危重醫(yī)學(xué)(英文版).課件

1、 Critical Care MedicineDr. Huang PeizhiZhongshan Hospital of Fudan UniversitWhat is critical care medicine？Multidisciplinary healthcare specialty cares for patients with acute, life-threatening illness or injury which including continuum of life support from the scene through dischargeCoordinated ca

2、re systems, analysis of treatment options, protocols, guidelines for the care of individual patientsMonitoring and therapyIntensive care medicine in Europe What is critical illness ?A condition where life cannot be sustained without invasive therapeutic interventionsCharacterized by acute loss of ph

3、ysiologic reserveCardiac arrest, shock, sepsis, severe trauma, coma Dysfunction of one or more organ systems : hemodynamic insufficiency, respiratory failure , abnormalities of fluid and electrolytes Characters of CCM (1) life support from site of accident to injury during transportation and managem

4、ent in emergency department (ED) and to surgical intervation in operating room or in intensive care unit (ICU)Require emergency medicine and Intensive care medicine Characters of CCM (2)Team action by physicians with various specialty backgroundsAdded expertise in resuscitation No focus of interest

5、to a single body system, but wide variety of illness Intensivist - ability to provide effective critical care is in all cases Emergency and critical care medicine (ECCM) systemPre-hospital care (self-help, help from bystanders, ambulance personnel via transport)life support in Emergency department ,

6、 operation room and ICUEM physician is based in the ED, intensivist remained in ICU History of CCMIn 1940s: physician sitting at the bedside through the long night 1st ICU opened in Europe in 1950sIn 1970： set up society of CCM in USA Since 1991: teaching of CCM in ChinaIn 2001: set up committee of

7、CCM in Shanghai Intensive Care Unit (ICU) What is ICU ?Multidisciplinary multi-professional medical/nursing fieldA very high nurse to patient ratio (3-4:1)The availability of invasive monitoringThe use of mechanical and pharmacological life sustaining therapies (mechanical ventilation, vasopressors,

8、 continuous dialysis, defibrillation, pacemaker) Service in ICUElementary serviceBedside monitor systemTreatment equipmentExperiment instrument Elementary ServicePatient area (special functional bed and bedside monitor) Central monitoring field（central monitor and functional connected bedside monito

9、r）Employment area ( placement equipment and therapeutic roomBedside Monitor SystemNon-invasive monitoringInvasive monitoring Non-invasive Cardiovascular Monitoring Electrocardiographic monitoring: changes of T waves and ST segment or arrhythmiaEchocardiographyNon-invasive blood pressure( NBP ): alar

10、m to higher or lower BPDoppler ultrasound Non-invasive Respiratory MonitoringRespiratory rate (RR ), respiratory wave End tidal partial pressure of carbon dioxide (Pet-CO2) : alveolar PCO2 close to PaCO2 normal value is 4 5% ( 2835mmHg ) ( 3.74.7 kpa )Pulse oximetry : pulse saturation of oxygen (SpO

11、2 ) Invasive Monitoring Central venous pressure (CVP） ：nearly close right atrium pressure. Invasive blood pressure (IBP ) : SBP90mmHg, or MAP40mmHg suggest hypotension .Arterial oxygen saturation (SaO2）：arterial oxygenation , degree of hemoglobin binding to oxygen , 95%97% is normal .Arterial blood

12、gas analysis (PH、PaO2 、Pa CO2 ).Gastric mucous membran PH(PHi) Pulmonary Arterial CatheterizationSwan-Ganz catheterRight ventricular pressure (RVP)Pulmonary capillary wedge pressure( PCWP）Pulmonary artery wedge pressure( PAWP)Pulmonary arterial pressure (PAP)Cardiac output( CO)Cardiac index (CI) 3.5

13、 L/min/ m2 is normalOxygen delivery(DO2) :700-1400ml O2/minOxygen consumption(VO2) ：250 O2/minMixed venous oxygen saturation(SvO2):7385 Therapeutic EquipmentMechanical ventilator (respirator)DefibrillatorTranscutaneous or transvenous cardiac pacingCardiopulmonary resuscitation machine (Thumpor)Exper

14、imental InstrumentBlood gas analyzerAn elevated serum lactate level ( 1 mmol/L) identifies tissue hypoperfusion in patient at risk who are not hypotensiveDetect meter ：rapidly detect blood sugar or CTnT , CTnI or Brain natriuretic peptide ( BNP) Organ Function Support in ICU Respiratory supportCircu

15、latory supportRenal supportGastrointestinal supportCerebral support Respiratory SupportIndication: hypoxemia, hypercapmia respiratory failure, cardiac arrestMonitoring ：arterial blood gas analysis Pet-CO2 、 SpO2 Treatment: (1) Oxygen therapy ( when SaO2 38C or 90 beats/min(3) Tachypnea, with a respi

16、ratory rate 20 breaths/min or PaCO2 12 x 109/L or 10% band forms on a peripheral blood smearDefinition of SepsisSepsis = infection plus physiologic changes known as SIRS criteriaSevere sepsis = sepsis with acute organ dysfunction Septic shock = sepsis with shock refractory to fluid resuscitationTrea

17、tment of Severe SepsisRecombinant human activated protein C(rhAPC) : anti-coagulant and Anti-inflammatory effect to improve survival in patients with organ dysfunction.Depression apoptosis and induce super expression of anti-apoptosis protein Bcl-2 MODSMultiple organ dysfunction syndrome the most cause of death in ICUOrigin for dysfunction of intestinal barrierCell apoptosisEndothelium damageMitochondrion dysfunction New ManagementParenteral nutrit