危重医学 ppt课件.ppt

CriticalCareMedicine,Dr.HuangPeizhiZhongshanHospitalofFudanUniversit,1,Whatiscriticalcaremedicine？,Multidisciplinaryhealthcarespecialtycaresforpatientswithacute,life-threateningillnessorinjurywhichincludingcontinuumoflifesupportfromthescenethroughdischargeCoordinatedcaresystems,analysisoftreatmentoptions,protocols,guidelinesforthecareofindividualpatientsMonitoringandtherapyIntensivecaremedicineinEurope,2,Whatiscriticalillness?,AconditionwherelifecannotbesustainedwithoutinvasivetherapeuticinterventionsCharacterizedbyacutelossofphysiologicreserveCardiacarrest,shock,sepsis,severetrauma,comaDysfunctionofoneormoreorgansystems:hemodynamicinsufficiency,respiratoryfailure,abnormalitiesoffluidandelectrolytes,3,CharactersofCCM(1),lifesupportfromsiteofaccidenttoinjuryduringtransportationandmanagementinemergencydepartment(ED)andtosurgicalintervationinoperatingroomorinintensivecareunit(ICU)RequireemergencymedicineandIntensivecaremedicine,4,CharactersofCCM(2),TeamactionbyphysicianswithvariousspecialtybackgroundsAddedexpertiseinresuscitationNofocusofinteresttoasinglebodysystem,butwidevarietyofillnessIntensivist-abilitytoprovideeffectivecriticalcareisinallcases,5,Emergencyandcriticalcaremedicine(ECCM)system,Pre-hospitalcare(self-help,helpfrombystanders,ambulancepersonnelviatransport)lifesupportinEmergencydepartment,operationroomandICUEMphysicianisbasedintheED,intensivistremainedinICU,6,HistoryofCCM,In1940s:physiciansittingatthebedsidethroughthelongnight1stICUopenedinEuropein1950sIn1970：setupsocietyofCCMinUSASince1991:teachingofCCMinChinaIn2001:setupcommitteeofCCMinShanghai,7,IntensiveCareUnit(ICU),8,WhatisICU?,Multidisciplinarymulti-professionalmedical/nursingfieldAveryhighnursetopatientratio(3-4:1)TheavailabilityofinvasivemonitoringTheuseofmechanicalandpharmacologicallifesustainingtherapies(mechanicalventilation,vasopressors,continuousdialysis,defibrillation,pacemaker),9,ServiceinICU,ElementaryserviceBedsidemonitorsystemTreatmentequipmentExperimentinstrument,10,ElementaryService,Patientarea(specialfunctionalbedandbedsidemonitor)Centralmonitoringfield（centralmonitorandfunctionalconnectedbedsidemonitor）Employmentarea(placementequipmentandtherapeuticroom,11,BedsideMonitorSystem,Non-invasivemonitoringInvasivemonitoring,12,Non-invasiveCardiovascularMonitoring,Electrocardiographicmonitoring:changesofTwavesandSTsegmentorarrhythmiaEchocardiographyNon-invasivebloodpressure(NBP):alarmtohigherorlowerBPDopplerultrasound,13,Non-invasiveRespiratoryMonitoring,Respiratoryrate(RR),respiratorywaveEndtidalpartialpressureofcarbondioxide(Pet-CO2):alveolarPCO2closetoPaCO2normalvalueis45%(2835mmHg)(3.74.7kpa)Pulseoximetry:pulsesaturationofoxygen(SpO2),14,InvasiveMonitoring,Centralvenouspressure(CVP）：nearlycloserightatriumpressure.Invasivebloodpressure(IBP):SBP40mmHgsuggesthypotension.Arterialoxygensaturation(SaO2）：arterialoxygenation,degreeofhemoglobinbindingtooxygen,95%97%isnormal.Arterialbloodgasanalysis(PH、PaO2、PaCO2).GastricmucousmembranPH(PHi),15,PulmonaryArterialCatheterization,Swan-GanzcatheterRightventricularpressure(RVP)Pulmonarycapillarywedgepressure(PCWP）Pulmonaryarterywedgepressure(PAWP)Pulmonaryarterialpressure(PAP)Cardiacoutput(CO)Cardiacindex(CI)3.5L/min/m2isnormalOxygendelivery(DO2):700-1400mlO2/minOxygenconsumption(VO2)：250O2/minMixedvenousoxygensaturation(SvO2):7385,16,TherapeuticEquipment,Mechanicalventilator(respirator)DefibrillatorTranscutaneousortransvenouscardiacpacingCardiopulmonaryresuscitationmachine(Thumpor),17,ExperimentalInstrument,BloodgasanalyzerAnelevatedserumlactatelevel(1mmol/L)identifiestissuehypoperfusioninpatientatriskwhoarenothypotensiveDetectmeter：rapidlydetectbloodsugarorCTnT,CTnIorBrainnatriureticpeptide(BNP),18,OrganFunctionSupportinICU,RespiratorysupportCirculatorysupportRenalsupportGastrointestinalsupportCerebralsupport,19,RespiratorySupport,Indication:hypoxemia,hypercapmiarespiratoryfailure,cardiacarrestMonitoring：arterialbloodgasanalysisPet-CO2、SpO2Treatment:(1)Oxygentherapy(whenSaO238Cor90beats/min(3)Tachypnea,witharespiratoryrate20breaths/minorPaCO212x109/Lor10%bandformsonaperipheralbloodsmear,31,DefinitionofSepsis,Sepsis=infectionplusphysiologicchangesknownasSIRScriteriaSeveresepsis=sepsiswithacuteorgandysfunctionSepticshock=sepsiswithshockrefractorytofluidresuscitation,32,TreatmentofSevereSepsis,RecombinanthumanactivatedproteinC(rhAPC):anti-coagulantandAnti-inflammatoryeffecttoimprovesurvivalinpatientswithorgandysfunction.Depressionapoptosisandinducesuperexpressionofanti-apoptosisproteinBcl-2,33,MODS,MultipleorgandysfunctionsyndromethemostcauseofdeathinICUOriginfordysfunctionofintestinalbarrierCellapoptosisEndotheliumdamageMitochondriondysfunction,34,NewManagement,Parenteralnutritio