重症监护病房的设置方面.doc

ASPECTS OF THE INTENSIVE CARE UNIT SETTING 重症监护病房的设置方面Patients with critical illness in the intensive care unit (ICU) usually require advanced life support with mechanical ventilation, inotropic medications, or dialysis. 在重症监护病房（ICU）与重大疾病的患者，通常需要机械通气，正性肌力药物，或透析的高级生命支持。 Morbidity associated with critical illness includes complications of both acute and chronic diseases, nosocomial and iatrogenic consequences, and impaired quality of life among survivors. 与重大疾病相关的发病率，包括急性和慢性疾病，院内感染和医源性的后果，以及幸存者的生活质量受损并发症。 Critically ill patients are at a higher risk of death than any other hospital population. 危重病人在一个较高的死亡风险比其他任何医院人口。 Accordingly, the goals of critical care are to reduce the morbidity and mortality, to maintain organ function, and to restore health. 因此，危重病的目标是降低发病率和死亡率，以维持器官的功能，并恢复健康。 Unlike many other specialties, critical care medicine is not limited to a particular population, disease, diagnosis, or organ system. 不像许多其他的特色，危重病急救医学并不局限于某一特定人群，疾病诊断，或器官系统。The Intensivist-Led Multidisciplinary Team Intensivist为首的多学科小组Staffing of ICUs with critical care physicians, often referred to as intensivists, who provide mandatory consultation or are responsible for all care is associated with a significantly lower ICU and hospital mortality and a shorter ICU and hospital length of stay. 重症监护医生，危重，提供了强制性的咨询，或负责所有的护理是显着降低重症监护病房和住院死亡率和较短的重症监护病房和住院时间长，通常被称为加护病房的人员编制。 These findings may be due to the on-site availability of trained physicians dedicated to appropriate triage, prevention, diagnosis, monitoring, treatment, and palliation of critically ill patients. 这些研究结果可能是由于专门适当分流的预防，诊断，监测，治疗和姑息治疗的危重病人受过训练的医生对网站的可用性。In addition, daily rounds by an ICU physician who leads a multidisciplinary team appears to improve outcomes, probably because leadership, communication, and organizational culture can streamline the process of critical care. 此外，由ICU医生每天查房谁领导的多学科团队出现改善的结果，可能是因为领导，沟通，组织文化可以简化关键护理的过程中。 These favorable findings may be due to the intensivist-coordinated teamwork of nurses, respiratory therapists, dietitians, and pastoral care workers. 这些有利的结果可能是由于护士intensivist协调的团队精神，呼吸治疗师，营养师，和牧灵工作者。Applying Evidence to Prevent Complications of Critical Illness 运用证据，以防止并发症，危重病Considerable randomized trial evidence about effective preventive and therapeutic interventions has emerged in the ICU during the last decade. 在过去十年中，约相当有效的预防和治疗干预措施的随机试验证据已经出现在ICU。 However, barriers to the application of this evidence reflect the ICU setting itself, which is characterized by fast-paced decision making by many clinicians, sometimes leading to a lack of responsibility and decision-making authority as well as errors of omission. 然而，应用这方面的证据的障碍，反映ICU的设置本身，这是由快节奏的决策许多医生特点，有时会导致缺乏责任和决策权以及遗漏的错误。 Effective strategies to encourage implementation of evidence-based recommendations include interactive education, audit and feedback, written or computerized reminders, involvement of local opinion leaders, and multifaceted approaches. 有效的战略，鼓励实施以证据为基础的建议，包括互动式教育，审计和反馈，书面或电脑提醒，当地舆论领袖的参与，和多方面的办法。In the ICU setting, preprinted physician orders may help guide but should never dictate management. 在ICU设置，预印的医嘱可能帮助指导，但不应该规定管理。 Sample physician orders for a previously healthy, mechanically ventilated patient with community-acquired pneumonia and the acute respiratory distress syndrome ( Table 103-1 ) emphasize evidence-based management, including low tidal volume ventilation, daily interruption of sedation infusion, early enteral small bowel nutrition, elevation of the head of the bed to decrease aspiration pneumonia, stress ulcer prophylaxis, thromboprophylaxis, and intensive insulin therapy if stress hyperglycemia develops. 1 2 以前健康，机械通气病人与社区获得性肺炎和急性呼吸窘迫综合症（表103-1）样品医嘱强调以证据为基础的管理，包括小潮气量通气，每天中断镇静输液，早期肠内小肠营养，海拔头床，以减少吸入性肺炎，应激性溃疡的预防，预防血栓，和强化胰岛素治疗应激性高血糖的发展 。1 2 TABLE 103-1 - 表103-1 - INTENSIVE CARE UNIT BEST PRACTICE ADMISSION ORDERS: A PATIENT WITH COMMUNITY-ACQUIRED PNEUMONIA AND ARDS 深切治疗部的最佳实践许令：与社区获得性肺炎及急性呼吸窘迫综合征患者Community-Acquired Pneumonia and ARDS Management 社区获得性肺炎和ARDS管理 Orders 订单 Re-evaluate 重新评估 Mechanical ventilation 机械通气Target tidal volume, 57 mL/kg of ideal body weight; pressure control, 14 cm; rate, 12; FIO 2 , 0.5; PEEP, 14 cm 目标潮气量5-7毫升/公斤理想体重;压力控制，14厘米;率，12; FIO 2，0.5，PEEP，14厘米As needed 根据需要Maintenance fluid 保养液Lactated Ringers solution, 75 mL/hr IV 乳酸林格氏液，75毫升/小时IVAs needed 根据需要Sedation 镇静Midazolam, 28 mg/hr IV, bolus 24 mg as needed; daily interruption 0700 until 0900; restart at half prior infusion at 0900 unless instructed otherwise 咪唑安定，2-8毫克/小时，丸剂需要2-4毫克四，每日中断，直到0900 0700;一半在0900之前输液重新启动，除非另有指示Daily 日报Analgesia 镇痛Morphine, 14 mg IV as needed 吗啡，1-4毫克四，根据需要As needed 根据需要Antibiotics 抗生素Moxifloxacin, 400 mg IV once daily; cefotaxime,1 gIV tid 莫西沙星，400毫克四，每日一次;头孢噻肟，1克IV TIDDaily 日报Head of bed 床主管45-Degree elevation from horizontal 从横向45度的仰角As needed 根据需要Small bowel enteral nutrition 小肠肠内营养10 mL/hr of a commercial balanced feeding containing about 1 kcal/mL; increase by 10 mL q6h to maximum of 70 mL/hr 10毫升/商业平衡喂养大卡/毫升约含1小时; q6h增加10毫升，70毫升/小时的最大Daily 日报Stress ulcer prophylaxis 应激性溃疡预防Ranitidine, 50 mg IV q8h 雷尼替丁，50毫克IV q8hDaily 日报Thromboprophylaxis 血栓Unfractionated heparin, 5000 U SC q12h 普通肝素，5000 U SC q12hDaily 日报Intensive insulin therapy: if glucose level 200 mg/dL 胰岛素强化治疗：如果血糖水平 200毫克/升50 U insulin in 50 mL NS; start 0.5 U/hr, repeat measurement of glucose q1h for 4 hours; treat according to intensive insulin therapy algorithm 50 U胰岛素在生理盐水50毫升;启动0.5 U /小时，重复测量4个小时的血糖q1h;治疗胰岛素强化治疗算法As per algorithm 至于每个算法Calibrate capillary glucometer with laboratory glucose values 校准实验室血糖值的毛细管血糖仪Every morning 每天早上 -Laboratory and radiology tests 实验室和放射学测试Glucose level q4h when stable; arterial blood gas analysis with each ventilator change; other tests as per ICU team 血糖水平q4h时，每个呼吸变化与稳定;动脉血气分析，每加护病房团队的其他测试As needed 根据需要Monitoring 监测Electrocardiography, oximetry, arterial catheter, central venous catheter, Foley catheter, as per monitoring protocols 心电图，血氧饱和度，动脉导管，中心静脉导管，尿管，按监控协议As needed 根据需要ARDS = acute respiratory distress syndrome; Fio 2 = fraction of inspired oxygen; ICU = intensive care unit; IV = intravenously; NS = normal saline; PEEP = positive end-expiratory pressure; SC = subcutaneously. 急性呼吸窘迫综合征急性呼吸窘迫综合征; FIO 2 =吸入氧浓度;加护病房=重症监护单位;四=静脉注射; NS =生理盐水;偷看=正端呼气压力，SC =皮下。Fluid Resuscitation 液体复苏Intravenous fluids to maintain or to restore intravascular volume are an important component of ICU therapy. 静脉输液，以维持或恢复血容量的ICU治疗的重要组成部分 。 Crystalloids are readily available and inexpensive, whereas colloids generally require less volume to achieve a specific physiologic goal. 晶体溶液都是现成的，而且价格便宜，而胶体一般需要较少的量，以实现特定的生理目标。 Albumin is a naturally occurring protein colloid that increases intravascular oncotic pressure, but its use also carries a small risk of infection. 白蛋白是一种自然产生的蛋白质胶体，增加血管oncotic压力，但它的使用也进行少量的感染风险。 In a randomized trial of 7000 patients allocated to fluid replacement with either normal saline or 4% albumin, mortality was 21% in each group, and there were no differences in organ failure, duration of mechanical ventilation, need for renal replacement therapy, or length of ICU or hospital stay. 3 On the basis of these data, either crystalloid- or albumin-based fluid resuscitation can be recommended for most critically ill patients, although crystalloids may be preferred for patients with head injuries. 在分配补液或者生理盐水或4白蛋白的7000例患者，随机试验的死亡率为21，各组有没有差异器官功能衰竭，机械通气时间，肾脏替代治疗的需要，或长度ICU或住院。3在这些数据的基础上，无论是晶体或基于白蛋白液体复苏，可以建议对大多数危重病人，虽然晶体溶液可能为头部受伤患者的首选。Intravenous Sedation and Analgesia 静脉镇静和镇痛Endotracheal intubation, central venous catheterization, postoperative pain management, and other ICU procedures require that most patients receive sedation, analgesia, or both. 气管插管，中心静脉导管，术后疼痛管理，和其他ICU的程序要求，大多数患者接受镇静，镇痛，或两者兼而有之。 In a randomized trial, transient daily interruption of sedatives was associated with a shorter duration of mechanical ventilation and ICU length of stay compared with continuous infusion. 4 A standardized, nurse-implemented approach to sedation and analgesia by use of a validated sedation scale can target specific physiologic goals, shorten the duration of mechanical ventilation, and potentially reduce resource consumption compared with a continuous infusion. 在随机试验，每日镇静剂短暂中断与持续时间较短的机械通气和ICU住院时间比连续输注。4一个标准化，护士实施的镇静和镇痛方法使用一个有效的镇静规模可以针对特定的生理目标，缩短机械通气时间，并与持续静脉滴注相比，潜在地减少资源消耗。Stress Ulcer Prophylaxis 应激性溃疡预防A complex interplay of systemic and local factors, such as impaired microcirculation, decreased mucosal integrity, and Helicobacter pylori infection, may predispose to bleeding for upper gastrointestinal stress ulceration in critically ill patients. 一个复杂的相互作用，可能会使受损改善微循环，降低粘膜的完整性，幽门螺旋杆菌感染，全身和局部因素，如危重病人上消化道应激性溃疡出血。 In patients who are mechanically ventilated for at least 48 hours or who have a coagulopathy, the incidence of clinically important bleeding is at most 4%; in this group, H 2 -receptor antagonists are the only agents that have been shown to reduce the risk of clinically important bleeding in randomized trials. 5 Because this treatment is associated with a trend toward an increased risk of ventilator-associated pneumonia, patients should also receive effective strategies to prevent pneumonia, such as minimal ventilator circuit changes, use of heat and moisture exchangers and filters, and elevation of the head of the bed. 机械通风至少48小时或有凝血功能障碍的患者，临床上重要出血的发病率是4;在本组中，H 2受体拮抗剂已被证明，以减少风险的唯一代理商重要的临床随机试验中的 出血。5 由于这种治疗方法是走向呼吸机相关性肺炎的风险增加的趋势，患者也应得到有效的策略，如最小的呼吸机回路的变化，利用热能和预防肺炎，湿交换器和过滤器，和床头抬高。Thromboprophylaxis 血栓Due to immobility, inflammation, and procedures, venous thromboembolism is a common complication of critical illness. 由于行动不便，炎症和程序，静脉血栓栓塞是一种常见的并发症，危重病。 Anticoagulant thromboprophylaxis is clearly beneficial in patients who do not have contraindications. 抗凝血栓显然是没有禁忌的患者有益 。 Either low-dose unfractionated heparin or low-molecular-weight heparin 6 is suitable, but low-molecular-weight heparin is more effective in orthopedic trauma patients. 7 Mechanical devices (such as antiembolic stockings or pneumatic compression devices) are recommended for patients with contraindications to anticoagulants. 无论是低剂量普通肝素或低分子量 肝素6 是合适的，但低分子量肝素是创伤骨科患者更为有效。7）机械设备（如antiembolic长袜或充气加压装置建议以抗凝血剂的禁忌症患者。Long-Term Outcomes for Survivors 对幸存者的长期结果For survivors of critical illness, triggers for ICU discharge are restoration of hemodynamic stability, ability to protect the airway, and spontaneous breathing. 对于重大疾病的幸存者，触发加护病房出院，血流动力学稳定，保护呼吸道的能力和自主呼吸恢复。 However, biomarkers of inflammation, residual organ dysfunction, and functional disabilities persist in most ICU survivors. 然而，生物标志物炎症，残留器官功能障碍和功能障碍，坚持以最ICU的幸存者。 Treatments administered in the ICU also have serious sequelae. 在ICU管理的治疗也有严重的后遗症 。 For example, neuromuscular blockers and corticosteroids may contribute to polyneuropathy. 例如，神经肌肉阻断剂和皮质类固醇可能会导致神经病。 These problems have particularly serious adverse consequences for elderly critically ill patients who are deconditioned before hospitalization. 这些问题特别严重的不良后果，老人危重患者住院前deconditioned 。In addition, anxiety, post-traumatic stress, and major mood disorders are common among patients and their caregivers. 此外，焦虑，创伤后应激和主要情绪障碍的患者和他们的照顾者。 Therefore, although ICU discharge and hospital discharge are milestones in a patients trajectory, critical illness has rarely completely resolved when patients leave the ICU or the hospital. 因此，虽然加护病房出院和出院病人的轨迹的里程碑，重大疾病已很少彻底解决，当患者离开加护病房或医院。 Accordingly, multidimensional rehabilitation may be necessary to optimize the long-term outcomes among survivors of critical illness. 因此，多维康复可能需要优化重大疾病的幸存者之间的长期结果 。Predictions, Preferences, and End-of-Life Care 预测，偏好和最终的生活护理Prognostic information, which can help clinicians make better triage and treatment decisions, is generally welcomed by families. 预后信息，它可以帮助医生做出更好的分流和处理决定，是由家庭的普遍欢迎 。 Options include the Acute Physiology and Chronic Health Evaluation score, the Simplified Acute Physiology Score, and the Mortality Prediction Model. 选项包括急性生理和慢性健康评估评分，简化急性生理评分，和死亡率的预测模型。 More recently, specific measures of organ dysfunction at the time of ICU admission (the Logistic Organ Dysfunction score) and serially during the course of critical illness (the Multiple Organ Dysfunction score and the Sequential Organ Failure Assessment score) have helped describe baseline and evolving organ dysfunction. 最近，在入住ICU的时间（物流器官功能障碍评分），并连续在重大疾病（多器官功能障碍评分和序贯器官衰竭评估得分）的过程中器官功能障碍的具体措施帮助描述了基线和不断变化的器官功能障碍。 Despite the ubiquity of these scoring 尽管这些得分的普及 systems, their utility as prognostic tools for individual patients is limited. 系统，其作为个别病人的预后工具的效用是有限的。 Furthermore, an intensivists prediction of survival for a mechanically ventilated patient is generally a better estimate of ICU mortality than are baseline measures of the severity of illness, the use of inotropic agents, or evolving and resolving organ dysfunction scores. 此外，机械通气患者的生存intensivist的预测一般是更好地估计了ICU死亡率比基线疾病的严重性，正性肌力药的使用，或器官功能障碍评分的不断发展和解决措施。As the population ages and new technologies are developed, use of basic and advanced life support will increase. 随着人口的老龄化和新技术的开发，使用的基本和高级生命支持将增加。 Because demand for ICU beds is outstripping supply, selection of patients to receive critical care is challenging. 由于ICU的病床供不应求，接受重症监护的病人选择是一项挑战。 Three common but not mutually exclusive approaches to rationing of ICU beds are admission of the sickest patients; admission on a first-come, first-served basis; and triage on the grounds of likely relative benefit. 三种常见的，但不是相互排斥的的方法配给ICU的病床入院的病童入场，先到先得，先到先得;，分流可能相对受益的理由。 Patients who are refused ICU admission because of a perceived minimum potential to benefit have a three-fold higher hospital mortality than patients who are admitted to the ICU. 谁是拒绝了，因为认为可能性最小的受益三倍入住ICU的病人的住院死亡率高于入住ICU的患者。 However, when ICU beds are reduced because of bed closures, admitted patients are generally sicker, are less frequently admitted for monitoring, and have shorter stays without adverse effects. 然而，当ICU病床减少因为床封，入院病人一般病情加重，不经常监测承认，短期停留，并没有任何不良影响。 These data suggest that physicians can ration ICU beds to maximize benefit by adapting admission and discharge thresholds. 这些数据表明，医生可以配给ICU的病床，以最大限度地适应入院和出院阈值受益 。The prognosis of many critically ill patients improves once they are in the ICU. 许多危重病人的预后改善，一旦他们在 ICU。 For others, responses are delayed or not realized, organ dysfunction evolves but does not resolve, and complications arise. 他人，响应延迟或没有意识到，器官功能障碍的发展，但没有解决，和并发症的出现。 Despite the best efforts of the multidisciplinary ICU team, critical illness proves fatal in 5 to 40% of adults. 尽管ICU的多学科团队尽了最大努力，在5到40的成年人是致命的重大疾病证明。 When a therapeutic trial of critical care is started, and particularly when it is failing, it