外科重症监测治疗课件

1、Intensive care外科重症监测治疗Intensive care外科重症监测治疗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. 重症监护病房(intensive care unit, ICU)是将疑难危重患者集中监测治疗的单位。What is ICHistor

2、y of ICUICU developed from the poliomyelitis脊髓灰质炎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 pts1952年夏，丹麦哥本哈根脊灰流行，造成延髓性呼吸麻痹，多死于呼吸衰竭。病人被集

3、中，通过气管切开保持呼吸道畅通并进行肺部人工通气，使死亡率显著下降。治疗效果的改善，使有关医生认识到加强监护和治疗的重要性。History of外科重症监测治疗课件外科重症监测治疗课件Type of ICU patientsTerminal illness or irreversibleTerminal cancerPermanent brain damageInfectious disease? SARS-management of mechanically ventilated severe acute respiratory syndrome (SARS) patients in the

4、 isolation intensive care unit (ICU)-successful Type of ICU patientsTerminal icostICU is generally the most expensive, technologically advanced and resource intensive area of medical care. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion

5、accounting for about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004). costICU is generally the most Gerneral ICU ward Gerneral IICU equipment监测设备monitoring equipment :多功能生命体征监测仪、呼吸功能监测仪、心脏血流动力学监测仪、脉搏血氧饱和度仪、血气分析仪、心电图机。监护仪器按系统或器官功能参数分门排列，左列显示功能参数，右列为治疗参数。治疗设备:呼吸机、除颤器、输液泵、

6、注射泵、起搏器、主动脉内球囊反搏器、血液净化仪、麻醉机、中心供氧、中心吸引装置、体外膜式肺氧合(ECMO)装 。ICU equipm监护仪心功能监测系统监护仪心功能监测系统心电图机心电图机便携式血气电解质肾功检验仪便携式血气电解质肾功铁肺重症监护病房的最早尝试铁肺重症监护病房的呼吸机呼吸机Defibrillator 除颤器Defibrilla制氧机Pulse Oxymetry血氧饱和仪制氧机Pulse OICU收治对象-外科重危病人创伤、大手术器官移植后监测循环失代偿者有呼吸衰竭可能，需呼吸器治疗者严重水电解质紊乱，酸碱平衡失调者麻醉意外、心肺复苏后病人单个或多个器官功能不全者严重代谢障碍性疾

7、病(甲亢、肾上腺、垂体危象)ICU收治对象-外科What do we do in ICU?monitoringECG heart rate, rhythm, ischemiaBlood pressure non-invasive invasive arterial,central venous, pulmonary arteryHemodynamic measurement cardiac outputPulse oxymetry and capnographyIntracranial,intraabdominal pressureMany others electrolyte, CNSWha

8、t do weWhat do we do in ICU?-TreatmentHemodynamic support -inotrope and vasoactive medicationMechanical ventilationOrgan support (eg.dialysis) Sedation and analgesiaTreatment of underlying illnessesEnteral/parenteral nutritionWhat do we do in ICU?-TreatmeWhy are scoring systems needed?Scoring system

9、s can provide:-Defining population of critically ill ptsA tool for comparative audit A mechanism to decide resource allocationAn aid for the clinical management of patientsWhy are scoring systems needed“Its more important to know what sort of person this disease has, than what sort of disease this p

10、erson has.”William Osler 1849-1919“Its more important to know wHistory1953 Virginia Apgar1974 Glasgow Coma ScaleAPACHE & SAPS physiologically based classification systemsGeneral severity scoresAim at stratifying patients based on their severity1985 1993: general outcome prediction models1991 APACHE

11、III1993 SAPS II2005 SAPS III2006 APACHE IVDuring process of evolution of models, main prognostic determinants of outcome changedHistory1953 Virginia ApgarScoring SystemThe most commonly utilized scoring systems are the APACHE (acute physiology and chronic health evaluation) system, the MPM (mortalit

12、y probability model), the SAPS (simplified acute physiology score) system. These were all designed to predict outcomes in critical illness and use severity-of-illness scoring systems with common variables. These include age; vital signs; assessments of respiratory, renal, and neurologic function; an

13、d an evaluation of chronic medical illnesses Scoring SystemThe most commonlAPACHEWilliam KnausInitially 34 physiological variables1985 APACHE II 12 variablesAPACHE II allows probability of death before hospital discharge to be estimatedStandardised mortality ratio APACHEWilliam KnausAssessment of Se

14、verity of Illness-HistoryAPACHE & SAPS physiologically based classification systemsGeneral severity scoresAim at stratifying patients based on their severity1985 1993: general outcome prediction models1991 APACHE III1993 SAPS II2005 SAPS III2006 APACHE IVDuring process of evolution of models, main p

15、rognostic determinants of outcome changedAssessment of Severity of IllnAPACHE- acute physiology and chronic health evaluation William Knaus 1985 APACHE II 12 variablesThe APACHE II system is the most commonly used severity-of-illness scoring system in North America. Age, type of ICU admission (after

16、 elective surgery vs. nonsurgical or after emergency surgery), a chronic health problem score, and 12 physiologic variables (the most severely abnormal of each in the first 24 h of ICU admission) are used to derive a score. APACHE II allows probability of death before hospital discharge to be estima

17、tedStandardised mortality ratio APACHE- acute physiology and APACHEacute physiology and chronic health evaluation APACHE 071 . More recently, the APACHE III scoring system has been released. This scoring system is similar to APACHE II, in that it is based upon age, physiologic abnormalities, and chr

18、onic medical comorbidities. The database from which this score was derived is larger APACHE 0299, Tab 14-1 in textbookAPACHEacute physiology and chrAPACHE II score = (acute physiology score) + (age points) + (chronic health points)Scores range from 0 71 Score risk of hospital deathAPACHE II score =

19、(acute physi外科重症监测治疗课件外科重症监测治疗课件SAPSSimplified Acute Physiology Score17 variables The SAPS II score, used more frequently in Europe, was derived in a manner similar to the APACHE scores. Le Gall reduced former 34-variable APACHE score to 14 parameters This score is not disease specific but rather in

20、corporates three underlying disease variables (AIDS, metastatic cancer, and hematologic malignancy). 专科评分 神经系统 Glasgow coma score(GCS)* 心脏功能 Goldman 肝硬化 Child-Turcotte 烧伤指数SAPSSimplified Acute Physiolo外科重症监测治疗课件外科重症监测治疗课件MPMMortlity probability modelMPM- 1985MPM- 1993MPM0，MPM24，MPM48 The MPM can be

21、used to calculate a direct probability of death in patients admitted to the ICU Severity-of-illness scoring systems suffer from the problem of inability to predict survival in individual patients. These tools should be used as important data to complement clinical bedside decision-making. MPMMortlit

22、y probability modelMPM (Mortality Prediction Models)Developed by Stanley LemeshowUses data collected during first hour of ICU admission; 24 hours; 72 hoursSeries of true/false questionsWeighted according to their individual contribution to mortalityMPM (Mortality Prediction ModeMonitoring of Respira

23、tory function床旁观察既简单又实用。general:Consciousness Respiratory movements， Respiratory rate、apnea呼吸音。mucousMonitoring呼吸运动的观察呼吸频率(RR)Adult RR 10-18 beat/min每分钟肺泡通气量(minute ventilation,MV MV)=tidal volume(VT)dead volume(VD)RR呼吸运动的观察呼吸频呼吸功能测定肺容量监测反映静态通气功能潮气量(tidal volume,VT)补吸气量(inspiratory reserve volume,IR

24、V)深吸气量(inspiratory capacity,IC)补呼气量(expiratory reserve volume,ERV)残气量(residual volume,RV)功能残气量(functional residual capacity,FRC)肺活量(vital capacity,VC)肺总量(total lung capacity,TLC)Normal- 80% predicted value呼吸功能测定肺容量监Oxygen therapy 氧治疗Oxygen therapy is the administration of oxygen as a medical interve

25、ntion, which can be for a variety of purposes in both chronic and acute patient care. 氧治疗是通过吸入不同浓度的氧，使吸入氧浓度(F1O2)和肺泡气的氧分压(PAO2)升高，以升高动脉血氧分压(PaO2)，达到缓解或纠正低氧血症的目的。Indication: Cardiac and resp arrestResp failure type,typeCardiac failure or MIShockIncrease metabolic demandsPost-operative statesCarbon mo

26、noxide poisoningOxygen theOxygen therapy氧疗方法:高流量系统，如文图里(Venturi)面罩(F1O2稳定)。低流量系统，如鼻导管吸氧、面罩吸氧、带贮气囊面罩吸氧等(F1O2不稳定) 。氧疗护理:加强监测、预防交叉感染、湿化吸入气体、注意防火和安全。Oxygen theMechanical Ventilation 机械通气:人工气道In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing Artificia

27、l airway: endotracheal intubation or tracheostomy气管插管或气管切开。MechanicalIndication of mechanical ventilationAcute lung injury (including ARDS, trauma) Apnea with respiratory arrestChronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) 50 m

28、mHg 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 physical signs of res

29、piratory distress Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of inspired oxygen (FiO2) SB:呼酸 ABSB:呼碱:AB=SB 正常。两者均增加:失代偿性代碱；两者均降低:失代偿性代酸碱剩余(BE):-3+3mmol/L缓冲液(BB):包括HCO-3和P-r。正常值4555mmol/L。血浆阴离子间隙(AGp):正常值7-16mmol/LTCO2(CO2总量)正常值28-35 3mmol/LArterial bPulse Ox

30、imetry脉搏血氧饱和度 (SpO2)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. 脉搏血氧饱和度是通过脉搏血氧监测仪(pulse oximeter ，POM)利用红外线测定末梢组织中氧合血红蛋白含量，间接测得SpO2。正常值9

31、5100%。 SpO2监测的影响因素正铁血红蛋白(MetHb)与碳氧血红蛋白(COHb)愈高其SpO2测值愈低。体温因素:低体温致SpO2降低。低血压肢端末梢循环不良:当50mmHg，SpO2下降。测定部位:测定部位其皮肤组织愈厚，精确度愈低。皮肤色素:色素沉着、指甲染料SpO2偏低。血管收缩剂:使SpO2测值下降。Pulse Oximexpiratory C02 monitoring，PETC02 呼气末C02监测PETC02 end-tidal CO2 呼气末C02监测主要根据红外线原理、质谱原理、拉曼散射原理和图声分光原理而设计，主要测定呼气末二氧化碳。 noninvasive呼气末二氧

32、化碳浓度(EtC02) 呼出气二氧化碳浓度在呼气末最高，接近肺泡气水平(约3.55)，其与PaC02的相关性良好，可据此间接估计PaC02。正常值3545mmHgexpiratoryHemodynamic monitoring 血流动力学监测Hemodynamicmeasurements are important to establish a precise diagnosis,determine apropriate therapy.Monitor may be categorized into Non-invasive electrocardiogram(ECG) non-invasiv

33、e blood pressure (NIBP) urine output echocardiography and DopplerInvasive Arterial blood pressure central venous pressure Pulmonary artery catheter, Swan-Ganz catheter漂浮导管 HemodynamiElectrocardiogram,ECG心电图ECG diagnose ischemia, MI arrhythmia monitoring function of pacerElectrocar动脉压(NIBP, ABP)Non-i

34、nvasive blood pressure devices use an oscillotonometric technique. 袖带测压、自动无创测压(NIBP)They can give erroneous result in pts with arrhythmia(Af)。Invasive: Arterial blood pressure use an arterial catheter and tranducer technique动脉穿刺插管直接测压mean arterial presssure,MAP 平均动脉压是指心动周期的平均血压。能评估左室泵功能、器官和组织血流。正常值8

35、13.3kPa 。 MAP=DBp1/3(SBpDBp)COSVR。动脉压(NIBP, central venous pressure,CVP 中心静脉压CVP can be monitored using catheters inserted via the internal jugular,subclavian and femoral veins. CVP 胸腔内上、下腔静脉或右心房内的压力。是评估血容量、右心前负荷及右心功能的重要指标。正常值为5-12cmH2O 。 CVP过低为血容量不足或静脉回流受阻；CVP过高为输入液体过多或心功能不全。适应症:各类大中手术，尤心胸颅脑手术；各种休克

36、；脱水、失血和血容量不足；心力衰竭；大量静脉输血、输液或静脉高能量营养。central ve外科重症监测治疗课件CVP注意事项注意事项:判断导管插入上、上腔静脉或右房无误。玻璃管零点对第4肋间右心房水平。确保管道内无凝血、空气，管道无扭曲。测压时确保静脉内导管通畅无阻。加强管理，严格无菌操作。并发症:感染、出血和血肿、其它血气胸、血气栓等。CVP注意事项注意事Swan-Ganz catheter 漂浮导管Swan-Ganz导管用聚氯乙烯材料推压而成，不透X线。成人有5F、6F、7F、7.5F，全长110cm，每10cm有黑色环形标记。儿童有4F和5F，全长60cm。四腔Swan-Ganz导管:

37、端孔为主腔开口用于监测肺动脉压和采集血标本。距管端30cm处有一侧孔, 用于监测右房压、CVP、CO和输液。热敏计位于距管端4cm处，用于感知热阻抗的变化，尾端与计算机相连。端孔1-2mm处有一气囊与尾端的注射器相连可注入气体(1.25-1.5ml)。Swan-Ganz Swan-Ganz原理心室舒张末期，主动脉瓣和肺动脉瓣均关闭，而二尖瓣开放形成液流内腔。心室舒张末压(LVDEP)=肺动脉舒张压(PADP)=肺小动脉楔压(PAWP)=肺毛细血管楔压(PCWP) 。PCWP:pulmonary artery capillary wedge pressure临床意义估价左右心室功能区别心源性和非

38、心源性肺水肿指导治疗选择最佳PEEP确定漂浮导管位置Swan-Ganz原肺动脉楔压(pulmonary aortic wedge pressure,PAWP) 正常值为0.81.6kPa。可判定左心室功能，反映血容量是否充足。2.4kPa:左心功能不全、急性心源性肺水肿；2.4kPa:急性肺损伤、ARDS。肺毛细血管楔压(PCWP) 正常值0.671.87kPa。反映左心房平均压及左心室舒张末期压。 0.8kPa:体循环血容量不足；2.4kPa:即将或已出现肺淤血； 4kPa: 肺水肿。平均肺动脉压(mean pulmonary arterial presssure ,MPAP) 正常值1.4

39、72.0kPa。MPAP升高见于肺血流量增加、肺血管阻力升高、二尖瓣狭窄、左心功不全。MPAP降低见于肺动脉瓣狭窄。肺动脉楔压(pulmSwanGanz导管适应证ARDS左心衰循环功能不稳定急性心肌梗塞区分心源性和非心源性肺水肿心血管手术肺栓塞严重创伤，各类休克，嗜铬细胞瘤等。SwanGanz导床边盲目置管就是通过导管在某一心脏内的压力波形来间接判断其位置所在，需同步心电图监测。波形变化依次为右房，右室，肺动脉和肺毛压。漂浮导管测得右房、右室、肺动脉及肺毛细血管楔压床边盲目置管就是通过Swan-Ganz导管并发症心律失常气囊破裂肺梗塞肺动脉破裂和出血导管打结血栓形成心包填塞感染Swan-Gan

40、z导心输出量(cardiac output,CO)正常值48L/min。指每分钟心脏的射血量，反映左心功能。CO降低见于回心血量减少、心脏流出道阻力增加、心肌收缩力减弱。经Swan-Ganz导管热稀释法测定心排血量，脉动脉与右心房的血液温度差值与时间、流量有关，据此即可计算出心排出量。心功能曲线心输出量(cardiHemodynamic monitoring每搏排出量(stroke volume,SV)指一次心搏由一侧心室射出的血量。成年人安静、平卧时为6090ml。SV与心肌收缩力、心脏前负荷、后负荷有关。心脏指数(CI) 正常值2.84.2L/min.m2。CI2.5提示心衰；CI1.8为心源性休克。体循环阻力指数(system vascular resistanc