外科重症监测治疗

Intensivecare

外科重症监测治疗

5/8/20241外科重症监测治疗WhatisICU?Anintensivecareunit(ICU)isaspeciallystaffedandequippedhospitalwarddedicatedtothemanagementofpatientswithlife-threateningillnesses,injuriesorcomplications.重症监护病房(intensivecareunit,ICU)是将疑难危重患者集中监测治疗的单位。5/8/20242外科重症监测治疗HistoryofICUICUdevelopedfromthepoliomyelitis脊髓灰质炎epidemicintheearly1950s,whentheuseoflong-termartificialventilationresultedinreducedmortality.Mortalityofpolioepidemic87%Droppedto27%bytheuseofanesthesiamachinesforventilationofpts1952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。5/8/20243外科重症监测治疗5/8/20244外科重症监测治疗5/8/20245外科重症监测治疗TypeofICUpatientsTerminalillnessorirreversibleTerminalcancerPermanentbraindamageInfectiousdisease?SARS√--managementofmechanicallyventilatedsevereacuterespiratorysyndrome(SARS)patientsintheisolationintensivecareunit(ICU)--successful×5/8/20246外科重症监测治疗costICUisgenerallythemostexpensive,technologicallyadvancedandresourceintensiveareaofmedicalcare.IntheUnitedStatesestimatesofthe2000expenditureforcriticalcaremedicinerangedfromUS$15-55billionaccountingforabout0.5%ofGDPandabout13%ofnationalhealthcareexpenditure(Halpern,2004).5/8/20247外科重症监测治疗GerneralICUward

5/8/20248外科重症监测治疗ICUequipment监测设备monitoringequipment

: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、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。5/8/20249外科重症监测治疗监护仪心功能监测系统5/8/202410外科重症监测治疗心电图机5/8/202411外科重症监测治疗便携式血气电解质肾功检验仪5/8/202412外科重症监测治疗铁肺—重症监护病房的最早尝试5/8/202413外科重症监测治疗呼吸机5/8/202414外科重症监测治疗Defibrillator除颤器5/8/202415外科重症监测治疗制氧机PulseOxymetry血氧饱和仪5/8/202416外科重症监测治疗ICU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病(甲亢、肾上腺、垂体危象)5/8/202417外科重症监测治疗WhatdowedoinICU?monitoringECGheartrate,rhythm,ischemiaBloodpressure

non-invasiveinvasivearterial,centralvenous,pulmonaryarteryHemodynamicmeasurement

cardiacoutputPulseoxymetryandcapnographyIntracranial,intraabdominalpressureManyotherselectrolyte,CNS5/8/202418外科重症监测治疗WhatdowedoinICU?--TreatmentHemodynamicsupport-inotropeandvasoactivemedicationMechanicalventilationOrgansupport(eg.dialysis)SedationandanalgesiaTreatmentofunderlyingillnessesEnteral/parenteralnutrition5/8/202419外科重症监测治疗Whyarescoringsystemsneeded?Scoringsystemscanprovide:-DefiningpopulationofcriticallyillptsAtoolforcomparativeauditAmechanismtodecideresourceallocationAnaidfortheclinicalmanagementofpatients5/8/202420外科重症监测治疗“It’smoreimportanttoknowwhatsortofpersonthisdiseasehas,thanwhatsortofdiseasethispersonhas.”

WilliamOsler1849-19195/8/202421外科重症监测治疗History1953–VirginiaApgar1974–GlasgowComaScaleAPACHE&SAPS–physiologicallybasedclassificationsystemsGeneralseverityscoresAimatstratifyingpatientsbasedontheirseverity1985–1993:generaloutcomepredictionmodels1991–APACHEIII1993–SAPSII2005–SAPSIII2006–APACHEIVDuringprocessofevolutionofmodels,mainprognosticdeterminantsofoutcomechanged5/8/202422外科重症监测治疗ScoringSystemThemostcommonlyutilizedscoringsystemsaretheAPACHE(acutephysiologyandchronichealthevaluation)system,theMPM(mortalityprobabilitymodel),theSAPS(simplifiedacutephysiologyscore)system.Thesewerealldesignedtopredictoutcomesincriticalillnessanduseseverity-of-illnessscoringsystemswithcommonvariables.Theseincludeage;vitalsigns;assessmentsofrespiratory,renal,andneurologicfunction;andanevaluationofchronicmedicalillnesses

5/8/202423外科重症监测治疗APACHEWilliamKnausInitially34physiologicalvariables1985–APACHEII12variablesAPACHEIIallowsprobabilityofdeathbeforehospitaldischargetobeestimatedStandardisedmortalityratio5/8/202424外科重症监测治疗AssessmentofSeverityofIllness--HistoryAPACHE&SAPS–physiologicallybasedclassificationsystemsGeneralseverityscoresAimatstratifyingpatientsbasedontheirseverity1985–1993:generaloutcomepredictionmodels1991–APACHEIII1993–SAPSII2005–SAPSIII2006–APACHEIVDuringprocessofevolutionofmodels,mainprognosticdeterminantsofoutcomechanged5/8/202425外科重症监测治疗APACHE--acutephysiologyandchronichealthevaluationWilliamKnaus1985–APACHEII12variablesTheAPACHEIIsystemisthemostcommonlyusedseverity-of-illnessscoringsysteminNorthAmerica.Age,typeofICUadmission(afterelectivesurgeryvs.nonsurgicalorafteremergencysurgery),achronichealthproblemscore,and12physiologicvariables(themostseverelyabnormalofeachinthefirst24hofICUadmission)areusedtoderiveascore.APACHEIIallowsprobabilityofdeathbeforehospitaldischargetobeestimatedStandardisedmortalityratio5/8/202426外科重症监测治疗APACHEacutephysiologyandchronichealthevaluationAPACHEⅡ0～71

.Morerecently,theAPACHEIIIscoringsystemhasbeenreleased.ThisscoringsystemissimilartoAPACHEII,inthatitisbaseduponage,physiologicabnormalities,andchronicmedicalcomorbidities.Thedatabasefromwhichthisscorewasderivedislarger

APACHEⅢ0～299,Tab14-1intextbook5/8/202427外科重症监测治疗APACHEIIscore=(acutephysiologyscore)+(agepoints)+(chronichealthpoints)Scoresrangefrom0–71Scoreriskofhospitaldeath5/8/202428外科重症监测治疗5/8/202429外科重症监测治疗5/8/202430外科重症监测治疗SAPS—SimplifiedAcutePhysiologyScore17variablesTheSAPSIIscore,usedmorefrequentlyinEurope,wasderivedinamannersimilartotheAPACHEscores.

LeGallreducedformer34-variableAPACHEscoreto14parametersThisscoreisnotdiseasespecificbutratherincorporatesthreeunderlyingdiseasevariables(AIDS,metastaticcancer,andhematologicmalignancy).

专科评分神经系统Glasgowcomascore(GCS)*心脏功能Goldman肝硬化Child-Turcotte

烧伤指数5/8/202431外科重症监测治疗5/8/202432外科重症监测治疗5/8/202433外科重症监测治疗MPM—MortlityprobabilitymodelMPM-Ⅰ1985MPM-Ⅱ1993MPM0，MPM24，MPM48

TheMPMcanbeusedtocalculateadirectprobabilityofdeathinpatientsadmittedtotheICUSeverity-of-illnessscoringsystemssufferfromtheproblemofinabilitytopredictsurvivalinindividualpatients.Thesetoolsshouldbeusedasimportantdatatocomplementclinicalbedsidedecision-making.5/8/202434外科重症监测治疗MPM(MortalityPredictionModels)DevelopedbyStanleyLemeshowUsesdatacollectedduringfirsthourofICUadmission;24hours;72hoursSeriesoftrue/falsequestionsWeightedaccordingtotheirindividualcontributiontomortality5/8/202435外科重症监测治疗MonitoringofRespiratoryfunction床旁观察既简单又实用。general:ConsciousnessRespiratorymovements，Respiratoryrate、apnea呼吸音。mucous5/8/202436外科重症监测治疗呼吸运动的观察呼吸频率(RR)AdultRR10-18beat/min每分钟肺泡通气量(minuteventilation,MV

MV)=[tidalvolume(VT)－deadvolume(VD)]×RR5/8/202437外科重症监测治疗呼吸功能测定肺容量监测—反映静态通气功能潮气量(tidalvolume,VT)补吸气量(inspiratoryreservevolume,IRV)深吸气量(inspiratorycapacity,IC)补呼气量(expiratoryreservevolume,ERV)残气量(residualvolume,RV)功能残气量(functionalresidualcapacity,FRC)肺活量(vitalcapacity,VC)肺总量(totallungcapacity,TLC)Normal--->80%predictedvalue5/8/202438外科重症监测治疗Oxygentherapy氧治疗Oxygentherapyistheadministrationofoxygenasamedicalintervention,whichcanbeforavarietyofpurposesinbothchronicandacutepatientcare.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:

CardiacandresparrestRespfailuretypeⅠ,typeⅡCardiacfailureorMIShockIncreasemetabolicdemandsPost-operativestatesCarbonmonoxidepoisoning5/8/202439外科重症监测治疗Oxygentherapy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。5/8/202440外科重症监测治疗MechanicalVentilation机械通气:人工气道Inmedicine,mechanicalventilationisamethodtomechanicallyassistorreplacespontaneousbreathing

Artificialairway:endotrachealintubationortracheostomy气管插管或气管切开。5/8/202441外科重症监测治疗IndicationofmechanicalventilationAcutelunginjury(includingARDS,trauma)ApneawithrespiratoryarrestChronicobstructivepulmonarydisease(COPD)Acuterespiratoryacidosiswithpartialpressureofcarbondioxide(pCO2)>50mmHgandpH<7.25,whichmaybeduetoparalysisofthediaphragmduetoGuillain-Barrésyndrome,MyastheniaGravis,spinalcordinjury,ortheeffectofanaestheticandmusclerelaxantdrugsIncreasedworkofbreathingasevidencedbysignificanttachypnea,retractions,andotherphysicalsignsofrespiratorydistressHypoxemiawitharterialpartialpressureofoxygen(PaO2)withsupplementalfractionofinspiredoxygen(FiO2)<55

mmHgHypotensionincludingsepsis,shock,congestiveheartfailure

Neurologicaldiseases5/8/202442外科重症监测治疗TypesofventilatorsVentilationcanbedeliveredvia:Hand-controlledventilationsuchas:

Bagvalvemask

Continuous-floworAnaesthesia(orT-piece)bag

Amechanicalventilator.Typesofmechanicalventilatorsinclude:Transportventilators.Theseventilatorsaresmall,morerugged,andcanbepoweredpneumaticallyorviaACorDCpowersources.ICUventilators..NICUventilators.Designedwiththepretermneonateinmind,.PAPventilators.theseventilatorsarespecificallydesignedfornon-invasiveventilation.thisincludesventilatorsforuseathome,inordertotreatsleepapnea5/8/202443外科重症监测治疗MechanicalVentilation:modesControlmodeventilation(CMV):控制通气Asist/controlmodeventilation(A/CMV):辅助/控制通气Intermittentmandatoryventilation(IMV):间歇指令通气SynchronizedIntermittentmandatoryventilation(SIMV):同步间歇指令通气Pressuresupportventilation(PSV):压力支持通气Positiveendrespiratorypressure(PEEP):呼气末正压通气WeaningfromMechanicalVentilat呼吸机的撤离:临床综合判断、撤机生理参数、撤机观察呼吸频率、节律、深度、呼吸方式；监测心率、血压、有无出汗、紫绀、呼吸窘迫。5/8/202444外科重症监测治疗arterialblood-gasanalysis(ABG)Evaluationofrespiratorygasexchangeisroutineincriticalillness.The"goldstandard"remainsarterialblood-gasanalysis,wherepH,partialpressuresofO2andCO2,andO2saturationaremeasureddirectly.Witharterialblood-gasanalysis,thetwomainfunctionsofthelung—oxygenationofarterialbloodandeliminationofCO2—canbedirectlyassessed.Importantly,thebloodpH,whichhasaprofoundeffectonthedrivetobreathe,canbeassessedonlybysamplingofarterialblood.Thoughsamplingofarterialbloodisgenerallysafe,itmaybepainfulandcannotprovidecontinuousinformationforcliniciansroutinely.Giventheselimitations,noninvasivemonitoringofrespiratoryfunctionisoftenemployedinthecriticalcaresetting.5/8/202445外科重症监测治疗Arterialblood-gasanalysispH:7.35～7.45PaO2

:12～13.3kPa(90~100mmHg)PaCO2:4.7～6kPa(35~45mmHg)SaO2(SAT):正常值96~100%CaO2(动脉血O2含量):正常值16~20ml/dl实际HCO-3(AB)和标准HCO-3(SB):22～27mmol/L(24)AB>SB:呼酸AB<SB: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45～55mmol/L。血浆阴离子间隙(AGp):正常值7-16mmol/LTCO2(CO2总量)正常值28-353mmol/L5/8/202446外科重症监测治疗PulseOximetry

脉搏血氧饱和度(SpO2)PulseOximetryisthemostcommonlyutilizednoninvasivemonitorofrespiratoryfunction.Thistechniquetakesadvantageofdifferencesintheabsorptivepropertiesofoxygenatedanddeoxygenatedhemoglobin.脉搏血氧饱和度是通过脉搏血氧监测仪(pulseoximeter，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95～100%。

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。5/8/202447外科重症监测治疗expiratoryC02monitoring，PETC02呼气末C02监测PETC02end-tidalCO2

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3.5％～5％)，其与PaC02的相关性良好，可据此间接估计PaC02。正常值35～45mmHg5/8/202448外科重症监测治疗Hemodynamicmonitoring血流动力学监测Hemodynamicmeasurementsareimportanttoestablishaprecisediagnosis,determineapropriatetherapy.Monitormaybecategorizedinto

Non-invasive

electrocardiogram(ECG)non-invasivebloodpressure(NIBP)urineoutputechocardiographyandDopplerInvasive

ArterialbloodpressurecentralvenouspressurePulmonaryarterycatheter,Swan-Ganzcatheter漂浮导管

5/8/202449外科重症监测治疗Electrocardiogram,ECG心电图ECGdiagnoseischemia,MIarrhythmia

monitoringfunctionofpacer5/8/202450外科重症监测治疗动脉压(NIBP,ABP)Non-invasivebloodpressuredevicesuseanoscillotonometrictechnique.袖带测压、自动无创测压(NIBP)Theycangiveerroneousresultinptswitharrhythmia(Af)。Invasive:

Arterialbloodpressureuseanarterialcatheterandtranducertechnique动脉穿刺插管直接测压meanarterialpresssure,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8~13.3kPa。MAP=DBp＋1/3(SBp－DBp)＝CO×SVR。5/8/202451外科重症监测治疗centralvenouspressure,CVP

中心静脉压CVPcanbemonitoredusingcathetersinsertedviatheinternaljugular,subclavianandfemoralveins.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；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。5/8/202452外科重症监测治疗5/8/202453外科重症监测治疗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。5/8/202454外科重症监测治疗Swan-Ganzcatheter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: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)。5/8/202455外科重症监测治疗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:pulmonaryarterycapillarywedgepressure临床意义估价左右心室功能区别心源性和非心源性肺水肿指导治疗选择最佳PEEP确定漂浮导管位置5/8/202456外科重症监测治疗肺动脉楔压(pulmonaryaorticwedgepressure,PAWP)正常值为0.8~1.6kPa。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0.67~1.87kPa。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(meanpulmonaryarterialpresssure,MPAP)正常值1.47~2.0kPa。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。5/8/202457外科重症监测治疗Swan－Ganz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。5/8/202458外科重症监测治疗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5/8/202459外科重症监测治疗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5/8/202460外科重症监测治疗心输出量(cardiacoutput,CO)正常值4~8L/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5/8/202461外科重症监测治疗Hemodynamicmonitoring每搏排出量(strokevolume,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60~90m