內(nèi)科學危重病學總論

CriticalCareMedicine

HuangPeizhiZhongshanHospitalofFudanUniversity第1頁第2頁Objectives

Assessment(APACHII,shock,RF,MODS)Monitoring(arterialblood-gasanalysis,SpO2,pulmonaryarterycatheter

)Neurologicdysfunction第3頁Assessmentofseverityofillness

AgeVitalsignsRespiratoryfunctionRenalfunctionNeurologicalfunctionChronicmedicalillnesses第4頁APACHII

First24h:mild<10,severe>20

Acute:12variables(0-4)vitalsign(5)+oxygenation+Lab(5)+(15-GCS)Age:(0-6)Chronichealth(0-5)

第5頁DefinitionofShock

Astateofinadequatetissueperfusion/oxygendelivery(hypoperfusion/hypoxia)AmultisystemdisorderAffectsallorgansLacticacidosis(>4mmol/L)第6頁clinicalassessmentofshockCardiovascularstatusEffectofcirculatoryinadequacyonotherorgans-tachycardia

-Hypotension

-tachypnea

-coolskinandextremities-acutealteredmentalstatus

-oliguria

第7頁Hypotension

MAP=CO×SVR

preloadafterloadHR×cardiacfunction

myocardialvalvularpulsepressure(cold)conductionpreicardialMAP=CO×SVR=pulsepressure(warm)

SV第8頁CategoriesofShockCO,bloodVolume=hypovolemicCO,bloodVolume=cardiogenicCO,SVR=high-outputhypotension(e.g.,septicshock)第9頁RespiratoryfailureAcutehypoxemic:ALI/ARDS,(PaO2/FiO2<300/<200)Alveolarhypoventilation:Neurogenic(CNS,neuromuscularfunction)load(s)ontherespiratorysystem(resistiveloads,compliance,MV)Lungatelectasis:perioperativeperiodHypoperfusionofrespiratorymusclesinshockrespiratorydistressduetopulmonaryedema,lacticacidosis,andanemia第10頁RespiratoryfailureHypoxemia:PaO2(<60mmHg)Hypercapnia:PaCO2(>50mmHg)Mixed:PaO2+PaCO2Hypoperfusion:hyper-lactacidemia第11頁

RespiratorySupportIndication

PaO2,PaCO2,,abnormalPHTreatmentOxygentherapyMechanicalventilationinvasive

forcomaorseverenon-invasiveweaningfromventilation第12頁MODSSIRS+InfectionSepsisSevereSepsisMODS第13頁MonitoringinICUNon-invasivemonitoringInvasivemonitoring第14頁RespiratoryMonitoringThe"goldstandard"ofevaluatingrespiratorygasexchangeisarterialbloodgasanalysis=PH,PaO2,

PaCO2,

SaO2

(

95%～97%)Pulseoximetryprovidesnoninvasivecontinuousmonitoringofpatientwithrespiratoryfailure

=SpO2

(pulsesaturationofoxygen)Oxygenindex(OI)=PaO2/FiO2>300第15頁Pulseoximetry（SpO2）第16頁RespiratorysystemmechanicsPIP(peakinspiratorypressures)ResistancecompliancePLP(plateaupressures)ChestwallcomplianceLungcompliance第17頁Pressure-TimecurveonVCV

cmH2O

第18頁Pressure-TimecurveonPCV

第19頁CardiovascularMonitoringECGchangesofTwavesandSTsegme