pre-icu training for r1课件

Pre-ICU training for R1,Jun 22, 2008,ICU 的重要性,1/31/2 的美國人在他們生命的最後一年住過ICU, 而1/4 1/5 的人死在那兒。 除了死亡，受苦 (suffering)是ICU病人最常遭遇到的 。 ICU病人的家屬及朋友對ICU表示相當的不滿 (dissatisfaction )- 顯示受苦的不僅僅是病患本身。 ICUI龐大的花費是驚人的。,” Inevitable Surprises “ Peter Schwartz,降低醫療成本最有效方式, 就是不要再將大筆經費耗竭在病人生命結束前的三十天。 今日的醫生, 受到習俗或法律的驅迫,不顧病人自身的利益, 想盡辦法維持他們的生命, 甚至不惜犧牲她們的生活品質。 在生命的最後一個月, 比起加護病房的病患, 安寧療護的病患可以省下至少三千美元。,ICU 的問題,ICU 工作人員之間，缺乏溝通、團隊工作不佳、無法解決問題的情形相當常見。 在護理人員之間的情況，更是常見、重要 。 這些將造成無法有共識，也容易導致病患的不良結果。 ICU 病人或他們的代理人，常常抱怨照護者有關溝通的量質:醫病之間的接觸，常常太遲、太簡短、而導致治療目標的混淆、衝突、乃至於不確定性。,End-of-life Care,Pain or symptom control Life sustaining therapy Support for dying patients and their family,End-of-life care (臨終照護),Limitation of Medical Care DNR (拒絕急救) Withhold life sustaining (不給治療) Withdrawal life sustaining (停止治療) Patient-centered care Resource allocation Different Professions: oncology service vs ICU team,Resource Allocation(資源分配),當2位病患需住進 ICU 時，只有1個空床，誰應該優先住進去？ 預後評分-住院病患嚴重度評估表 解決方法: 增加ICU床數 增加現有ICU的有效利用,加護病房病患收治及轉出標準,收治標準 壹. 優先次序之原則 貳. 疾病診斷之原則 參. 客觀條件之原則,收治標準,必須選擇那些對於重症加護可能受益的病人。 有兩類不同情況的病人，在一般治療之下另施予重症加護治療，並無太大助益。 病況太輕而無助益 (too well to benefit)或是 病況太重而無助益 (too sick to benefit)。 加護病房之重症治療的目的，在改善極為危險和不穩定病況病患的預後。 在決定病況的好與壞而有無實質助益時，是主觀的判斷。 醫師必須去評估重症病患的疾病嚴重度和預後。結合臨床判斷，以最好的方式決定預後。 重症加護病房的轉入，決定必須根據不同的情況，給予優先順序(priority)，利用不同診斷和客觀的分析。,重症加護病房轉出條件,所有重症/加護病房的住院病患，必須持續地評估，直到不再需要重症加護治療。 當病患的生理狀態穩定，而加護觀察不再需要時， 當病患的生理狀態已退化，而不再考慮積極治療，可轉介至次階的照護時。,Technology changes what is today,Conflicts: Multiple members of the different healthcare teams may be confronted. Eroded Trust: With the increasing technology and multi-specialty, the “sacred trust” between patient and physician has eroded. Dysfunction : between oncology services and ICU teams,ICU照護,生活品質 尊嚴 自主權 資源分配 充分告知 臨終照護,ICU 的目標,ICU的臨床醫師，傳統上，認為他們的目標是治療疾病、恢復身體健康和功能。 必要時，這些目標也應該包括保障病患的好死(good death)。 Robert D. Crit Care Med 2001; 29: 2332,撤除維生治療,first blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, finally tube feedings,結論,重症醫學早期 重大的發現與發明，降低了疾病的罹病率和死亡率。 近年來逐漸發現 重症醫師逐漸認知對病人的責任，必須超越 “治療疾病”，而包括提供病人有尊嚴而可忍受的死亡。,結論,以痊癒模式的醫療: (curative model) 常以診斷性的檢查與治療性的介入，來達到病情的治癒。 以緩和模式的醫療: (palliative model) 以症狀解除、改善身體功能及減緩情緒上、心理上、靈性上的痛楚為主 。 前者強調疾病的治療，後者則以症狀的治療為主。,Procedure Note,Critical Care Physical Examination,Vital signs: Temperature, pulse, respiratory rate, BP (vital signs should be given in ranges) Input/Output: IV fluid volume/urine output. Special parameters: Oxygen saturation, pulmonary artery wedge pressure (PAWP), systemic vascular resistance (SVR), ventilator settings, impedance cardiography. General: Mental status, Glasgow coma score, degree ofdistress. HEENT: PERRLA, EOMI, carotid pulse. Lungs: Inspection, percussion, auscultation for wheezes, crackles. Cardiac: Lateral displacement of point of maximal impulse; irregular rate, irregular rhythm (atrial fibrillation); S3gallop (LV dilation), S4 (myocardial infarction), holosystolicapex murmur (mitral regurgitation). Cardiac murmurs: 1/6 = faint; 2/6 = clear; 3/6 - loud; 4/6= palpable; 5/6 = heard with stethoscope off the chest; 6/6= heard without stethoscope. Abdomen: Bowel sounds normoactive, abdomen soft andnontender. Extremities: Cyanosis, clubbing, edema, peripheral pulses2+. Skin: Capillary refill, skin turgor.,Critical Care Physical Examination,Neuro Deficits in strength, sensation. Deep tendon reflexes: 0 = absent; 1 = diminished; 2 = normal; 3 = brisk; 4 = hyperactive clonus. Motor Strength: 0 = no contractility; 1 = contractility but no joint motion; 2 = motion without gravity; 3 = motion against gravity; 4 = motion against some resistance; 5 = motion against full resistance (normal). Labs: CBC, INR/PTT; chem 7, chem 12, Mg,pH/pCO2/pO2. CXR, ECG, impedance cardiography, otherdiagnostic studies.,Impression/Problem list,Discuss diagnosis and plan for each problem by system. Neurologic Problems: List and discuss neurologic problems Pulmonary Problems: Ventilator management. Cardiac Problems: Arrhythmia, chest pain, angina. GI Problems: H2 blockers, nasogastric tubes, nutrition. Renourinary Problems: Fluid status: IV fluids, electrolyte therapy. Check BUN, creatinine. Monitor fluids and electrolytes. Monitor inputs and outputs. Hematologic Problems: Blood or blood products, DVT prophylaxis, check hematocrit/hemoglobin. Infectious Disease: Plans for antibiotic therapy; antibiotic day number, culture results. Endocrine/Nutrition: Serum glucose control, parenteral or enteral nutrition, diet.,Admission Check List,1. Call and request old chart, ECG, and x-rays. 2. Stat labs: CBC, Biochem, cardiac enzymes (myoglobin, troponin, CPK), INR, PTT, C&S, ABG, UA, cardiac enzymes (myoglobin, troponin, CPK). 3. Labs: Toxicology screens and drug levels. 4. Cultures: Blood culture x 2, urine and sputum culture (before initiating antibiotics), sputum Gram stain, urinalysis. . 5. CXR, ECG, diagnostic studies. 6. Discuss case with resident, attending, and family.,Critical Care Progress Note,ICU Day Number: Antibiotic Day Number: Subjective: Patient is awake and alert. Note any events that occurred overnight. Objective: Temperature, maximum temperature, pulse, respiratory rate, BP, 24- hr input and output, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output. Lungs: Clear bilaterally Cardiac: Regular rate and rhythm, no murmur, no rubs. Abdomen: Bowel sounds normoactive, soft-nontender. Neuro: No local deficits in strength, sensation.