《急危重症的监护》PPT课件.ppt

1、急危重症的监护 Intensive Care/Critical Care,方向韶 中山大学附属第二医院 急诊科,1,急危重症监护,将危重患者、先进设备、掌握设备和技术的优秀医务人员同时集中于一体，充分发挥有经验和专业知识的医务人员的能力，也充分利用有限高级贵重设备，利用仪器、设备和技术方法，更加频繁进行快速有效的生命、器官检查或者连续监测，及必要的功能支持、加强的照料护理。目的是为迅速掌握患者病情及其变化情况，挽救患者生命和器官功能。,2,History of Critical Care,Critical care evolved from an historical recognition

2、that the needs of patients with acute, life-threatening illness or injury could be better treated if they were grouped into specific areas of the hospital. Nurses have long recognized that very sick patients receive more attention if they are located near the nursing station.,3,History of Critical C

3、are,Florence Nightingale wrote about the advantages of establishing a separate area of the hospital for patients recovering from surgery,4,In 1927, the first hospital premature-born infant care center was established at the Sarah Morris Hospital in Chicago During World War II, shock wards were estab

4、lished to resuscitate and care for soldiers injured in battle or undergoing surgery The nursing shortage, which followed World War II, forced the grouping of postoperative patients in recovery rooms to ensure attentive care,5,In 1947-1948, the polio (poliomyelitis) epidemic raged through Europe and

5、the United States, resulting in a breakthrough in the treatment of patients dying from respiratory paralysis. Patients with respiratory paralysis and/or suffering from acute circulatory failure required intensive nursing care Bjorn Aage Ibsen (1915-2007) became involved in the poliomyelitis outbreak

6、 in Denmark; Patients were managed in 3 special 35 bed areas; In this fashion, mortality declined from 90% to around 25%.,6,During the 1950s, the development of mechanical ventilation led to the organization of respiratory intensive care units (ICUs) in many European and American hospitals. Created

7、in 1958, Johns Hopkins Bayview Medical Centerbecame the first multidisciplinary intensive care unit (ICU) in the United States.,7,By the late 1960s, most United States hospitals had at least one ICU. In 1970, an organization committed to meeting the needs of critical care patients: the Society of Cr

8、itical Care Medicine (SCCM). Between 1990 and the present, critical care significantly reduced in-hospital time as well as costs incurred by patients with diseases such as cerebrovascular insufficiency and respiratory failure.,8,Landmark of History of Critical Care,1950 iron lungs (polio and brain s

9、tem paralysis) 1958 Peter Safar: the first multidisciplinary first Intensive Care Unit at Baltimore City Hospital 1970 Swan Ganz catheter Transplantation,9,Landmark of History of Critical Care,World War II, shock wards,10,Landmark of History of Critical Care,1950 iron lungs (polio and brain stem par

10、alysis),11,Polio Survivors in Iron Lung,12,Landmark of History of Critical Care,1958 Peter Safar: the first multidisciplinary intensive care unit first Intensive Care Unit at Baltimore City Hospital Father of CPR: combined the A (Airway) and the B (Breathing) of CPR with the C (chest compressions),1

11、3,Landmark of History of Critical Care,1970 Jeremy Swan and William Ganz: Swan-Ganz catheter (pulmonary artery catheterization ),14,ICU of the Second affiliated hospital,15,ICU of the Second affiliated hospital,16,急诊危重症监护地位的争议,17,Specialized types of ICUs include,Emergency Intensive Care Unit，EICU C

12、oronary Care Unit (CCU) for heart disease Medical Intensive Care Unit (MICU) Surgical Intensive Care Unit (SICU) Pediatric Intensive Care Unit (PICU) for children Neuroscience Critical Care Unit (NCCU) Shock/Trauma Intensive Care Unit (STICU) Neonatal Intensive Care Unit (NICU) for babies,18,急诊重症监护室

13、的定位和发展前景争议和困惑 与“危重医学”学科间的关系 ：“短期医疗行为” 还是“全程治疗 ” EICU也不同于急诊抢救室,19,EICU的位置和基本设置要求,EICU应该位于急诊的抢救区附近，与急诊抢救区直接相通连，要相对安静和独立。 EICU内部环境的设计和布局应该兼顾患者和工作人员的需要，常常将一个封闭的大房间划分为病床监护区、护士站、治疗室和工作室，留置一定空间放置备用的抢救、监护设备和设施。,20,EICU的主要设备,分为监测设备和治疗设备两种： 常用的监测设备有:各种监护仪、心电图机、心脏血液动力学监测设备以及血糖仪、快速血气和生化分析仪等。 常用治疗设备有：输液泵、注射泵、无创和

14、有创呼吸机、除颤器、抢救车、抢救药品和各种护理用具等。,21,multi-parameter monitors,22,Pulse oximeter,23,Blood gas analyzer,24,Medical Ventilator,25,Laryngoscope (Tracheal intubation ),26,27,Hemofiltration,28,Continuous veno-venous hemofiltration (CVVHF),29,Defibrillator,Manual external defibrillator,Automated external defibri

15、llator (AED),30,Intensive Care Monitoring,31,EICU的收治对象,通常主要收治急性中毒、急性危重病、严重慢性病急性发作、严重创伤以及未确诊但有高危因素的患者等几大类。 有时EICU还会接受部分不能马上入院的危重患者先进行抢救和部分专科治疗，当然也难以推辞临终患者和晚期肿瘤患者。,32,EICU的管理要求,封闭式病房 ：优点和缺点 EICU医师 工作制度：三级查房制度和值班制度 护理制度：对护士的技术和应变能力要求高 EICU治疗水准的标准化和规范化,33,四点关键,采用规范的治疗流程； 有一个具有相当权威的、可以处理各种政策和协调各个医务人员工作的有

16、能力领导者； 护士要有相当高的专业水平并掌握重症监护技术和熟练各种医疗设备的使用； 医生和护士有十分精强的协调关系。,34,合理使用监护和支持技术,认识和避免监护设备存在的负面问题 合理掌握监护的指征和使用设备,35,危重症的生命与器官功能监护策略,36,1. 心电参数监护,Detection of arrhythmias Permits monitoring of heart rate Evaluation of pacemaker function Detect myocardial ischemia Electrolyte abnormalities,37,Locations of th

17、e unipolar precordial leads on the body surface,38,Electrocardiography (ECG),39,40,Reminders,Consider potassium derangements in any arrhythmia in the ICU Focus on treating the underlying electrolyte disturbance promptly,41,Torsade de pointes,The ECG reading demonstrates a rapid, polymorphic ventricu

18、lar tachycardia with a characteristic twist of the QRS complex around the isoelectric baseline. It is also associated with a fall in arterial blood pressure, which can produce fainting.,42,Characteristic tracing showing the twisting (blue line) of a torsade de pointes,43,Lead II electrocardiogram sh

19、owing Torsades being shocked by an Implantable cardioverter-defibrillator back to the patients baseline cardiac rhythm.,44,Acute Myocardial Infarction,45,2. 血压监护（ Blood Pressure monitoring ）,Related to both cardiac function and the peripheral circulation Standard and universal for critically ill pat

20、ients BP does not reflect cardiac output (CO) BP can be high with a low CO if vasoconstriction occurs and vice versa,46,Can be measured intermittently with a cuff or continuously with an arterial line An additional use of arterial catheterization is to provide access for arterial blood sampling. Thi

21、s is often indicated in patients who require frequent sampling of blood for arterial blood gases or other blood tests.,47,中心静脉压（central venous pressure ）,Be inserted via the subclavian, internal jugular provide estimates of central venous pressure (CVP) and measurement of central venous oxygen satur

22、ation (ScvO2) CVP reflects the balance between systemic venous return and cardiac output Have difficulty to assess left-sided preload (only secondarily reflects changes in pulmonary venous and left-sided pressures ),48,锁骨下静脉穿刺示意图,49,颈内静脉穿刺示意图,50,视频1,51,中心静脉压与血压之间关系,52,3. 血氧饱和度（ Pulse oximetry ）,Affo

23、rds a noninvasive estimate of arterial oxygen saturation A standard of care in many institutions The reliability of this method may be limited in patients with severe hypoxemia, abnormal arterial pulsations, and hypoperfusion of the site of measurement,53,Clinical Applications,Adjusting inspired oxy

24、gen, during weaning from mechanical ventilation Testing different levels of PEEP, inverse I:E ratio, or other mechanical ventilator adjustments Monitoring during procedures such as bronchoscopy, gastrointestinal endoscopy, cardioversion, hemodialysis,54,4. 肺动脉插管Pulmonary Artery Catheterization,Monit

25、oring CVP Provides information related to left heart filling pressures Allows sampling of pulmonary artery blood for determination of mixed venous oxygen saturation. Thermodilution cardiac output measurements are made using a thermistor-tipped catheter.,55,56,57,pulmonary capillary wedge pressure (P

26、CWP),Estimates left ventricular end-diastolic pressure and thus serves as an estimate of left ventricular preload,58,Clinical Applications,Pressure MeasurementsIn most instances, PCWP is an accurate indicator of left ventricular end-diastolic pressure Mixed Venous Oxygen is an indicator of systemic

27、oxygen utilization. Measuring cardiac output (CO) by thermodilution,视频2,3,59,漂浮导管的进展,混合静脉血氧饱和度（ Svo2）的监测： Svo2是通过改良的7.5或8F 热稀释肺动脉导管作连续静脉血氧饱和度监测。 该导管的主要特点是含有光学纤维，能将光线传至血流，也能将来自血流的光线传出。光源由三个二极管组成，通过其中一根光纤可发射出三种不同波长的红光可变光束，这种光被血流血红蛋白成分吸收、折射，并从第二根光纤反射到光源探测器上，然后转换成电信号，输送到资料处理机上。所计算出的血氧饱和度是5秒内的平均值，每12秒测量一

28、次,60,漂浮导管的进展,连续测定CO： 美国Baxter公司生产的VigilanceVGS1型连续心排血量监测仪，连接其专用的美国Baxter公司生产的744H型六腔Swan-Ganz CCO/Svo2导管。 其原理是从导管热电阻丝向心腔内脉冲式释放一已知的正性热量，在其下游部位即肺动脉内借助热敏电极记录到反应血液温度差的温度-时间变化曲线，根据热稀释原理计算出心输出量。 优点：每隔30-60秒自动测量并显示数据，免去了常用的注射冰盐水的麻烦和由于注射操作不易严格掌握带来的重复性差等缺点。,61,5. 组织灌注的评估,通过对皮肤、温度、尿量、酸中毒、胃粘膜内PH值的改变等监测进行,62,循环

29、与心脏功能支持,对于所有的循环功能不全的患者，治疗的目的是在纠正基础病的同时(如外科止血或消除感染)，尽早恢复向组织输送氧。 循环支持的几个决定因素：前负荷、心肌收缩力和后负荷，以及心率。其措施包括呼吸支持、心脏负荷控制、血容量补充或控制、血管活性药物及正性肌力药物、心输出量管理（如主动脉内球囊反搏术）等。,63,呼吸系统功能监护,64,1. 临床症状体征与呼吸功能基本参数监测,呼吸相关临床症状体征 呼吸频率和深度 呼吸力学监测 呼吸波形及呼吸功监测 肺功能监测 弥散功能监测 呼气末二氧化碳分压,65,2.血气分析,氧分压(PO2)：血浆中物理溶解的氧分子产生的分压力；正常值80-100mmH

30、g。 血氧饱和度(SO2)：血红蛋白实际结合氧量(氧含量)与应结合氧量(氧容量)之比；正常值95-100%。 氧含量：血液实际结合的氧量；等于1.34血红蛋白量氧饱和度,66,二氧化碳分压(PCO2)：血浆中溶解的二氧化碳产生的压力；正常值35-45mmHg。 酸碱度(PH值)：溶液内氢离子浓度的负对数；正常值7.35-7.45。 氧合指数（PaO2/FiO2）：是监测肺换气功能的主要指标，当PaO2/FiO2300mmHg时，为急性呼吸衰竭。,67,碳酸氢离子(HCO3-)：每毫升血浆中含有的HCO3-浓度，即为实际碳酸氢盐(AB)；正常值242mmol/L。受呼吸性、代谢性因素影响。 标准

31、碳酸氢盐(SB)：正常值253mmol/L；反映代谢性因素。,68,缓冲碱(BB)：血液中起缓冲作用的全部碱量；正常值45-55mmol/L。 碱剩余(BE)：正常值3mmol/L；测定代谢性酸碱紊乱的指标。 二氧化碳结合力(CO2CP)：受代谢性、呼吸性两方面影响；正常值22-31mmol/L。,69,3. 胸部影像学检查,胸部X线 超声波检查 胸部CT,70,呼吸功能支持与气道管理,气道管理：开放和畅通呼吸道、祛除气道分泌物和异物、气道湿化 氧气疗法：PaO2保持在8Kpa或者血氧饱和度90 无创呼吸支持：持续正压气道通气(CPAP),71,机械通气支持：,紧急气管插管机械通气：在积极的氧

32、气疗法前提下，仍存在低氧血症(PaO28kPa或SaO290)、存在高碳酸血症甚至意识不清、由于神经肌肉疾患导致肺活量下降等。 通气模式：容量控制通气方式、压力控制通气方式 通气策略：潮气量、呼吸频率、呼气末正压、吸呼气时间比,72,撤机的指征,患者氧合良好，在吸氧浓度8kPa； 能维持CO2分压在正常范围内；可满足断开呼吸机后的呼吸功耗； 神志清楚，反应良好。 撤机方法包括严密监护患者病情下，逐渐增加患者自主呼吸的时间或逐渐降低通气支持的水平。,73,肾功能监护,尿量：监测肾功能最基本、直接的指标，通常记录每小时及24小时尿量 尿液常规检查：尿比重1.020提示肾灌注不足，为肾前性肾功能衰竭

33、；比重1.010的低比重尿则为肾性肾功能衰竭。 血、尿肾脏生化学监测：评价肾小球滤过功能和肾小管重吸收功能 。,74,肾脏支持,评估和纠正呼吸或循环障碍； 处理肾脏功能不全引起的任何威胁生命的情况； 排除尿道梗阻； 确定病因和明确肾功能不全的原因，并立即开始治疗； 了解用药史，适当更改医嘱； 有适应证的患者应及早使用肾脏替代疗法。,75,肾脏替代疗法,无法控制的高血钾症； 对利尿剂无反应的严重水钠潴留； 严重的尿毒症； 严重酸中毒。,76,肝功能监护,血清胆红素：评估肝脏排泄功能。 血清白蛋白：评估肝脏合成功能。 谷丙转氨酶（ALT）、谷草转氨酶（AST）：评估肝实质细胞有否损伤。 凝血酶原时

34、间（PT）：评估肝脏合成功能。凝血酶原时间和凝血因子、和有关，而这些因子也均在肝脏合成。特别是因子，是肝脏合成的半衰期短的凝血因子，半衰期46h，是肝功能受损时最早减少的凝血因子。,78,胃肠道功能的监护,危重患者出现消化道应激性溃疡的比例较高 不能进食者，除给予全肠道外营养外，尽早予肠道内营养,79,脑功能的监护,重症监护治疗的目的是通过保证正常的动脉血氧含量及维持脑灌注压在70mmHg以上，以免产生继发性损害，并使大脑获得最佳的氧合。 Glasgow昏迷评分标准，颅内压监测，颈静脉球部氧饱和度、脑组织氧合压监测，脑多普勒超声，脑电图。,80,神经系统重症监护治疗,应保护气道通畅，常用的措施

35、是气管内插管或气管切开，必要时用机械通气维持正常的气体交换。 控制颅内压和脑灌注压 抗惊厥治疗等,81,凝血功能的监护,对临床上出现：严重或多发性出血倾向；不易用原发病解释的微循环衰竭或休克；多发性微循环栓塞的症状和体征，如广泛性皮肤、粘膜栓塞、灶性缺血性坏死、脱落及溃疡形成，或伴有早期的不明原因的肺、肾、脑等脏器功能不全；抗凝治疗有效等情况，要注意是否有DIC的可能。,82,营养检测和支持,危重症患者营养支持目的在于供给细胞代谢所需要的能量与营养底物，维持组织器官结构与功能； 通过营养素的药理作用调理代谢紊乱，调节免疫功能，增强机体抗病能力，从而影响疾病的发展与转归，这是实现重症患者营养支持

36、的总目标。,83,General Principles of Critical Care,84,Early Identification of Problems,Critically ill patients are at high risk for developing complications ICU practitioner must remain alert to early manifestations of organ system dysfunction, complications of therapy, potential drug interactions, and other premonitory data Early identifying and acting on new problems demands frequent and regular review of all information available,85,86,87,Effective Use of the Problem-Oriented Medical Record,The special importance of finding, tracking