危重病医学.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Critical Care Medicine,Dr.Huang Peizhi,Zhongshan Hospital,of Fudan Universit,What is critical care medicine？,Multidisciplinary healthcare,specialty cares for patients with,acute,life-threatening illness or injury,which including,continuum of life support,from the scene through discharge,Coordinated care systems,analysis of treatment options,protocols,guidelines for the care of individual patients,Monitoring and therapy,Intensive care medicine,in,Europe,What is critical illness?,A condition where,life cannot be sustained,without,invasive therapeutic interventions,Characterized by,acute,loss of physiologic reserve,Cardiac arrest,shock,sepsis,severe trauma,coma,Dysfunction of one or more organ systems:hemodynamic insufficiency,respiratory failure,abnormalities of fluid and electrolytes,Characters of CCM(1),life support,from,site of accident,to,injury during,transportation,and,management in emergency department(,ED,),and to,surgical intervation in operating room or,in intensive care unit(,ICU,),Require emergency medicine and Intensive care medicine,Characters of CCM(2),Team,action by physicians with,various specialty backgrounds,Added expertise in,resuscitation,No focus of interest to a single body system,but,wide variety of illness,Intensivist,-ability to provide effective critical care is in all cases,Emergency and critical care medicine(ECCM)system,Pre-hospital care(,self-help,help from bystanders,ambulance personnel via transport),life support in Emergency department,operation,room and ICU,EM physician is based in the ED,intensivist remained in ICU,History of CCM,In,1940s,:physician sitting at the bedside through the long night,1st ICU,opened in Europe in,1950,s,In,1970,：set up society of,CCM,in USA,Since,1991,:teaching of CCM,in China,In 2001:set up committee of CCM in Shanghai,Service in ICU,Elementary service,Bedside monitor system,Treatment equipment,Experiment instrument,Elementary Service,Patient area,(special functional bed and bedside monitor),Central monitoring field,（central monitor and functional connected bedside monitor）,Employment area,(placement equipment and therapeutic room,Bedside Monitor System,Non-invasive monitoring,Invasive monitoring,Non-invasive Cardiovascular Monitoring,Electrocardiographic monitoring,:,changes of T waves and ST segment or arrhythmia,Echocardiography,Non-invasive blood pressure(,NBP,):,alarm to higher or lower BP,Doppler ultrasound,Non-invasive Respiratory Monitoring,Respiratory rate(,RR,),respiratory wave,End tidal partial pressure of carbon dioxide(,Pet-CO,2,):alveolar PCO,2,close to PaCO,2,normal value is 4 5%(2835mmHg)(3.74.7 kpa),Pulse oximetry:pulse saturation of oxygen(,SpO,2,),Invasive Monitoring,Central venous pressure(,CVP,）：nearly close right atrium pressure.,Invasive blood pressure(,IBP,):SBP,40mmHg suggest hypotension.,Arterial oxygen saturation(,SaO,2,）：arterial oxygenation,degree of hemoglobin binding to oxygen,95%97%is normal.,Arterial blood gas analysis,(,PH,、,PaO,2,、,Pa CO,2,).,Gastric mucous membran PH(,PHi,),Pulmonary Arterial Catheterization,Swan-Ganz,catheter,Right ventricular pressure(,RVP,),Pulmonary capillary wedge pressure(,PCWP,）,Pulmonary artery wedge pressure(,PAWP,),Pulmonary arterial pressure(,PAP,),Cardiac output(,CO,),Cardiac index(,CI,),3.5 L/min/m,2,is normal,Oxygen delivery(,D,O,2,):700-1400ml,O,2,/min,Oxygen consumption(V,O,2,)：250,O,2,/min,Mixed venous oxygen saturation(,Sv,O,2,):7385,Therapeutic Equipment,Mechanical ventilator(respirator),Defibrillator,Transcutaneous or transvenous,cardiac pacing,Cardiopulmonary resuscitation machine(Thumpor),Experimental Instrument,Blood gas analyzer,An elevated,serum lactate,level(,1 mmol/L)identifies tissue,hypoperfusion,in patient at risk who are not,hypotensive,Detect meter：rapidly detect blood sugar,or,CTnT,CTnI,or,Brain natriuretic peptide(,BNP,),Organ Function Support in ICU,Respiratory,support,Circulatory,support,Renal,support,Gastrointestinal support,Cerebral,support,Respiratory Support,Indication,:hypoxemia,hypercapmia,respiratory failure,cardiac arrest,Monitoring,：arterial blood gas analysis,Pet-CO,2,、SpO,2,Treatment,:,(1),Oxygen therapy,(when SaO,2,38,C or,90,beats/min,(3)Tachypnea,with a respiratory rate,20,breaths/min or PaCO,2,12 x 10,9,/L,or,10%band forms on a peripheral blood smear,Definition of Sepsis,Sepsis=,infection,plus physiologic changes known as,SIRS,criteria,Severe sepsis=sepsis with acute organ dysfunction,Septic shock=,sepsis with shock,refractory to fluid resuscitation,Treatment of Severe Sepsis,Recombinant human activated protein C(,rhAPC,):,anti-coagulant and Anti-inflammatory effect,to improve survival in patients with organ dysfunction.,Depression apoptosis and induce super expression of anti-apoptosis protein Bcl-2,MODS,Multiple organ dysfunction syndrome,the most cause of death in ICU,Origin for dysfunction of intestinal barrier,Cell apoptosis,Endothelium damage,Mitochondrion dysfunction,New Management,Parenteral nutrition for central or peripheral vein administration and enteral for feeding tube positioned in the small bowel ,blood substitute,New types of respirator,New,CRRT,instrument,Hand-carried,ultrasound device,New,non-invasive,hemodynamic monitoring,Sublingual PH monitoring,Thank you,！,