內(nèi)科學(xué)-危重病學(xué)總論課件

CriticalCareMedicine

HuangPeizhiZhongshanHospitalofFudanUniversity內(nèi)科學(xué)危重病學(xué)總論內(nèi)科學(xué)危重病學(xué)總論Objectives

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

)Neurologicdysfunction內(nèi)科學(xué)危重病學(xué)總論Assessmentofseverityofillness

AgeVitalsignsRespiratoryfunctionRenalfunctionNeurologicalfunctionChronicmedicalillnesses內(nèi)科學(xué)危重病學(xué)總論APACHII

First24h:mild<10,severe>20

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

內(nèi)科學(xué)危重病學(xué)總論DefinitionofShock

Astateofinadequatetissueperfusion/oxygendelivery(hypoperfusion/hypoxia)AmultisystemdisorderAffectsallorgansLacticacidosis(>4mmol/L)內(nèi)科學(xué)危重病學(xué)總論clinicalassessmentofshockCardiovascularstatusEffectofcirculatoryinadequacyonotherorgans-tachycardia

-Hypotension

-tachypnea

-coolskinandextremities-acutealteredmentalstatus-oliguria

內(nèi)科學(xué)危重病學(xué)總論Hypotension

MAP

=CO

×SVR

preloadafterloadHR×cardiacfunction

myocardialvalvularpulsepressure

(cold)conductionpreicardialMAP

=CO

×SVR

=pulsepressure

(warm)

SV

內(nèi)科學(xué)危重病學(xué)總論CategoriesofShockCO

,bloodVolume

=hypovolemicCO

,bloodVolume

=cardiogenicCO

,SVR

=high-outputhypotension(e.g.,septicshock)內(nèi)科學(xué)危重病學(xué)總論RespiratoryfailureAcutehypoxemic:ALI/ARDS,(PaO2/FiO2<300/<200)Alveolarhypoventilation:Neurogenic(CNS,neuromuscularfunction)load(s)ontherespiratorysystem

(resistiveloads,compliance

,MV

)Lungatelectasis:perioperativeperiodHypoperfusionofrespiratorymusclesinshockrespiratorydistressduetopulmonaryedema,lacticacidosis,andanemia內(nèi)科學(xué)危重病學(xué)總論RespiratoryfailureHypoxemia:PaO2

(<60mmHg)Hypercapnia:PaCO2

(>50mmHg)Mixed:PaO2

+PaCO2

Hypoperfusion:hyper-lactacidemia內(nèi)科學(xué)危重病學(xué)總論

RespiratorySupportIndication

PaO2

,PaCO2,

,abnormalPHTreatmentOxygentherapyMechanicalventilationinvasive

forcomaorseverenon-invasiveweaningfromventilation內(nèi)科學(xué)危重病學(xué)總論MODSSIRS+InfectionSepsisSevereSepsisMODS內(nèi)科學(xué)危重病學(xué)總論MonitoringinICUNon-invasivemonitoringInvasivemonitoring內(nèi)科學(xué)危重病學(xué)總論RespiratoryMonitoringThe"goldstandard"ofevaluatingrespiratorygasexchangeisarterialbloodgasanalysis=PH,PaO2,

PaCO2,

SaO2

(

95%～97%)Pulseoximetryprovidesnoninvasivecontinuousmonitoringofpatientwithrespiratoryfailure

=SpO2

(pulsesaturationofoxygen)Oxygenindex(OI)=PaO2/FiO2>300內(nèi)科學(xué)危重病學(xué)總論P(yáng)ulseoximetry（SpO2

）內(nèi)科學(xué)危重病學(xué)總論RespiratorysystemmechanicsPIP(peakinspiratorypressures)ResistancecompliancePLP(plateaupressures)ChestwallcomplianceLungcompliance內(nèi)科學(xué)危重病學(xué)總論P(yáng)ressure-TimecurveonVCV

cmH2O

內(nèi)科學(xué)危重病學(xué)總論P(yáng)ressure-TimecurveonPCV

內(nèi)科學(xué)危重病學(xué)總論CardiovascularMonitoringECGchangesofTwavesandSTsegmentarrhythmiaNBP

E