)此間接估計(jì)PaC02。 正常值3545mmHg,49,Hemodynamic monitoring 血流動(dòng)力學(xué)監(jiān)測,Hemodynamicmeasurements are important to establish a precise diagnosis,determine apropriate therapy.Monitor may be categorized into Non-invasive electrocardiogram(ECG) non-invasive blood pressure (

31、NIBP) urine output echocardiography and Doppler Invasive Arterial blood pressure central venous pressure Pulmonary artery catheter, Swan-Ganz catheter漂浮導(dǎo)管,50,Electrocardiogram,ECG心電圖,ECG diagnose ischemia, MI arrhythmia monitoring function of pacer,51,動(dòng)脈壓(NIBP, ABP),Non-invasive blood pressure devic

32、es use an oscillotonometric technique. 袖帶測壓、自動(dòng)無創(chuàng)測壓(NIBP) They can give erroneous result in pts with arrhythmia(Af)。 Invasive: Arterial blood pressure use an arterial catheter and tranducer technique動(dòng)脈穿刺插管直接測壓 mean arterial presssure,MAP 平均動(dòng)脈壓是指心動(dòng)周期的平均血壓。能評(píng)估左室泵功能、器官和組織血流。正常值813.3kPa 。 MAP=DBp1/3(SBpD

33、Bp)COSVR。,52,central venous pressure,CVP 中心靜脈壓,CVP can be monitored using catheters inserted via the internal jugular,subclavian and femoral veins. CVP 胸腔內(nèi)上、下腔靜脈或右心房內(nèi)的壓力。 是評(píng)估血容量、右心前負(fù)荷及右心功能的重要指標(biāo)。 正常值為5-12cmH2O 。 CVP過低為血容量不足或靜脈回流受阻；CVP過高為輸入液體過多或心功能不全。 適應(yīng)癥: 各類大中手術(shù)，尤心胸顱腦手術(shù)；各種休克；脫水、失血和血容量不足；心力衰竭；大量靜脈輸血、輸

34、液或靜脈高能量營養(yǎng)。,54,CVP注意事項(xiàng),注意事項(xiàng): 判斷導(dǎo)管插入上、上腔靜脈或右房無誤。 玻璃管零點(diǎn)對(duì)第4肋間右心房水平。 確保管道內(nèi)無凝血、空氣，管道無扭曲。 測壓時(shí)確保靜脈內(nèi)導(dǎo)管通暢無阻。 加強(qiáng)管理，嚴(yán)格無菌操作。 并發(fā)癥:感染、出血和血腫、其它血?dú)庑?、血?dú)馑ǖ取?55,Swan-Ganz catheter 漂浮導(dǎo)管,Swan-Ganz導(dǎo)管用聚氯乙烯材料推壓而成，不透X線。成人有5F、6F、7F、7.5F，全長110cm，每10cm有黑色環(huán)形標(biāo)記。兒童有4F和5F，全長60cm。 四腔Swan-Ganz導(dǎo)管:端孔為主腔開口用于監(jiān)測肺動(dòng)脈壓和采集血標(biāo)本。距管端30cm處有一側(cè)孔, 用于監(jiān)

35、測右房壓、CVP、CO和輸液。熱敏計(jì)位于距管端4cm處，用于感知熱阻抗的變化，尾端與計(jì)算機(jī)相連。端孔1-2mm處有一氣囊與尾端的注射器相連可注入氣體(1.25-1.5ml)。,56,Swan-Ganz原理,心室舒張末期，主動(dòng)脈瓣和肺動(dòng)脈瓣均關(guān)閉，而二尖瓣開放形成液流內(nèi)腔。 心室舒張末壓(LVDEP)=肺動(dòng)脈舒張壓(PADP)=肺小動(dòng)脈楔壓(PAWP)=肺毛細(xì)血管楔壓(PCWP) 。 PCWP:pulmonary artery capillary wedge pressure 臨床意義 估價(jià)左右心室功能 區(qū)別心源性和非心源性肺水腫 指導(dǎo)治療 選擇最佳PEEP 確定漂浮導(dǎo)管位置,57,肺動(dòng)脈楔壓(

36、pulmonary aortic wedge pressure,PAWP) 正常值為0.81.6kPa?？膳卸ㄗ笮氖夜δ埽从逞萘渴欠癯渥?。2.4kPa:左心功能不全、急性心源性肺水腫；2.4kPa:急性肺損傷、ARDS。 肺毛細(xì)血管楔壓(PCWP) 正常值0.671.87kPa。反映左心房平均壓及左心室舒張末期壓。 0.8kPa:體循環(huán)血容量不足；2.4kPa:即將或已出現(xiàn)肺淤血； 4kPa: 肺水腫。 平均肺動(dòng)脈壓(mean pulmonary arterial presssure ,MPAP) 正常值1.472.0kPa。MPAP升高見于肺血流量增加、肺血管阻力升高、二尖瓣狹窄、左心功

37、不全。MPAP降低見于肺動(dòng)脈瓣狹窄。,58,SwanGanz導(dǎo)管適應(yīng)證,ARDS左心衰 循環(huán)功能不穩(wěn)定 急性心肌梗塞 區(qū)分心源性和非心源性肺水腫 心血管手術(shù) 肺栓塞 嚴(yán)重創(chuàng)傷，各類休克，嗜鉻細(xì)胞瘤等。,59,床邊盲目置管,就是通過導(dǎo)管在某一心臟內(nèi)的壓力波形來間接判斷其位置所在，需同步心電圖監(jiān)測。波形變化依次為右房，右室，肺動(dòng)脈和肺毛壓。,漂浮導(dǎo)管測得右房、右室、肺動(dòng)脈及肺毛細(xì)血管楔壓,60,Swan-Ganz導(dǎo)管并發(fā)癥,心律失常 氣囊破裂 肺梗塞 肺動(dòng)脈破裂和出血 導(dǎo)管打結(jié) 血栓形成 心包填塞 感染,61,心輸出量(cardiac output,CO),正常值48L/min。指每分鐘心臟的射血

38、量，反映左心功能。CO降低見于回心血量減少、心臟流出道阻力增加、心肌收縮力減弱。 經(jīng)Swan-Ganz導(dǎo)管熱稀釋法測定心排血量，脈動(dòng)脈與右心房的血液溫度差值與時(shí)間、流量有關(guān)，據(jù)此即可計(jì)算出心排出量。,心功能曲線,62,Hemodynamic monitoring,每搏排出量(stroke volume,SV)指一次心搏由一側(cè)心室射出的血量。成年人安靜、平臥時(shí)為6090ml。SV與心肌收縮力、心臟前負(fù)荷、后負(fù)荷有關(guān)。 心臟指數(shù)(CI) 正常值2.84.2L/min.m2。CI2.5提示心衰；CI1.8為心源性休克。 體循環(huán)阻力指數(shù)(system vascular resistance index,SVRI)體循環(huán)阻力 (SVR)表示心室射血期作用于心室肌的負(fù)荷，是監(jiān)測左心室后負(fù)荷的指標(biāo)。是指每平方米體