ICU护士应当掌握的知识课件

1、ICU护士应当掌握的知识1ICU护士应当了解的知识循环系统血流动力学基本理论不同疾病的特点血管活性药物抗心律失常药物呼吸系统氧疗机械通气模式和特点不同疾病机械通气原则肾脏急性肾损伤(AKI)定义和诊断标准利尿药物肾脏替代治疗IHDCRRT水电平衡酸碱平衡2ICU护士应当具备的技能CPR气道管理氧疗呼吸机无创通气有创通气血流动力学监测PACPiCCOCRRT血气分析电解质紊乱鉴别诊断患者转运患者评估3血流动力学中的欧姆定律R = P / flowPinPoutflowR5器官灌注压肾脏灌注RPP = MAP IAPFG = GFP PTP = MAP IAP x 2脑灌注CPP = MAP IC

2、P6健康与疾病时的自身调节015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope7疾病时的自身调节机制015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)control3 weeks1 week8无创血压监测普遍应用低血压71% (105/149)高血压73% (108/149)应用升压药47% (70

3、/149)局限性高血压时低估低血压时高估心律失常时准确性下降Chatterjee A, DePriest K, Blair R, et al. Results of a survey of blood pressure monitoring by intensivists in critically ill patients: a preliminary study. Crit Care Med 2010; 38: 2335-233810有创压力监测12有创血压监测 真实收缩压真实收缩压14有创血压的测量15什么血压?收缩压活动性出血舒张压急性冠脉综合征平均压器官灌注 16血流动力学监测: 技

4、巧确认患者的平均动脉压家属病历记录检查患者平均动脉压的测定方法无创 vs. 有创确定无创血压与有创血压的差值17中心静脉压监测Why?How?上腔静脉 vs. 下腔静脉平卧位 vs. 半卧位多腔中心静脉插管通过哪个腔测量如果同时输液随呼吸周期呈显著波动18容量负荷试验: 判断标准心率改变血压改变CVP / PAWP改变CO / SV改变20容量负荷试验: 判断标准每10分钟测定CVPCVP 2 mmHg继续快速补液CVP 2 5 mmHg暂停快速补液, 等待10分钟后再次评估CVP 5 mmHg停止快速补液每10分钟测定PAWPPAWP 3 mmHg继续快速补液PAWP 3 7 mmHg暂停快

5、速补液, 等待10分钟后再次评估PAWP 7 mmHg停止快速补液Weil MH, Henning RJ: New concepts in the diagnosis and fluid treatment of circulatory shock. Anesth Analg 1979; 58:124-132血管活性药物的使用标准配制DA: 3 x BWt / 50 mlNE: .3 x BWt / 50 ml抽药量需要计算剂量调整方便不同患者间不可互换更换频繁非标准配制DA: 10 mg/mlNE: 1 mg/ml抽药量无需计算剂量调整需要计算不同患者间可互换无需频繁更换23血管活性药物的使

6、用：多巴胺(10 mg/ml)多巴胺剂量(g/kg/min)体重(kg)125101520400.240.481.202.403.604.80500.300.601.503.004.506.00600.360.721.803.605.407.20700.420.842.104.206.308.40800.480.962.404.807.209.60900.541.082.705.408.1010.801000.601.203.006.009.0012.0024第一阶段：对照经中心静脉输注血管活性药物儿茶酚胺最低输注速度2 ml/hr不规定更换注射器的方法第二阶段：干预双泵更换接近输注完毕前，将

7、配好药物的注射器放在另一微量泵上，预冲管路使用快速推注功能直至管路开口处看到液体流出设置新微量泵的输注速度(与原有微量泵相同)新微量泵开始输注关闭原有微量泵Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R133血管活性药物：注射器更换方法26血管活性药物：更换注射器方法更换血管活性药物相关事件(CVIP)换泵后15分钟内收缩压变化 20 mmHg换泵后15分

8、钟内心率变化 20 bpm出现房性或室性心律失常Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R13327血管活性药物：更换注射器方法Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement

9、 program. Crit Care 2007; 11: R13328定容通气30I吸气峰压(PIP)平台压(Pplat)机械通气 传统模式定容通气气道压力不恒定潮气量吸气流量气道阻力呼吸系统顺应性吸气潮气量恒定定压通气吸气相气道压力恒定吸气潮气量不恒定吸气力量压力控制/支持水平吸气时间气道阻力呼吸系统顺应性31机械通气 传统模式定容通气监测指标：压力定压通气监测指标：容量（潮气量）32机械通气 新模式的理解Pressure regulated volume control (PRVC)Simens Servo 300/300A, ServoiAdaptive pressure ventil

10、ation (APV)Hamilton GalileoAuto-FlowDrger Savina, Evita 2 dura, Evita 4Variable Pressure ControlCardiopulmonary Corporation Venturi33机械通气 新模式的理解压力控制通气(PC)通气量会随着肺的顺应性变化而变化，有可能出现通气不足容量控制(VC)模式，通气量虽有保证，却易引起气压伤PRVC就是综合PC和 VC的优点而开发出的一种新的控制通气模式其独特之处是在确保预先设置的潮气量参数的基础上，呼吸机能自动连续监测胸肺顺应性和容积压力关系，并据此反馈调节下一次通气的吸气

11、压水平，使气道压尽可能降低，以减少正压通气的气压伤34机械通气 新模式的理解The ventilator is continuously, breath by breath, adapting the inspiratory pressure to changes in the volume/pressure relationship.When the target volume has been achieved and the measured volume increases above or decreases below the preset tidal volume, the pr

12、essure level is regulated in small steps of max 3 cmH2O until preset volumes are delivered.max 3 cmH2O机械通气 新模式的理解压力控制/支持通气目标：潮气量500 mlVt 500 ml?Vt 500 ml?监测指标Vt?PIP?36肾脏功能少尿( 0.5 ml/kg/hr)组织灌注不足的标志若不及时纠正可能导致急性肾功能衰竭连续2小时尿量减少必须给予紧急处理37正常少尿缺血加剧急性肾小管坏死此时开始治疗组织灌注不足的临床表现皮肤花斑四肢冰冷毛细血管再充盈时间延长尿量减少意识障碍代谢性酸中毒乳酸

13、酸中毒ScvO2 20 cm H2OAvoid circuit s.Only contaminatedSemirecumbency.30-45 degreesKinetic beds-.-.Surgery/Neuro医院获得性肺炎 预防指南43Pharmacological measuresETFCDCCCCSATS/ IDSARecommendationsOral care-.-.?. - ClorhexidineSDD?.ControversialBiofilm formation-.PendingProphylactic Abx?-. SubgroupsStress ulcer prop

14、hylaxis?.MV48h -CoagulopTransfusion restriction-.CAD Hb 7g/dLGlycemic control-.Post-Surg/150Sedation-.Sedation breakAdequate Abx-.Short courseNutrition-.Enteral/Post-pyloric床头抬高 现状床头抬高角度19.2 13.4 (中位数19, 范围0 - 90)机械通气患者16.8非机械通气患者23.1大多数患者(71%)处于平卧位Grap MJ, Munro CL, Bryant S, et al. Predictors of b

15、ackrest elevation in critical care. Intensive Crit Care Nurs 2003; 19: 68-74估测HOB角度的准确性HOB 30HOB 45估测角度50p .00170p 30 30随后2周, 测定插管患者床头抬高角度最后2周, 将角度提示装置放置在床档, 并测定床头抬高角度对护理人员进行调查, 以了解对该装置的满意度Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-b

16、ed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157床头抬高 如何实施使用装置前使用装置后测定总数, n166102平均角度, 2231依从人数, n

17、38 (22.9%)73 (71.6%)依从定义为床头角度 28Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157床头抬高 如何实施32名护士完成调查问卷 回收率100%该装置改进现有方法72%该装置有助于监测床头抬高情况88% 希望该装置永久使用84%既往了解ICU中床头抬高指南94%

18、改进了对于抬高床头重要性的认识66%Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157每日清单59每日提醒导管留置时间60Seguin P, Laviolle B, Isslame S, et al. Effectiveness of simple daily sensitization

19、 of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010; 36: 1202-1206每日提醒导管留置时间61Seguin P, Laviolle B, Isslame S, et al. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization.

20、 Intensive Care Med 2010; 36: 1202-1206每日提醒导管留置时间62Seguin P, Laviolle B, Isslame S, et al. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010; 36: 1202-1206每日目标清单Hartford医院800张床位的I级创伤中心教学医院12张床外科ICU查房

21、时的目标清单源自Baltimore的Johns Hopkins医院清单列举了各种方面的目标临床治疗安全性每日两次查房时使用/p/articles/mi_m0NUZ/is_10_10/ai_109026749?tag=untagged access on July 8, 200863每日目标清单患者为何住ICU?镇静水平是否适当?疼痛控制水平是否适当?床头是否抬高30度?是否进行脱机 / 拔管评估?Current vent support needed RWP candidate?组织灌注是否充分?心律失常得到治疗 / 控制?BP控制适当?容量状态适当?IV液体适当?营养支持充分?肠道?PUD预防?电解质WNL?血糖控制?血色素 / 血球压积(H/H)正常?凝血指标正常?DVT预防