医、技学院(华盛顿医疗手册培训 重症监护)

1、The Washington Manual of Medical Therapeutics -Critical CAreDepartment of Critical CareCui Wei1.ContentsRespiratory FailureShock2.Respiratory Failure3.General PrinciplesHypercapnic respiratory failure may produce a respiratory acidosis (pH 7.35).Hypoxic respiratory failure can result in hypoxemia (a

2、rterial oxygen tension PaO2 60 mm Hg or arterial oxygen saturation SaO2 90%). The acute respiratory distress syndrome (ARDS) is a form of hypoxic respiratory failure caused by acute lung injury. The common end result is disruption of the alveolar capillary membrane, leading to increased vascular per

3、meability and accumulation of inflammatory cells and protein-rich edema fluid within the alveolar space.The American-European Consensus Conference has defined ARDS as follows: (a) acute bilateral pulmonary infiltrates, (b) ratio of PaO2 to inspired oxygen concentration (FIO2) 90%, PaO260mmHgMinute V

4、olume of VentilationDetermined by Vt and fIn COPD patients, the goal of PaCO2 is the baseline level, not the normal level23.Ventilator ManagementPEEP: Positive End-Expiratory Pressure Lung Complance OxygenationShunt FractionWork of BreathingIncrease the risk of barotrauma and cardiovascular compromi

5、seInitial: 3-5cmH2OIncerments: 3-5cmH2OHigh level: 20-25cmH2OGoal 1: PaO255-60mmHgGoal 2: FiO260%Goal 3: Avoid CV compromise24.Ventilator ManagementInspiratory Flow40-80L/min for adult ptsTrigger Sensitivity-2-5cmH2O or 3-5L/minFlow-byIn flow-triggered systemDecrease pts work of breathing25.Problems

6、 and ComplicationsWorsening respiratory distressNOTE alarm, Vt, airway pressureDisconnected ventilator circuitVentilate manually Suction if manual ventilation is difficultCheck vital sign and rapid physical examinationVentilator is never used again unless making sure its working properly26.Problems

7、and ComplicationsHigh PIPPneumothorax, hemothorax, or hydropneumothoraxAirway occlusionBronchospasmIncreased accumulation of condensate in the ventilator circuit tubingMain-stem intubationWorsening pulmonary edemaDevelopment of gas trapping with auto-PEEP27.Problems and ComplicationsLoss of VtLeakag

8、e: circuit, tube or patientAsynchronous BreathingUnmet respiratory demandsInappropriate setting of ventilationPatients condition worseningHypotensionDue to positive inspiratory pressureIncrease preloadAdministration of dobutamine28.Problems and ComplicationsAuto-PEEPGas trapped of pts due to airway

9、diseases or inadequate expiratory timeAdjust ventilation parameter, increase PEEPBarotrauma or VolutraumaAssociated with high PIP, PEEP, or Pplatsubcutaneous emphysema, pneumoperitoneum, pneumomediastinum, pneumopericardium, air embolism, and pneumothorax Maybe life-threateningReduce inspiratory pre

10、ssure29.Problems and ComplicationsPositive fluid balanceCardiac arrhythmiasAspirationVentilator-Associated Pneumonia (VAP)Upper gastrointestinal hemorrhageAcid-base complicationsOxygen toxicity30.Weaning from Mechanical VentilationGradual withdrawal of mechanical ventilatory support, depending on th

11、e condition of the patient and on the status of the cardiovascular and respiratory systems MethodsSIMVT-tubePSVProtocol-guided weaning is safe and successful31.ExtubationShould be performed early in the dayPatient educated about the necessity of extubation, the need of cough, and the possibility of

12、reintubationExtubated after the cuff is deflated completelyEncourage the patient for cough and deep breathing, and vital sign should be moniteredExtubation should not be reattempted for 24 to 72 hours after reintubation32.SHOCK33.General PrinciplesOxygen DeliveryBlood FlowTissue HypoxiaOrgan Malfuct

13、ionCellular MetabolismOliguriaUnconsciousPulse34.General PrinciplesSurvival of ShockFluid AdministraionDegree of Organ DysfunctionReversal of Etiologic Process35.ClassificationHemodynamicHypovolemicBleedingMass fluid lossCardiogenicMyocarditisAMICardiomyo-pathyObstructivePericardial TamponadePulmona

14、ry EmbolismDistributiveSepticAllergicNeurogenic36.Hemodynamic patternsType of ShockCISVRPVRSvO2RAPRVPPAPPAOPCardiogenicNHypovolemicNDistributiveN-NN-N-N-N-N-Obstructive-NN-N-37.Cardiogenic ShockMostly followed by acute myocardial infarction (AMI) due to pump failureBP60mmHgCO18mmHgSVRHypoperfusion38

15、.Cardiogenic ShockCertain ConcernPaO260mmHgHct30%Non-invasive or invasive ventilation Necessary fluid managementPharmacological treatmentInotropes and vasopressorsVasodilators not used in severe hypotensive pts.DOPAMINE used as the first-line drug (BP60mmHg)An PAC maybe help for inotropes and fluid

16、infusion39.Cardiogenic ShockMechanically Circulatory Assist DevicesIn pts. not respond to medical therapyIABP is controlled electronically for synchronizing with the pts ECGDefinitive treatment must be considered including non-invasive or invasive procedures40.Septic Shock41.Septic ShockSIRSSEPSISSE

17、VERE SEPSISSEPTIC SHOCKFLUID MANAGEMENTINFECTION CONTROLANTIMICROBIAL THERAPYGOAL42.Septic Shock Protocol43.Resuscitative PrinciplesFluid ResuscitationInitial IV fluid challengeThe amount of fluid based on clinical parameters Arterial BP, Urine Output, Cardiac filling pressure, COCrystalloid fluid s

18、olutions prefer to colloid fluidHematocrits of 20% to 25% for the young, and 30% for the older44.Resuscitative PrinciplesVesopressors and inotropesDopamine10mcg/kg/minincrease BPDobutamineEpinephrineNorepinephrineVasopressinMilrinone45.Hemodynamic MonitoringPulmonary artery catheterization46.Pulmona

19、ry Artery CatheterizationIndicationAllows to measure intravascualr and intracardiac pressure (CVP, RAP, PAP, PAWP), CO, PvO2Differentiate cardiogenic or noncardiogenic pulmonary edemaIdentify the etiology of shockEvaluate acute renal failure or unexplained acidosisEvaluate cardiac disordersMonitor high-risk surgical patients in the perioperative setting47.Pulmonary Artery CatheterizationMethod48.Interpretation of Hemodynamic Parame