1、Intensive care外科重症监测治疗外科重症监测治疗What is ICU?What is ICU?v 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.v 重症监护病房重症监护病房(intensive care unit,ICUintensive care unit,ICU)是将是将疑难危
2、重患者集中监测治疗的单位。疑难危重患者集中监测治疗的单位。History of ICUHistory of ICUvICU developed from the poliomyelitis脊脊髓灰质炎髓灰质炎epidemic in the early 1950s,when the use of long-term artificial ventilation resulted in reduced mortality.Mortality of polio epidemic 87%Mortality of polio epidemic 87%Dropped to 27%by the use of
3、 anesthesia Dropped to 27%by the use of anesthesia machines for ventilation of ptsmachines for ventilation of ptsv 19521952年夏，丹麦哥本哈根脊灰流行，造成延髓性呼吸麻痹，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善，使有
4、关医生认识到加强监护和治疗的重要性。Type of ICU patientsvTerminal illness or irreversiblevTerminal cancervPermanent brain damagevInfectious disease?SARS-management of mechanically ventilated severe acute respiratory syndrome(SARS)patients in the isolation intensive care unit(ICU)-successful costvICU is generally the
5、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 accounting for about 0.5%of GDP and about 13%of national health care expenditure(Halpern,2004)Gerneral IC
6、U wardGerneral ICU ward ICU ICU equipmentv监测设备监测设备monitoring equipment :多功能多功能生命体征监测仪、呼吸功能监测仪、心脏血流动生命体征监测仪、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、力学监测仪、脉搏血氧饱和度仪、血气分析仪、心电图机。心电图机。监护仪器按系统或器官功能参数分门排列，左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。列显示功能参数，右列为治疗参数。v治疗设备治疗设备:呼吸机、除颤器、输液泵、注射泵、呼吸机、除颤器、输液泵、注射泵、起搏器、主动脉内球囊反搏器、
7、血液净化仪、麻起搏器、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、体外膜式肺氧醉机、中心供氧、中心吸引装置、体外膜式肺氧合合(ECMO)ECMO)装装 。监护仪监护仪v 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检验仪铁肺铁肺重症监护病房的最早尝试重症监护病房的最早尝试呼吸机呼吸机Defibrillator 除颤器除颤器制氧机制氧机v Pulse Oxymetryv 血氧饱和仪ICUICU收治对象收治对象-外科重危病人外科重危病人v创伤、大手术创伤、大手术v器官移植后监测器官移植后监测v循环失代偿者循环失代偿者v有呼吸衰竭可能，需呼吸器治疗
8、者有呼吸衰竭可能，需呼吸器治疗者v严重水电解质紊乱，酸碱平衡失调者严重水电解质紊乱，酸碱平衡失调者v麻醉意外、心肺复苏后病人麻醉意外、心肺复苏后病人v单个或多个器官功能不全者单个或多个器官功能不全者v严重代谢障碍性疾病严重代谢障碍性疾病(甲亢、肾上腺、垂体危甲亢、肾上腺、垂体危象象)What do we do in ICU?monitoringvECG heart rate,rhythm,ischemiavBlood pressure non-invasive invasive arterial,central venous,pulmonary arteryvHemodynamic measu
9、rement cardiac outputvPulse oxymetry and capnographyvIntracranial,intraabdominal pressurevMany others electrolyte,CNSWhat do we do in ICU?-TreatmentvHemodynamic support-inotrope and vasoactive medicationvMechanical ventilationvOrgan support(eg.dialysis)vSedation and analgesiavTreatment of underlying
10、 illnessesvEnteral/parenteral nutritionWhy are scoring systems needed?v Scoring systems can provide:-Defining population of critically ill ptsv A tool for comparative audit v A mechanism to decide resource allocationv An aid for the clinical management of patients“Its more important to know what sor
11、t of person this disease has,than what sort of disease this person has.”William Osler 1849-1919Historyv 1953 Virginia Apgarv 1974 Glasgow Coma Scalev APACHE&SAPS physiologically based classification systemsv General severity scoresv Aim at stratifying patients based on their severityv 1985 1993:gene
12、ral outcome prediction modelsv 1991 APACHE IIIv 1993 SAPS IIv 2005 SAPS IIIv 2006 APACHE IVv During process of evolution of models,main prognostic determinants of outcome changedScoring SystemvThe most commonly utilized scoring systems are vthe APACHE(acute physiology and chronic health evaluation)s
13、ystem,v the MPM(mortality probability model),v 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.v These include age;vital signs;assessments of respiratory,renal,and neur
14、ologic function;and an evaluation of chronic medical illnesses APACHEvWilliam KnausvInitially 34 physiological variablesv1985 APACHE II 12 variablesvAPACHE II allows probability of death before hospital discharge to be estimatedvStandardised mortality ratio Assessment of Severity of Illness-Historyv
15、 APACHE&SAPS physiologically based classification systemsv General severity scoresv Aim at stratifying patients based on their severityv 1985 1993:general outcome prediction modelsv 1991 APACHE IIIv 1993 SAPS IIv 2005 SAPS IIIv 2006 APACHE IVv During process of evolution of models,main prognostic de
16、terminants of outcome changedAPACHE-acute physiology and chronic health evaluation v William Knaus 1985 APACHE II 12 variablesv The APACHE II system is the most commonly used severity-of-illness scoring system in North America.v Age,type of ICU admission(after elective surgery vs.nonsurgical or afte
17、r 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 estimatedv Standardised mortality ratio APACHEvacute
18、 physiology and chronic health evaluation vAPACHE 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 chronic medical comorbidities.The database from which this score was derived is
19、larger vAPACHE 0299,Tab 14-1 in textbookAPACHE II score=(acute physiology score)+(age points)+(chronic health points)Scores range from 0 71 Score risk of hospital deathSAPSSimplified Acute Physiology Scorev 17 variables The SAPS II score,used more frequently in Europe,was derived in a manner similar
20、 to the APACHE scores.Le Gall reduced former 34-variable APACHE score to 14 parameters This score is not disease specific but rather incorporates three underlying disease variables(AIDS,metastatic cancer,and hematologic malignancy).专科评分专科评分 神经系统神经系统 Glasgow coma score(GCS)*心脏功能心脏功能 Goldman 肝硬化肝硬化 Ch
21、ild-Turcotte 烧伤指数烧伤指数MPMMortlity probability modelv MPM-1985v MPM-1993v MPM0，MPM24，MPM48 The MPM can be 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.
22、These tools should be used as important data to complement clinical bedside decision-making.MPM(Mortality Prediction Models)vDeveloped by Stanley LemeshowvUses data collected during first hour of ICU admission;24 hours;72 hoursvSeries of true/false questionsvWeighted according to their individual co
23、ntribution to Monitoring of Respiratory functionv床旁观察既简单又实用。vgeneral:Consciousness Respiratory movements，Respiratory rate、apnea 呼吸音。呼吸运动的观察呼吸运动的观察v呼吸频率(RR)vAdult RR 10-18 beat/min 每分钟肺泡通气量(minute ventilation,MV MV)=tidal volume(VT)dead volume(VD)RR呼吸功能测定呼吸功能测定v肺容量监测肺容量监测反映静态通气功能反映静态通气功能 潮气量(tidal vo
24、lume,VT)补吸气量(inspiratory reserve volume,IRV)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 Oxygen therapy 氧治疗氧治疗v Oxygen therapy is the administration
25、of oxygen as a medical intervention,which can be for a variety of purposes in both chronic and acute patient care.v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。vIndication:Cardiac and resp arrestResp failure type,typeCardiac failure or MIShockIncrease metabolic demandsP
26、ost-operative statesCarbon monoxide Oxygen therapyv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)。v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。Mechanical Ventilation Mechanical Ventilation 机械通气机械通气:人工气人工气道道vIn medicine,mechanical ventilation is a method to mechanically assist or replace
27、 spontaneous breathing vArtificial airwayArtificial airway:endotracheal intubation endotracheal intubation or tracheostomyor tracheostomy气管插管或气管切开。气管插管或气管切开。Indication of mechanical ventilationv Acute lung injury(including ARDS,trauma)v Apnea with respiratory arrestv Chronic obstructive pulmonary di
28、sease(COPD)v Acute respiratory acidosis with partial pressure of carbon dioxide(pCO2)50 mmHg 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 v Increased work of breath
29、ing as evidenced by significant tachypnea,retractions,and other physical signs of respiratory distress v Hypoxemia with arterial partial pressure of oxygen(PaO2)with supplemental fraction of inspired oxygen(FiO2)SB:ABSB:呼酸呼酸 ABSB:ABSB:呼碱呼碱:AB=SB AB=SB 正常。两者均增加正常。两者均增加:失代偿性代碱；失代偿性代碱；两者均降低两者均降低:失代偿性代酸
30、失代偿性代酸v碱剩余碱剩余(BE):-3BE):-3+3mmol/L+3mmol/Lv缓冲液缓冲液(BB):BB):包括包括HCOHCO-3 3和和P P-r r。正常值正常值45455555mmol/Lmmol/L。v血浆阴离子间隙血浆阴离子间隙(AGp):AGp):正常值正常值7-167-16mmol/Lmmol/LvTCOTCO2 2(CO(CO2 2总量总量)正常值正常值28-35 328-35 3mmol/Lmmol/LPulse Oximetry脉搏血氧饱和度脉搏血氧饱和度 (SpOSpO2 2)v Pulse Oximetry is the most commonly utili
31、zed noninvasive monitor of respiratory function.v This technique takes advantage of differences in the absorptive properties of oxygenated and deoxygenated hemoglobin.v 脉搏血氧饱和度脉搏血氧饱和度是通过脉搏血氧监测仪是通过脉搏血氧监测仪(pulse oximeter，POM)POM)利用利用红外线红外线测定末梢组织中氧合血红蛋白含量，间接测得测定末梢组织中氧合血红蛋白含量，间接测得SpOSpO2 2。正常值正常值9 95 51
32、00%100%。v SpOSpO2 2监测的影响因素监测的影响因素v 正铁血红蛋白(MetHb)与碳氧血红蛋白(COHb)愈高其SpO2测值愈低。v 体温因素:低体温致SpO2降低。v 低血压肢端末梢循环不良:当50mmHg，SpO2下降。v 测定部位:测定部位其皮肤组织愈厚，精确度愈低。v 皮肤色素:色素沉着、指甲染料SpO2偏低。v 血管收缩剂:使SpO2测值下降。expiratory C0expiratory C02 2 monitoringmonitoring，P PETETC0C02 2 呼气末呼气末C0C02 2监测监测P PETETC0C02 2 end-tidal CO2end
33、-tidal CO2 呼气末呼气末C0C02 2监测监测v主要根据红外线原理、质谱原理、拉曼散射原理主要根据红外线原理、质谱原理、拉曼散射原理和图和图声分光原理而设计，主要测定呼气末二氧声分光原理而设计，主要测定呼气末二氧化碳。化碳。noninvasivenoninvasivev呼气末二氧化碳浓度呼气末二氧化碳浓度(EtC0EtC02 2)呼出气二氧化碳呼出气二氧化碳浓度在呼气末最高，接近肺泡气水平浓度在呼气末最高，接近肺泡气水平(约约3.53.55 5)，其与，其与PaC0PaC02 2的相关性良好，可据此间接估的相关性良好，可据此间接估计计PaC0PaC02 2。v正常值正常值353545
34、mmHg45mmHHemodynamic monitoring 血流动血流动力学监测力学监测v Hemodynamicmeasurements are important to establish a precise diagnosis,determine apropriate therapy.Monitor may be categorized into vNon-invasiveNon-invasive electrocardiogram(ECG)non-invasive blood pressure(NIBP)urine output echocardiography and Doppl
35、ervInvasiveInvasive Arterial blood pressure central venous pressure Pulmonary artery catheter,Swan-Ganz catheter漂浮导管Electrocardiogram,ECGElectrocardiogram,ECG心电图心电图vECG diagnose ischemia,MI arrhythmia monitoring function of 动脉压动脉压(NIBP,ABP)vNon-invasive blood pressure devices use an Non-invasive blo
36、od pressure devices use an oscillotonometric technique.oscillotonometric technique.袖带测压、自动无创测压袖带测压、自动无创测压(NIBP)NIBP)They can give erroneous result in pts with They can give erroneous result in pts with arrhythmia(Af)arrhythmia(Af)。Invasive:Invasive:Arterial blood pressure use an Arterial blood press
37、ure use an arterial catheter and tranducer techniquearterial catheter and tranducer technique动脉穿动脉穿刺插管直接测压刺插管直接测压 mean arterial presssure,MAP 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。正常值能、器官和组织血流。正常值813.3813.3kPa kPa。MAP=DBpMAP=DBp1/3(SBp1/3(SBpDBp)DBp)CO
38、COSVRSVR。central venous pressure,CVP 中心静脉压中心静脉压v CVP can be monitored using catheters inserted via CVP can be monitored using catheters inserted via the the internal jugular,subclavianinternal jugular,subclavian and and femoral femoral veins.veins.v CVP CVP 胸腔内上、下腔静脉或右心房内的压力。胸腔内上、下腔静脉或右心房内的压力。v 是评估血
39、容量、右心前负荷及右心功能的重要指标。是评估血容量、右心前负荷及右心功能的重要指标。v 正常值为正常值为5 5-12cmH-12cmH2 2O O。v CVP CVP过低为血容量不足或静脉回流受阻；过低为血容量不足或静脉回流受阻；CVPCVP过高为输入过高为输入液体过多或心功能不全。液体过多或心功能不全。v 适应症适应症:各类大中手术，尤心胸颅脑手术；各种休克；脱水、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或静脉高能量营养。CVP注意事项注意事项v注意事项:判断导管插入上、上腔静脉
40、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。v并发症:感染、出血和血肿、其它血气胸、血气栓等。Swan-Ganz catheter 漂浮导管漂浮导管v Swan-GanzSwan-Ganz导管用聚氯乙烯材料推压而成，不透导管用聚氯乙烯材料推压而成，不透X X线。成人有线。成人有5 5F F、6F6F、7F7F、7.5F7.5F，全长全长110110cmcm，每每1010cmcm有黑色环形标记。有黑色环形标记。儿童有儿童有4 4F F和和5 5F F，全长全长6060cmcm。v 四腔四腔Swan-Ganz
41、Swan-Ganz导管导管:端孔端孔为主腔开口用于为主腔开口用于监测肺动脉压监测肺动脉压和采和采集血标本。距管端集血标本。距管端3030cmcm处有处有一侧孔一侧孔,用于监测用于监测右房压右房压、CVPCVP、COCO和和输液输液。热敏计热敏计位于距管端位于距管端4 4cmcm处，用于感知热阻抗的变处，用于感知热阻抗的变化，尾端与计算机相连。端孔化，尾端与计算机相连。端孔1-21-2mmmm处有一处有一气囊气囊与尾端的注与尾端的注射器相连可注入气体射器相连可注入气体(1.25-1.5(1.25-1.5ml)ml)。Swan-GanzSwan-Ganz原理原理v 心室舒张末期，主动脉瓣和肺动脉瓣
42、均关闭，而二尖瓣心室舒张末期，主动脉瓣和肺动脉瓣均关闭，而二尖瓣开放形成液流内腔。开放形成液流内腔。v 心室舒张末压心室舒张末压(LVDEP)=LVDEP)=肺动脉舒张压肺动脉舒张压(PADP)=PADP)=肺小动脉楔肺小动脉楔压压(PAWP)=PAWP)=肺毛细血管楔压肺毛细血管楔压(PCWP)PCWP)。v PCWP:pulmonary artery capillary wedge pressurePCWP:pulmonary artery capillary wedge pressurev 临床意义临床意义 估价左右心室功能估价左右心室功能 区别心源性和非心源性肺水肿区别心源性和非心源性
43、肺水肿 指导治疗指导治疗 选择最佳选择最佳PEEPPEEP 确定漂浮导管位置确定漂浮导管位置v肺动脉楔压肺动脉楔压(pulmonary aortic wedge pressure,PAWP)pulmonary aortic wedge pressure,PAWP)正常值为正常值为0.81.60.81.6kPakPa。可判定左心室功能，反映血容量是可判定左心室功能，反映血容量是否充足。否充足。2.42.4kPa:kPa:左心功能不全、急性心源性肺水肿；左心功能不全、急性心源性肺水肿；2.42.4kPa:kPa:急性肺损伤、急性肺损伤、ARDSARDS。v肺毛细血管楔压肺毛细血管楔压(PCWP)P
44、CWP)正常值正常值0.671.870.671.87kPakPa。反映左心反映左心房平均压及左心室舒张末期压。房平均压及左心室舒张末期压。0.80.8kPa:kPa:体循环血容量体循环血容量不足；不足；2.42.4kPa:kPa:即将或已出现肺淤血；即将或已出现肺淤血；4 4kPa:kPa:肺水肿。肺水肿。v平均肺动脉压平均肺动脉压(mean pulmonary arterial mean pulmonary arterial presssure,MPAP)presssure,MPAP)正常值正常值1.472.01.472.0kPakPa。MPAPMPAP升高见于肺升高见于肺血流量增加、肺血管
45、阻力升高、二尖瓣狭窄、左心功不全。血流量增加、肺血管阻力升高、二尖瓣狭窄、左心功不全。MPAPMPAP降低见于肺动脉瓣狭窄降低见于肺动脉瓣狭窄。SwanSwanGanzGanz导管适应证导管适应证vARDS左心衰v循环功能不稳定v急性心肌梗塞v区分心源性和非心源性肺水肿v心血管手术v肺栓塞v严重创伤，各类休克，嗜铬细胞瘤等。床边盲目置管床边盲目置管v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漂浮导管测得右房、右室、肺动脉及肺毛细血管楔压Swan-GanzSwan-Ganz导管
46、并发症导管并发症v 心律失常v 气囊破裂v 肺梗塞v 肺动脉破裂和出血v 导管打结v 血栓形成v 心包填塞v 感染心输出量心输出量(cardiac output,CO)v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。v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。心功能曲线心功能曲线Hemodynamic monitoringv每搏排出量每搏排出量(stroke volumestroke volume,SV),SV)指一次心搏由一侧心室射出的指一次心搏
47、由一侧心室射出的血量。成年人安静、平卧时为血量。成年人安静、平卧时为60906090mlml。SVSV与心肌收缩力、与心肌收缩力、心脏前负荷、后负荷有关。心脏前负荷、后负荷有关。v心脏指数心脏指数(CI)CI)正常值正常值2.84.22.84.2L/min.mL/min.m2 2。CICI2.52.5提示心衰；提示心衰；CICI1.81.8为心源性休克。为心源性休克。v体循环阻力指数体循环阻力指数(system vascular resistance indexsystem vascular resistance index,SVRI),SVRI)体循环体循环阻力阻力(SVR)SVR)表示心室
48、射血期作用于心室肌的负荷，是监测左表示心室射血期作用于心室肌的负荷，是监测左心室后负荷的指标。是指每平方米体表面积的心室后负荷的指标。是指每平方米体表面积的SVRSVR。正常值正常值为为1760260017602600dynedynesec/cmsec/cm5 5m m2 2。v肺循环阻力指数肺循环阻力指数(pulmonary vascular resistance indexpulmonary vascular resistance index,PVRI,PVRI)肺循肺循环阻力环阻力(PVR)PVR)是监测右心室后负荷的指标。正常值为是监测右心室后负荷的指标。正常值为4522545225d
49、ynedynesec/cmsec/cm5 5m m2 2。Hemodynamic monitoringv左心室做功指数(left ventricular stroke work index,LVSWI)是左心室收缩功能的反映。正常值为4468g/mm2。v右心室做功指数(right ventricular stroke work index,RVSWI)是右心室收缩功能的反映。正常值为48g/mm2。v氧输出(deferent oxygen,DO2)指单位时间内由左心室输送到全身组织氧的总量。DO2CI动脉血氧含量(CaO2)正常值520720ml/minm2。v氧 耗 量(V O2)指 机
50、体 实 际 的 氧 消 耗 量。正 常 值1001800ml/minm2。v氧摄取率(O2ext)是氧输出与氧耗量之比，与组织氧需求有关。正常值为2232%。肾功能的监测肾功能的监测v尿量、尿比重、尿常规及血、尿生化指标。v肾小管功能检测 肾浓缩-稀释试验 酚红排泄率(PSP):15min25%，2h55%尿/血渗透压比值v肾小球功能检测 肾小球滤过率(GFR)血浆肌酐(SCR)正常值83-177mol/L(1-2mg/dl)血尿素氮(BUN)正常值2.9-6.4mmol/L(8-20mg/dl)内生肌酐清除率:正常100-148L/24h(80-100ml/min)胃肠功能的监测和支持胃肠功
