医学精品课件：05.ICU.PPT

1、危重病医学,南方医科大学南方医院 重症医学科（ICU） 陈仲清,危重病医学 （critical care medicine) intensive care medicine 是一门研究危重病症发生、发展规律及其诊治的科学。,Intensive Care unit (ICU) Department of critical care medicine 是集中多专业的知识和技术，对重症病例进行病理生理功能的监测和积极治疗的专门单位。ICU有助于改善重症患者的死亡率、致残率，改进医疗质量，是体现医院整体医疗实力的窗口。,重症医学科/重症监测治疗室 /加护病房/深切治疗病房,的发展史,术后恢复室 186

2、3年南丁格尔曾撰文提到，“在小的乡村医院里，把病人安置在一间由手术室通出的小房间内，直至病人恢复或至少从手术的即时影响中解脱的情况已不鲜见”。即最早的术后恢复室(recovery room)。 重大灾害 1942年波士顿大火，麻省总医院一下收治39名重伤名，不得不组织专门人的员、专门的场所进行抢救，形成了ICU的基本雏形,疾病爆发流行 20世纪中叶，丹麦流行脊髓灰质炎，为抢救呼吸衰竭病人，麻醉科医师携带呼吸器介入了病房的抢救工作，并获得巨大成功，开创了ICU的先河。,重大战争 两次世界大战及朝战、越战的战场救护经验的积累，促进了危重医学的发展，如休克和多器官功能衰竭（MOF）的研究。 58年美

3、国巴的摩尔医院麻醉科医师safar也建立了一个专业性的监护单位，并正式命名重症监护病房ICU,真正促进ICU成立的因素主要有三个方面： 1.手术范围的扩大，新手术开展的需要 2.处理多脏器多功能衰竭问题的需要 3.分级护理管理制度的必然产物 60年代，电子工业飞速发展，监护仪问世，对ICU起推动作用。80年代，在我国相继建立ICU。90年代，蓬勃发展。,ICU的出现与发展的意义 1.提高医疗质量 2.经济化与效率化 3.教育进修的场所 4.医学研究的对象,ICU的分类/模式,综合性ICU(general ICU) 专科ICU SICU：外科ICU（surgical ICU) CCU:冠心病监测

4、治疗ICU(Coronary heart diseaseICU) RCU:呼吸系统疾病ICU（respiratory disease care unit) ECU:急诊ICU(emergrecy care unit) PICU:儿科ICU(pediatric ICU) PACU:麻醉后ICU（Postanesthesia care unit） NICU。,危重病医学的发展,美国重症医学学会（SCCM）成立于1970年 1990年ICU床位占医院总床位5-8% 2005年上升至10-15% ICU的投入竟占美国GDP的1%！ 欧洲和澳大利亚也呈现同样趋势。,危重病医学的发展,2005年中华医学会

5、重症医学分会成立 2007年重症医学被卫生部设为二级学科 2008年卫生部文件设重症医学科为诊疗科目，三甲医院必须设重症医学科 目前国内大医院ICU 95%以上是独立学科 南方医院2000年成立外科ICU 南方医院2011年成立重症医学科,ICU 病房,南方医院ICU病房,南方医院ICU病房,南方医院ICU病房,工作位置示意图,ICU 的主要功能:,Provide optimum life support 提供最好的生命支持 Provide adequate monitoring of vital functions 提供恰当的重要生理功能监测,ICU,Life support: Genera

6、l CVS Respiratory Renal CNS Metabolic,Monitoring 监测,心血管 呼吸 肝肾 神经 水电解质酸碱平衡 体温,马凡氏综合症(Marfans syndrome),ECMO,PICCO,ECMO,心脏移植术后病人,Information system of patients,PACS 或DICOM图像标签,医护人员通过如下工具可对图片进行调整分析： 工具（Tools） 图像（Image） 视图（View ）,Hemodynamic monitoring: 血流动力学监测,Assessment of intravascular volume 评估血容量 A

7、ssessment of cardiac function 评估心脏功能 Assessment of end organ perfusion 评估终末器官灌注,Hemodynamic monitoring:,ECG 心电图 NIBP 无创血压 IBP 有创血压 CVP 中心静脉压 PA catheter and PCWP 肺动脉导管,Noninvasive Hemodynamic Monitoring 无创血流动力学监测,Noninvasive BP Heart Rate, pulses Mental Status Mottling (absent),Skin Temperature Capi

8、llary Refill Urine Output,三导联和五导联心电图,Allows the recording of the six standard limb leads (I, II, III, aVR, aVL, aVF), as well as one precordial unipolar lead. Computer- assisted arrhythmia analysis and S-T analysis are possible.,EKG,Heart rate Cardiac rhythm (A fully computerized arrhythmia analysis

9、 is now available) Conduction defects. Myocardial ischemia (S-T segment monitoring),NIBP无创血压,Manual,Automatic,Indications for Arterial Blood Pressure 有创血压监测指征,Frequent titration of vasoactive drips Major surgery involving large fluid shifts CPB Aortic surgery Unstable blood pressures Frequent ABGs o

10、r labs Unable to obtain Non-invasive BP,INVASIVE BLOOD PRESSURE MONITORING (IBP):有创血压监测,An arterial canula is used. A non compliant saline-filled tube is used to connect the canula to the transducer, to the display It measures IBP on beat to beat basis.,CENTRAL VENOUS PRESSURE (CVP) AND PULMONARY AR

11、TERY (PA) MONITORING: 中心静脉压和肺动脉压监测,Invasive monitoring of the central circulation allows an estimate of cardiac preload. For access to the central circulation, various sites have been used including IJV(internal jugular), SCV (Subclavian), basilic vein and femoral vein.,CVP AND PA MONITORING,CVP and

12、 PA catheters can measure: CVP PAP PCWP CO Mixed venous SpO2,Central Venous Pressure Monitoring,CVP gives an estimate of the intravascular volume status and is an interplay of the: (1) circulating blood volume (2) venous tone and (3) right ventricular function.,CVP,BLOOD VOLUME (INCREASED VENOUS RET

13、URN RAISES CVP,CARDIAC COMPETENCE (REDUCED VENTRICULAR FUNCTION RAISES CVP),INTRATHORACIC AND INTRAPERITONEAL PRESSURE (RAISES CVP),SYSTEMIC VASCULAR RESISTENCE (INCREASED TONE RAISES CVP),NORMAL CVP MEASUREMENTS 中心静脉压测量,CVP monitoring should normally show measurements as follows: Mid Axilla: 6 - 12

14、 mmHg An isolated CVP reading is of limited value; a trend of readings is much more significant and should be viewed in conjunction with other parameters e.g. BP and urine output. 趋势变化更重要，结合血压、尿量等,Indications for central venous catheter placement 放置中心静脉导管指征,Major operative procedures involving large

15、 fluid shifts and / or blood loss or Major trauma Diagnosis of RV failure fluid management, Intravascular volume assessment Frequent venous blood sampling Venous access for vasoactive or irritating drugs,Chronic drug administration Inadequate peripheral IV access Rapid infusion of IV fluids Special

16、Uses: insertion of PA catheters insertion of transvenous pacing wires haemodialysis/plasmapheresis,POSITION OF PATIENT,3-way tap,manometer,Fluid Bag,Patient in supine position,Central Venous Access,氧输送生理,With this catheter: PAP, PCWP & CVP can be measured easily under most circumstances provides an

17、accurate estimate of the diastolic filling (preload) of the left heart Cardiac output determination using thermo-dilution technique is an equally important use of this catheter,PULMONARY ARTERY AND PULMONARY CAPILLARY WEDGE PRESSURE MONITORING 肺动脉压肺毛细血管楔压,Flow Directed Double Lumen Catheter* 1971 Th

18、ermodilution PA Catheter* 1972 Triple Lumen PA Catheter* Pediatric Catheter Cardiac Output Computer* 1973 Bi-polar Pacing Catheter* 1974 Fiberoptic Monitoring Catheter* 1977 Four Lumen TD Catheter 1978 Pacing TD* 1981 VIP Catheter* S-Tip Catheter* Heparin Coated TD Catheter*,Swan-Ganz Catheter HISTO

19、RY,1983 Thromboshield Heparin Coating 1984 Oximetry TD Catheter* 1985 Paceport Catheter* Chandler V-Pacing Probe* Sat-I Oximetry Catheter 1989 REF Volumetric TD Catheter* 1990 Sat-2 Oximetry Catheter 1991 REF-OX Catheter* 1992 REF Electrode-Free Volumetric TD Catheter 1993 Vigilance and IntelliCath

20、CCO Pulmonary Artery Catheter* CCOmbo Combination Catheter* 2000 CCOmbo Volumetric Catheter *,* First in Industry,锁骨下静脉穿刺SwanGanz导管置入,Indications For PAP & PCWP Monitoring,A. Cardiac problems/surgery: Poor LV function (EF 18 mm Hg) Recent MI Pts with right heart failure Procedures involving CPB Comp

21、lications of MI eg. MR, VSD, ventricular aneurysm. Hemodynamically unstable pts requiring inotropes or IABP counterpulsation Major procedures with large fluid shifts and/or blood loss in pts with CAD B. Non-cardiac situations: Shock of any cause or MOF Severe pulmonary disease , COPD , PHTN, or PE P

22、ts requiring high levels of PEEP Complicated surgical procedure Massive trauma Hepatic transplantation,正常的心臟，PAWP 約等於左心室舒張末期壓力 (LVEDP；left ventricular end-diastolic pressure). 二尖瓣 (mitral valve) 阻塞時；PAWP 大於 LVEDP 心臟功能 (heart compliance) 降低時；PAWP 小於 LVEDP,INVASIVE HEMODYNAMIC MONITORING,Parameters me

23、asured, 右室舒张末容积（EDV） New！ 右室射血分数（RVEF） New！ 右室收缩末容积（ESV） New！ 右心房压力（RAP） 肺动脉压力（PAP） 肺动脉嵌入压力（PCWP） 心输出量（CO） 心脏指数（CI） 每搏量（SV） New！ 混合静脉血氧饱和度（SvO2）,Using the Swan-Ganz catheter to diagnose肺动脉导管用于诊断,Shock (cardiogenic, distributive, obstructive, hypovolemic) Cardiogenic vs. noncardiogenic pulmonary edem

24、a (ARDS) pulmonary hypertension Acute mitral regurgitation, pericardial tamponade, etc,Respiratory Monitoring:呼吸监测,Monitoring of lung mechanics in ventilated patients,Respiratory Monitoring,Inspired and expired lung volumes (VT and MV)are measured. PIP, Plateau pressure (PP) and Mean airway pressure

25、 are measured. Dynamic lung compliance is calculated as DLC= VT / PIP Static lung compliance is calculated as SLC= VT / PP,Respiratory Monitoring Gas exchange: 监测气体交换,ABGs. 血气分析 Capnography 二氧化碳描记图 Pulse oximetry 脉搏血氧监测,ABGs血气分析,An arterial blood sample is used. ABG analysis measures: PaO2 PaCO2 pH

26、Some machines also measure Hb conc. And SpO2. Calculated Parameters include: HCO3 Base excess Total CO2 content. SpO2, if not directly measured.,ABGs: Clinical applications: 血气分析临床应用,Assess adequacy of gas exchange. Assess adequacy of respiratory support. Know the acid-base status of the individual.

27、 Assess the adequacy of different interventions on acid-base balance.,Capnography二氧化碳描记图,A typical capnogram obtained during controlled mechanical ventilation showing : Inspiratory baseline Expiratory upstroke Expiratory plateau Inspiratory downstroke,PULSE OXIMETRY:脉搏血氧监测 Spectrophotometry分光光度法,The

28、 present generation of pulse oximeters uses two wavelengths of light: 660 nm (red) and 940 nm (near infrared). The pulse oximeter measures the AC component of the light absorbance at each wavelength and then divides it by the corresponding DC component. R = AC660/DC660 / AC940/DC940,PULSE OXIMETRY:

29、CLINICAL APPLICATIONS.临床应用,The pulse oximeter is the most significant advance in oxygen monitoring since the development of the blood gas analyzer. Because it is noninvasive and virtually risk free when used properly, the pulse oximeter should be used in all clinical settings in which there is a pot

30、ential risk of arterial hypoxemia. It is the only oxygen monitor that provides continuous, real-time, noninvasive data on arterial oxygenation.,TEMPERATURE MONITORING: 体温监测,Temperature regulation is crucial to the survival of intact animals Although uncommon, hypothermia below 32 C is ominous.Ventri

31、cular irritability increases, and if the temperature decreases to 28 C cardiac arrest is likely. shivering can increase oxygen demand 135% to 468%,when respiratory and cardiovascular systems may be unable to respond normally to increased demand,Sites for monitoring body temperature,1.Oral. 2.Tympani

32、c membrane 3.Esophageal 4.Nasopharyngeal 5.Pulmonary arterial blood 6.Rectal 7.Bladder 8.Axillary 9.Forehead 10.Great toe,Renal Function Monitoring 肾功能监测,(1) Excrete potentially toxic metabolic end products排泄代谢产物 (2) Regulate water and tonicity 调节水电酸碱 (3) Produce hormones 生产激素,Renal Function Monitor

33、ing,Urine Volume: 尿量Normal 0.5- 1.0 ml/kg/hr oliguria: 0.5 ml/kg/hr Urine Specific Gravity:比重 is a measure of concentrating/ diluting capacity of the kidney, Urine Osmolality: 渗透压urine osmolality of greater than 500 mOsm/kgH2O indicates prerenal azotemia and less than 350 mOsm/kgH2O indicates acute

34、tubular necrosis.,Renal Function Monitoring,Serum Creatinine: 0.4- 1.2 mg/dl. Blood Urea Nitrogen: normal range is 8 to 20 mg/dl. Urinary Sodium: It is traditionally accepted that a urinary sodium level of less than 20 mEq suggests prerenal azotemia and a level of greater than 40 mEq, acute tubular

35、necrosis. Creatinine Clearance: Normal 1- 1.5 ml/kg/min.,Life support:生命支持,心血管 呼吸 肝肾 神经 水电解质酸碱平衡 体温 。,Life support: General 一般性全身支持,General body care include: Regular turning every 1 hour. Body and mouth hygiene Bowl and bladder care. Passive or active physiotherapy. Adequate nutrition.,Life support

36、: CVS 心血管,Hemodynamic manipulation is done to optimize CV function to achieve adequate tissue perfusion.优化血流动力学 This is done by: Optimizing preload, input/ output. Optimizing afterload, vasodilators or vasoconstrictors. Optimizing cardiac contractility, +ve ionotropes, -ve ionotropes.,早期目标导向性治疗(earl

37、y goal-directed therapy，EGDT),早期：一旦组织细胞出现灌注不足或缺氧状态，即应开始积极补充液体恢复容量，保证组织灌注 目标：是指在诊断后最初6小时内达到稳定血流动力学、改善组织灌注，重建氧平衡 指导：在血流动力学监测下指导的液体复苏 治疗：液体复苏采取的措施 严重脓毒症和(或)脓毒症休克患者经补液2040mlkg后仍呈低血压状态，或不论血压水平如何而血乳酸升高(4mmol/L)，即开始进行EGDT,在严重感染发生的6小时内达到上述复苏目标可降低患者病死率,sepsis: 早期目标指导治疗,Rivers E, Nguyen B, Havstad S, et al. E

38、arly goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368-1377,Life support: 呼吸,Simple O2 therapy using various O2 masks e.g Venturi masks of various FiO2, 21- 60 %, non-rebreathing mask with a reservoir bag give FiO2 80 %.氧疗 Mechanical ventilation机械通

39、气,Indications for Mechanical Ventilation 机械通气指征,A. Respiratory failure 呼吸衰竭 B. Protection of upper airway 保护气道 C. Relief of airway obstruction 解除气道梗阻 D. Improved pulmonary toilet 清洁气道 E. Refractory cardiogenic pulmonary edema 难治的心源性肺水肿,Origins of mechanical ventilation,Negative-pressure ventilators

40、(“iron lungs”) Non-invasive ventilation first used in Boston Childrens Hospital in 1928 Used extensively during polio outbreaks in 1940s 1950s Positive-pressure ventilators Invasive ventilation first used at Massachusetts General Hospital in 1955 Now the modern standard of mechanical ventilation,The

41、 era of intensive care medicine began with positive-pressure ventilation,The iron lung created negative pressure in abdomen as well as the chest, decreasing cardiac output.,Iron lung polio ward at Rancho Los Amigos Hospital in 1953.,1907:Pulmotor急救呼吸器,1996:Evita 4 高智能化的呼吸机,一九四七第一台铁肺,1901 - the first

42、 device,世界上第一台呼吸机,Principles : Ventilation &Oxygenation,The goal of ventilation is to facilitate CO2 release and maintain normal PaCO2 The primary goal of oxygenation is to maximize O2 delivery to blood (PaO2),ECMO(extracorporeal membrane oxygenation ) 体外生命支持,ARDS,Life support: Renal 生命支持：肾脏,Maintain adequate fluid and electrolyte balance and correct any abnormalities. Avoid hypovolemia, hypotension Avoid use of nephrotoxic drugs especially in those with a compromised renal function. Use of various forms of kidney dialysis.,Temperature monitor and treatment 体温监测和治疗,Tympanic membrane,