1、！可怕的惯性思维患者为何会停留在重症监护室中？重症监护室中危重患者心肺康复管理新策略ABCDE模式重症患者心肺康复服务所承担的使命模式的继承、发展以及创新EevidencePpracticeTtranslation为什么会产生ABCDE模式1.以循证为基础构架的方法2.临床工作团队成员之间合作改进的结果3.标准化的管理程序4.打破了危重患者过度镇静和延长戴机的循环跨学科的合作 Interdisciplinary而非传统的多学科交叉 MultidisciplinaryABCDE模式的核心A：Awakening，促醒B：(Spontaneous)Breathing Trial，自主呼吸测试 C：C
2、hoice of sedation，镇静剂的选择D：Delirium monitoring，谵妄的管理E：Early exercise&mobility，早期的运动和活动！请注意：让重症患者早日安返病房是每一个人的责任促醒和镇静剂选择的策略每日戒断的目标：RASS-2 to 0；or BIS 60 to 100(or 遵医嘱)1.咪达唑仑/氯羟去甲安定持续静脉滴注2.异丙酚静脉持续滴注3.芬太尼/二氢化吗啡酮/吗啡持续静脉滴注4.右旋美托咪定静脉持续滴注 保持镇静药物的持续静脉滴注除非患者达到RASS唤醒的目标 使用1/2先前的比率，用最小的剂量达到目标理想的镇静指数自主呼吸测试SBT的策略通
3、过短时间(30min-2Hrs)的动态观察,以评价患者完全耐受自主呼吸的能力,借此达到预测撤机成功的目的1.低水平CPAP法模式：换为CPAP，设置CPAP为5cmH2O2.低水平PSV法模式：换为PSV，压力支持水平设置在5-7cmH2O3.脱机试验方式：T管试验，并将cuff中气体抽出呼吸肌肌力训练心理支持痰液管理重症监护室中的谵妄 药物的影响 睡眠障碍 嘈杂的环境-BEEP!身体的不适：疼痛，机械通气，尿管，鼻饲管 陌生的环境 昼夜节律失调 活动受限评估工具：Confusion Assessment Method for the ICU(CAM-ICU)谵妄的干预策略：Stop.T.H.
4、I.N.K Toxic situations：有害的情况（CHF，休克，脱水，药物，新发的器官衰竭）Hypoxemia/Hypotension：低氧血症/低血压 Infection/+Sepisis：感染/+败血症 Non-pharmacologic Intervention：非药物的干预（眼镜，睡眠管理，噪音控制）K+/Electrolyte problems：钾离子或电解质紊乱FDA并未许可任何一种药物对谵妄进行治疗所有接受抗精神病药物治疗的患者都应注意它们的副反应，尤其是导致QT间期的延长Many patients with respiratory failure require mec
5、hanical ventilation for weeks or months before they can breathe unassisted.If such patients are confined to bed or chair simply because they are tied to their respirators,they are needlessly predisposed to muscular and skeletal wasting,thromboembolism,decubitus ulcers,and to at least some degree of
6、despair concerning their eventual rehabilitation.CHEST,68:4,OCTOBER,1975Robert Burns,M.D.,F.C.C.P.and Frederick L.Jones,Jr.,M.D.,F.C.C.P.Department of Thoracic MedicineGeisinger Medical CenterDanville,Pa,USAEarly Ambulation Of Patients Requiring Ventilatory Assistance Muscle Deterioration(Structural
7、 And Functional)Occurs Very Rapidly in MV/Critical IllnessThe New England Journal Of MedicineConclusionsThe combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers.These findings are consistent with increase
8、d diaphragmatic proteolysis during inactivity.Rapid Disuse Atrophy Of Diaphragm Fibers In Mechanically Ventilated HumansSanford Levine,M.D.,Taitan Nguyen,B.S.E.,et al March 27,2008 Vol.358 No.13:1327-35.Goal is not necessarily walking everyone,but getting them MOVING!Fast，NOT RUSH2-Step ProcessSafet
9、y Screen+Mobility Protocol Safety Screen 安全性筛查：MOVEN M:Myocardial stability，心肌稳定 50 HR*120；90 SBP*200；55 MAP*120；*or normal range for pt；No active ischemia x 24 hrs；No new IV antidysrhythmic agents x 24 hrs O:Oxygenation，氧合 FiO2 60%；PEEP 12；SPO292%(88%with activity)；10 RR 35 V:Vasopressor(s)minimal，
10、最小的升压药 No increase in vasopressor infusion in last 2 hrs E:Engages to voice，能够发声 or Pt opens eyes to verbal stimulation N:Neurologic stability，神经情况稳定 ICP 20mmHg；Absence of active seizures x 24hrs CONTRAINDICATIONS:Unstable fx；Active bleeding；Active fluid resuscitation；Open chest/abdomen 重症患者心肺康复运动3阶
11、段策略LEVEL 1:RASS-5 to+2Functional level:Total Assist PROM Bid x 10 reps with NR/CPT Splinting and repositioning every 2 hours by NR Bed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 Hrs Skilled therapeutic interventions by PT/OT as indicated重症患者心肺康复运动3阶段策略LEVEL 2:RASS-2 to+2
12、Functional level:Max to Mod Assist ROM Ex Bid with family/NR/CPT x 10 reps Splinting and repositioning every 2 Hrs by NR Bed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 Hrs OOB to neuro chair greater than 30 minutes but less than 2 Hrs Skilled therapeutic interventions by
13、 CPT/OT as indicated Participate in ADL重症患者心肺康复运动3阶段策略LEVEL 3:RASS-1 to+2Functional level:Mod Assist to Supervision Self-care exercise program Bid Reposition every 2 Hrs while in bed OOB to bedside chair with NR/CPT Tid greater than 30 minutes but less than 2 Hrs Ambulate as directed by CPT/OT Skilled therapeutic interventions by CPT/OT as indicated Participate in ADL综合的ABCDE模式能让您的患者获得最大益处别害怕！您的患者会比您期望的做得更好请记住！这是跨学科合作才能完成的任务诚邀您与我们一起推进中国心肺康复感谢聆听
