外科重症监测治疗.ppt

单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,单击此处编辑母版标题样式,Intensive care,外科重症监测治疗,What is ICU?,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,.,重症监护病房(,intensive care unit,ICU,),是将疑难危重患者集中监测治疗的单位。,History of ICU,ICU developed from the poliomyelitis,脊髓灰质炎,epidemic in the early 1950s,when the use of long-term artificial ventilation resulted in reduced mortality.,Mortality of polio epidemic 87%,Dropped to 27%by the use of anesthesia machines for ventilation of pts,1952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,。,Category of ICU,综合性,ICU(general ICU)、,专科,ICU,SICU,外科,ICU(surgery ICU),CICU，,冠心病,ICU(coronary intensive care unit,CCU),RICU，,呼吸系统疾病,ICU(respiratory intensive care unit,RCU),EICU，,急诊,ICU(emergency care unit),NICU，,新生儿,ICU(neonatalICU),心肺重症监护治疗病房(,CPICU),心脏外科重症监护治疗病房(,CSICU),神经外科重症监护治疗病房(,NSICU),危重肾病重症监护治疗病房(,UICU),Type of ICU patients,Terminal illness or irreversible,Terminal cancer,Permanent brain damage,Infectious disease?SARS,-management of mechanically ventilated severe acute respiratory syndrome(SARS)patients in the isolation intensive care unit(ICU)-successful,cost,ICU is generally the 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 ICU ward,监护仪,心功能监测系统,心电图机,铁肺,重症监护病房的最早尝试,Defibrillator,除颤器,制氧机,Pulse Oxymetry,血氧饱和仪,What do we do in ICU?,monitoring,ECG,heart rate,rhythm,ischemia,Blood pressure,non-invasive,invasive,arterial,central venous,pulmonary artery,Hemodynamic measurement,cardiac output,Pulse oxymetry and capnography,Intracranial,intraabdominal pressure,Many others,electrolyte,CNS,What do we do in ICU?-Treatment,Hemodynamic support-inotrope and vasoactive medication,Mechanical ventilation,Organ support(eg.dialysis),Sedation and analgesia,Treatment of underlying illnesses,Enteral/parenteral nutrition,Why are scoring systems needed?,Scoring systems can provide:,-Defining population of critically ill pts,A tool for comparative audit,A mechanism to decide resource allocation,An aid for the clinical management of patients,“,It,s more important to know what sort of person this disease has,than what sort of disease this person has.,”,William Osler 1849-1919,History,1953,Virginia Apgar,1974,Glasgow Coma Scale,APACHE&SAPS,physiologically based classification systems,General severity scores,Aim at stratifying patients based on their severity,1985,1993:general outcome prediction models,1991,APACHE III,1993,SAPS II,2005,SAPS III,2006,APACHE IV,During process of evolution of models,main prognostic determinants of outcome changed,APACHE,William Knaus,Initially 34 physiological variables,1985,APACHE II 12 variables,APACHE II allows probability of death before hospital discharge to be estimated,Standardised mortality ratio,Assessment of Severity of Illness-History,APACHE&SAPS,physiologically based classification systems,General severity scores,Aim at stratifying patients based on their severity,1985,1993:general outcome prediction models,1991,APACHE III,1993,SAPS II,2005,SAPS III,2006,APACHE IV,During process of evolution of models,main prognostic determinants of outcome changed,APACHE-,a,cute,p,hysiology,a,nd,c,hronic,h,ealth,e,valuation,William Knaus,1985,APACHE II 12 variables,The APACHE II system is the most commonly used severity-of-illness scoring system in,North America.,Age,type of ICU admission(after elective surgery vs.nonsurgical or after 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 estimated,Standardised mortality ratio,APACHE II score,=(acute physiology score)+(age points)+(chronic health points),Scores range from 0,71,Score risk of hospital death,SAPS,S,implified,A,cute,P,hysiology,S,core,17 variables,The,SAPS II score,used more frequently in,Europe,was derived in a manner similar 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,神经系统,Glasgow coma score(GCS)*,心脏功能,Goldman,肝硬化,Child-Turcotte,烧伤指数,MPM,M,ortlity,p,robability,m,odel,MPM-1985,MPM-1993,MPM,0,，,MPM,24,，,MPM,48,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.These tools should be used as important data to complement clinical bedside decision-making.,MPM(Mortality Prediction Models),Developed by Stanley Lemeshow,Uses data collected during first hour of ICU admission;24 hours;72 hours,Series of true/false questions,Weighted according to their individual contribution to mortality,Monitoring of Respiratory function,床旁观察,既简单又实用。,general,:,Consciousness,Respiratory movements,，,Respiratory rate,、,apnea,呼吸音。,mucous,呼吸运动的观察,呼吸频率(,RR),Adult 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,肺容量监测反映静态通气功能,潮气量(,tidal volume,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 value,Oxygen therapy,氧治疗,Oxygen therapy,is the administration of,oxygen,as a medical intervention,which can be for a variety of purposes in both,chronic,and,acute,patient care.,氧治疗,是通过吸入不同浓度的氧，使吸入氧浓度(,F,1,O,2,),和肺泡气的氧分压(,P,A,O,2,),升高，以升高动脉血氧分压(,P,a,O,2,)，,达到缓解或纠正低氧血症的目的。,Indication:,Cardiac and resp arrest,Resp failure type,type,Cardiac failure or MI,Shock,Increase metabolic demands,Post-operative states,Carbon monoxide poisoning,Oxygen therapy,氧疗方法,:高流量系统，如文图里(,Venturi),面罩(,F,1,O,2,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(,F,1,O,2,不稳定)。,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,机械通气,:,人工气道,In,medicine,mechanical ventilation is a method to mechanically assist or replace spontaneous,breathing,Artificial airway,:,endotracheal intubation or tracheostomy,气管插管或气管切开。,Indication of mechanical ventilation,Acute lung injury(including,ARDS,trauma),Apnea,with respiratory arrest,Chronic obstructive pulmonary disease,(,COPD,),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,Increased work of breathing as evidenced by significant,tachypnea,retractions,and other physical signs of respiratory distress,Hypoxemia,with arterial partial pressure of oxygen(PaO2)with supplemental fraction of inspired oxygen(FiO2)SB:,呼酸,ABSB:,呼碱:,AB=SB,正常。两者均增加:失代偿性代碱；两者均降低:失代偿性代酸,碱剩余(,BE):-3+3mmol/L,缓冲液(,BB):,包括,HCO,-,3,和,P,-,r,。,正常值4555,mmol/L。,血浆阴离子间隙(,AGp):,正常值7-16,mmol/L,TCO,2,(CO,2,总量)正常值28-35 3,mmol/L,Pulse Oximetry,脉搏血氧饱和度,(,SpO,2,),Pulse Oximetry is the most commonly utilized,noninvasive,monitor of respiratory function.,This technique takes advantage of differences in the absorptive properties of oxygenated and deoxygenated hemoglobin.,脉搏血氧饱和度,是通过脉搏血氧监测仪(,pulse oximeter,，,POM),利用,红外线,测定末梢组织中氧合血红蛋白含量，间接测得,SpO,2,。,正常值,9,5,100%,。,SpO,2,监测的影响因素,正铁血红蛋白(,MetHb),与碳氧血红蛋白(,COHb),愈高其,SpO,2,测值愈低。,体温因素:低体温致,SpO,2,降低。,低血压肢端末梢循环不良:当50,mmHg，SpO,2,下降。,测定部位:测定部位其皮肤组织愈厚，精确度愈低。,皮肤色素:色素沉着、指甲染料,SpO,2,偏低。,血管收缩剂:使,SpO,2,测值下降。,expiratory C0,2,monitoring，P,ET,C0,2,呼气末,C0,2,监测,P,ET,C0,2,end-tidal CO2,呼气末,C0,2,监测,主要根据红外线原理、质谱原理、拉曼散射原理和图,声分光原理而设计，主要测定呼气末二氧化碳。,noninvasive,呼气末二氧化碳浓度(,EtC0,2,),呼出气二氧化碳浓度在呼气末最高，接近肺泡气水平(约3.55)，其与,PaC0,2,的相关性良好，可据此间接估计,PaC0,2,。,正常值,35,45mmHg,Hemodynamic monitoring,血流动力学监测,Hemodynamicmeasurements are important to establish a precise diagnosis,determine apropriate therapy.Monitor may be categorized into,Non-invasive,electrocardiogram(ECG),non-invasive blood pressure,(,NIBP),urine output,echocardiography and Doppler,Invasive,Arterial blood pressure,central venous pressure,Pulmonary artery catheter,Swan-Ganz catheter,漂浮导管,Electrocardiogram,ECG,心电图,ECG diagnose,ischemia,MI,arrhythmia,monitoring function of pacer,动脉压,(,NIBP,ABP),Non-invasive blood pressure devices use an oscillotonometric technique.,袖带测压、自动无创测压(,NIBP),They can give erroneous result in pts with arrhythmia(Af),。,Invasive:,Arterial blood pressure use an arterial catheter and tranducer technique,动脉穿刺插管直接测压,mean arterial presssure,MAP,平均动脉压是指心动周期的平均血压。能评估左室泵功能、器官和组织血流。正常值813.3,kPa。,MAP=DBp1/3(SBpDBp)COSVR,。,central venous pressure,CVP,中心静脉压,CVP can be monitored using catheters inserted via the,internal jugular,subclavian,and,femoral,veins.,CVP,胸腔内上、下腔静脉或右心房内的压力。,是评估血容量、右心前负荷及右心功能的重要指标。,正常值为,5,-12cmH,2,O。,CVP,过低为血容量不足或静脉回流受阻；,CVP,过高为输入液体过多或心功能不全。,适应症,:,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、输液或静脉高能量营养,。,CVP,注意事项,注意事项:,判断导管插入上、上腔静脉或右房无误。,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。,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,Swan-Ganz,导管用聚氯乙烯材料推压而成，不透,X,线。成人有5,F、6F、7F、7.5F，,全长110,cm，,每10,cm,有黑色环形标记。儿童有4,F,和5,F，,全长60,cm。,四腔,Swan-Ganz,导管:,端孔,为主腔开口用于,监测肺动脉压,和采集血标本。距管端30,cm,处有,一侧孔,用于监测,右房压,、,CVP,、,CO,和,输液,。,热敏计,位于距管端4,cm,处，用于感知热阻抗的变化，尾端与计算机相连。端孔1-2,mm,处有一,气囊,与尾端的注射器相连可注入气体(1.25-1.5,ml)。,Swan-Ganz,原理,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。,心室舒张末压(,LVDEP)=,肺动脉舒张压(,PADP)=,肺小动脉楔压(,PAWP)=,肺毛细血管楔压(,PCWP),。,PCWP:pulmonary artery capillary wedge pressure,临床意义,估价左右心室功能,区别心源性和非心源性肺水肿,指导治疗,选择最佳,PEEP,确定漂浮导管位置,肺动脉楔压,(,pulmonary aortic wedge pressure,PAWP),正常值为0.81.6,kPa。,可判定左心室功能，反映血容量是否充足。2.4,kPa:,左心功能不全、急性心源性肺水肿；2.4,kPa:,急性肺损伤、,ARDS。,肺毛细血管楔压,(,PCWP),正常值0.671.87,kPa。,反映左心房平均压及左心室舒张末期压。0.8,kPa:,体循环血容量不足；2.4,kPa:,即将或已出现肺淤血；4,kPa:,肺水肿。,平均肺动脉压,(,mean pulmonary arterial presssure,MPAP),正常值1.472.0,kPa。MPAP,升高见于肺血流量增加、肺血管阻力升高、二尖瓣狭窄、左心功不全。,MPAP,降低见于肺动脉瓣狭窄,。,SwanGanz,导管适应证,ARDS,左心衰,循环功能不稳定,急性心肌梗塞,区分心源性和非心源性肺水肿,心血管手术,肺栓塞,严重创伤，各类休克，嗜铬细胞瘤等。,床边盲目置管,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,Swan-Ganz,导管并发症,心律失常,气囊破裂,肺梗塞,肺动脉破裂和出血,导管打结,血栓形成,心包填塞,感染,心输出量,(,cardiac output,CO),正常值48,L/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。,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,Hemodynamic monitoring,每搏排出量,(,stroke volume,SV),指一次心搏由一侧心室射出的血量。成年人安静、平卧时为6090,ml。SV,与心肌收缩力、心脏前负荷、后负荷有关。,心脏指数,(,CI),正常值2.84.2,L/min.m,2,。CI2.5,提示心衰；,CI1.8,为心源性休克。,体循环阻力指数,(,system vascular resistance index,SVRI),体循环阻力(,SVR),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,SVR。,正常值为17602600,dyne,sec/cm,5,m,2,。,肺循环阻力指数,(,pulmonary vascular resistance index,PVRI,),肺循环阻力(,PVR),是监测右心室后负荷的指标。正常值为45225,dyne,sec/cm,5,m,2,。,Hemodynamic monitoring,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4468,g/m,m,2,。,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48,g/m,m,2,。,氧输出,(,deferent oxygen,DO,2,),指单位时间内由左心室输送到全身组织氧的总量。,DO,2,CI,动脉血氧含量(,CaO,2,),正常值520720,ml/min,m,2,。,氧耗量,(,VO,2,),指机体实际的氧消耗量。正常值1001800,ml/min,m,2,。,氧摄取率,(,O,2,ext),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,尿量、尿比重、尿常规及血、尿生化指标。,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,肾小球功能检测,肾小球滤过率(,GFR),血浆肌酐(,SCR),正常值83-177,mol/L(1-2mg/dl),血尿素氮(,BUN),正常值2.9-6.4,mmol/L(8-20mg/dl),内生肌酐清除率:正常100-148,L/24h(80-100ml/min),胃肠功能的监测和支持,胃肠功能测定仪,胃肠测压仪,食管24,hPH,监测仪,胃电图,胃动素(,motilin,MTL),胃肠通过时间测定,肠粘膜,PH,值监测,肝功能的监测和支持,有黄疸,一般检测:血清胆红素、尿胆红素、尿中尿胆素原、粪内尿胆素原、血清,ALP,及7-,GT,活性、脂蛋白-,X,测定。,溶血性黄疸:网织红细胞计数和红细胞脆性试验。,肝细胞性或阻塞性黄疸:钡餐，血清总蛋白及白/球比例，血清蛋白电泳，凝血酶原。,肝细胞受损检测:空腹血糖，血氨，转氨酶。,无黄疸,磺溴酞钠潴留试验，尿内胆红素定量试验，空腹血糖、血氨、血清转氨酶测定等。,体温监测,正常体温,口腔舌下36.3-37.2，腋窝温度36-37,直肠温度36-37.5,测温部位:,直肠、食管、鼻咽、耳膜、口腔、腋下,皮肤与中心温度差:正常温差小于2,平均皮肤温度常测大腿内侧。,发热分类(口腔温度),低热37.4-38，中等高热38-39,高热39-40(41)，超高热40以上(41以上),脑功能监测,颅内压监测,方法:脑室内测压、硬膜外测压、腰穿测压、纤维光导测压,适应症:进行性颅内压、颅脑手术后、,PEEP,病人,影响因素:,P,a,CO,2、,P,a,O,2,、,气管插管、咳嗽、喷涕、体温、血压、颈静脉受压,脑电图,脑血流图,脑电阻(,REG),检查、,Doppler,血流测定,Thank you!,