ICU护士应当掌握的知识

1、1会计学ICU护士应当掌握的知识护士应当掌握的知识234PinPoutflowR56015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)Autoregulatory thresholdSubautoregulatory slope7015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)control3 weeks1 week89Chatterjee A, DePriest K, Blair R,

2、 et al. Results of a survey of blood pressure monitoring by intensivists in critically ill patients: a preliminary study. Crit Care Med 2010; 38: 2335-233810from Barbara Bates: A Guide to Physical Examination111213真实收缩压1415 1617181920Weil MH, Henning RJ: New concepts in the diagnosis and fluid treat

3、ment of circulatory shock. Anesth Analg 1979; 58:124-1322223多巴胺剂量多巴胺剂量(g/kg/min)体重体重(kg)125101520400.240.481.202.403.604.80500.300.601.503.004.506.00600.360.721.803.605.407.20700.420.808.40800.480.962.404.807.209.60900.541.082.705.408.1010.801000.601.203.006.009.0012.0024Ilan R, Fowler R

4、A, Ferguson ND, et al. Prolonged time to alarm in infusion devices operated at low flow rates. Crit Care Med 2008; 36: 2763-276525Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R133血管活性药物：注射器更换方法血管活性药物：注射

5、器更换方法26Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R13327Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R

6、13328Argaud L, Cour M, Martin O, et al. Changeovers of vasoactive drug infusion pumps: impact of a quality improvement program. Crit Care 2007; 11: R1332930I吸气峰压(PIP)平台压(Pplat)31323334The ventilator is continuously, breath by breath, adapting the inspiratory pressure to changes in the volume/pressur

7、e relationship.When the target volume has been achieved and the measured volume increases above or decreases below the preset tidal volume, the pressure level is regulated in small steps of max 3 cmH2O until preset volumes are delivered.max 3 cmH2O3637正常正常少尿少尿缺血加剧缺血加剧急性肾小管坏死急性肾小管坏死此时开始治疗此时开始治疗38改变胃排

8、空及胃液pH值的药物有生物膜的装置(气管插管, 鼻胃管)既往应用抗生素宿主因素(免疫抑制, 烧伤)消化道细菌定植细菌误吸细菌吸入医院获得性肺炎水, 药物溶液及呼吸治疗装置污染感染控制措施不够(洗手, 隔离衣, 手套)医务人员不足经胸种植原发性菌血症胃肠道细菌移位Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet

9、1999; 354: 1851-185842Non-Pharmacological measuresETFCDCCCCSATS/ IDSARecommendationsInfection control.-.SurveillanceHandwashing.-.ClorhexidineEarly weaning-.RT guidelinesNIV.-.COPD/Low O2Multidisciplinary tube-.Staff (1:1)ETT/OGT?.Subglottic suctionCuff pressure.-.20 cm H2OAvoid circuit s.Only conta

10、minatedSemirecumbency.30-45 degreesKinetic beds-.-.Surgery/Neuro43Pharmacological measuresETFCDCCCCSATS/ IDSARecommendationsOral care-.-.?. - ClorhexidineSDD?.M.ControversialBiofilm formation-.PendingProphylactic Abx?-. SubgroupsStress ulcer prophylaxis?.MV48h -CoagulopTransfusion restriction-.CAD H

11、b 7g/dLGlycemic control-.Post-Surg/150Sedation-.Sedation breakAdequate Abx-.Short courseNutrition-.Enteral/Post-pyloricGrap MJ, Munro CL, Bryant S, et al. Predictors of backrest elevation in critical care. Intensive Crit Care Nurs 2003; 19: 68-74HOB 30HOB 45估测角度50p .00170p 30 30Williams Z, Chan R, K

12、elly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated pa

13、tients. Crit Care Med 2008; 36: 1155-1157Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157使用装置前使用装置前使用装置后使用装置后测定总数, n166102平均角度, 2231依从人数, n38 (22.9%)73 (71.6%)依从定义为床头角

14、度 28Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008; 36: 1155-1157Williams Z, Chan R, Kelly E. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed e

15、levation in ventilated patients. Crit Care Med 2008; 36: 1155-11575960Seguin P, Laviolle B, Isslame S, et al. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010; 36: 1202-120661Seguin P, Laviolle B, I

16、sslame S, et al. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010; 36: 1202-120662Seguin P, Laviolle B, Isslame S, et al. Effectiveness of simple daily sensitization of physicians to the duration of

17、 central venous and urinary tract catheterization. Intensive Care Med 2010; 36: 1202-1206http:/ access on July 8, 200863http:/ access on July 8, 200864http:/ access on July 8, 200865第一天第一天第二天第二天课程概述危重病患者的评估血流动力学监测基础机械通气 1 VC与PSV休克机械通气 2 SIMV+PSV与高压报警少尿和急性肾功能衰竭机械通气 3 气道阻力升高时的通气严重创伤机械通气 4 PCV与氧和下降的处理神

18、经系统急症气道管理严重感染及感染性休克心律失常危重病患者的转运心肺脑复苏第一天第一天第二天第二天机械通气 1 VC, SIMV+PSV机械通气 3 气道阻力高, 顺应性低机械通气 2 气道高压报警, 低氧报警机械通气 4 转运CPR动脉血气分析气道管理创伤危重病患者的评估代谢及电解质紊乱6869015050100Organ blood flow(% Baseline)010020406080Organ artery pressure (mmHg)control3 weeks1 week70真实收缩压71 72改变胃排空及胃液pH值的药物有生物膜的装置(气管插管, 鼻胃管)既往应用抗生素宿主因素(免疫抑制, 烧伤)消化道细菌定植