內(nèi)科學(xué)危重病學(xué)總論

CriticalCareMedicine

HuangPeizhiZhongshanHospitalofFudanUniversity第1頁(yè)第2頁(yè)Objectives

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

)Neurologicdysfunction第3頁(yè)Assessmentofseverityofillness

AgeVitalsignsRespiratoryfunctionRenalfunctionNeurologicalfunctionChronicmedicalillnesses第4頁(yè)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(yè)DefinitionofShock

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

-Hypotension

-tachypnea

-coolskinandextremities-acutealteredmentalstatus

-oliguria

第7頁(yè)Hypotension

MAP=CO×SVR

preloadafterloadHR×cardiacfunction

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

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

RespiratorySupportIndication

PaO2,PaCO2,,abnormalPHTreatmentOxygentherapyMechanicalventilationinvasive

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

PaCO2,

SaO2

(

95%～97%)Pulseoximetryprovidesnoninvasivecontinuousmonitoringofpatientwithrespiratoryfailure

=SpO2

(pulsesaturationofoxygen)Oxygenindex(OI)=PaO2/FiO2>300第15頁(yè)P(yáng)ulseoximetry（SpO2）第16頁(yè)RespiratorysystemmechanicsPIP(peakinspiratorypressures)ResistancecompliancePLP(plateaupressures)ChestwallcomplianceLungcompliance第17頁(yè)P(yáng)ressure-TimecurveonVCV

cmH2O

第18頁(yè)P(yáng)ressure-TimecurveonPCV

第19頁(yè)CardiovascularMonitoringECGchangesofTwavesandSTsegme