危重病的早期预警ppt课件

.,1,ICU=重症医学？危重病的早期预警,浙江省人民医院ICU孙仁华,.,2,内容,背景危重病的早期预警小结,.,3,什么叫重症医学?,.,4,早期发现并积极处理危重症-提高抢救成功率的关键,ARDSALIARFAKIMOFMODS,.,5,病情的突然变化-病情变化被突然发现,研究显示：那些没有经过心肺复苏就死亡的住院患者中，约一半的患者在死亡前的24h内具有可逆的生命体征异常；80的院内心脏骤停的患者在发生事件前8h内已经出现了严重的生命体征的异常,.,6,从不同部门入ICU患者死亡率的差别,普通病房入ICU患者的死亡率高于从急诊室、手术室、麻醉复苏室入ICU者早期、恰当的治疗可以有效提高抢救成功率，降低致残率现代医学专业细分化与患者高龄化和复杂化的矛盾-发现延误、处理不当,.,7,HillmanKM等前瞻性研究了551例从不同科室入ICU患者情况：90例来自普通病房，239例来自OR，222例来自ED。普通病房入ICU患者APACHEII评分21，OR15，ED19；死亡率分别为47.6%、OR19.3%、ED31.5%；入ICU前经历的不良事件：普通病房72%、OR64.4%、ED61.8%。入ICU前8小时常见的不良事件：hypotension(n=199),tachycardian=73),tachypnoea(n=64),andsuddenchangeinlevelofconsciousness(n=42).,IntensiveCareMed(2002)28:16291634,.,8,危重病的早期预警,早期预警（Earlywarningscoringsystem，EWS）主要适用于ICU外区域，最早由英国Morgan等提出，并得到广泛的认可与应用。也有称physiologicaltrackandtriggerwarningsystems(TTs)具体评介方法并未统一，多达数十种，但多以简单、常用生理参数为基础。MEWS是比较常用的方法之一,.,9,RecommendationMultiple-parameteroraggregateweightedscoringsystemsusedfortrackandtriggersystemsshouldmeasure:heartraterespiratoryratesystolicbloodpressurelevelofconsciousnessoxygensaturationtemperature.,NICEclinicalguidelineNo.50.London;2007,.,10,RecommendationInspecificclinicalcircumstances,additionalmonitoringshouldbeconsidered;forexample:hourlyurineoutputbiochemicalanalysis,suchaslactate,bloodglucose,basedeficit,arterialpHpainassessment.,NICEclinicalguidelineNo.50.London;2007,.,11,危重病的早期预警,在EWS的基础上，国外许多医院成立：CriticalCareOutreachService(CCOS)，MedicalEmergencyTeam(MET)，RapidResponseTeams等以提高危重病人的抢救成功率。,.,12,改良早期危险评分（MEWS),.,13,JournalofCriticalCare(2012)27,424.e7424.e13,.,14,.,15,Contentofmeasurements.Thecombination(inwhite)ofallmeasurementstaken(N=2688)isshowncomparedwiththemeasurementswithapositiveMEWS(3points)inblack(n=988).Allpossiblecombinationswereanalyzed,andthosewithaprevalenceof4%ormorewereincluded.BPindicatessystolicbloodpressure;Resp,respiratoryrate;Temp,temperature;Sat,peripheralsaturationwithsupplementaryoxygentherapy,.,16,.,17,.,18,EarlyWarningScorescoringsystemEWS3210123Pulserate51-100101-110111-130130BP(systolic)200Respiratoryrate30Temperature37.5ConsciousnessAVPUEWS=EarlyWarningScore;BP=bloodpressure;A=alert;V=responsivetovoice;P=responsivetopain;U=unresponsive.Worriedaboutpatientscondition:1point;Urineproductionbelow75mlduringprevious4hours:1point;Saturationbelow90%despiteadequateoxygentherapy:3points.,january2013,vol.71,No1,.,19,13months(May2010-May2011),71,911EWSvaluesintheMedicalCentreAlkmaar.56%(40,183)onsurgicalwards,44%(31,728)onmedicalwards,.,20,.,21,Mortalityrateasapercentageofadmissionseachyear.Averagevaluespre-andpost-MEWSareshownalongwithPvalues,M.S.Pateletal.Injury,Int.J.CareInjured42(2011)14551459,.,22,.,23,ThedistributionofNEWSvaluesandtherelationshipwitheachofthefouroutcomesstudied.,SmithGB,etal.TheabilityoftheNationalEarlyWarningScore(NEWS)todiscriminatepatientsatriskofearlycardiacarrest,unanticipatedint