危重病的早期預(yù)警.ppt

1、ICU=重癥醫(yī)學(xué)？ 危重病的早期預(yù)警,浙江省人民醫(yī)院ICU 孫仁華,內(nèi)容,背景 危重病的早期預(yù)警 小結(jié),什么叫重癥醫(yī)學(xué)?,早期發(fā)現(xiàn)并積極處理危重癥-提高搶救成功率的關(guān)鍵,ARDS ALI ARF AKI MOF MODS,病情的突然變化-病情變化被突然發(fā)現(xiàn),研究顯示：那些沒(méi)有經(jīng)過(guò)心肺復(fù)蘇就死亡的住院患者中，約一半的患者在死亡前的24 h內(nèi)具有可逆的生命體征異常；80的院內(nèi)心臟驟停的患者在發(fā)生事件前8 h內(nèi)已經(jīng)出現(xiàn)了嚴(yán)重的生命體征的異常,從不同部門(mén)入ICU患者死亡率的差別,普通病房入ICU患者的死亡率高于從急診室、手術(shù)室、麻醉復(fù)蘇室入ICU者 早期、恰當(dāng)?shù)闹委熆梢杂行岣邠尵瘸晒β剩档椭職埪?

2、現(xiàn)代醫(yī)學(xué)專業(yè)細(xì)分化與患者高齡化和復(fù)雜化的矛盾-發(fā)現(xiàn)延誤、處理不當(dāng),Hillman KM等前瞻性研究了551例從不同科室入ICU患者情況：90例來(lái)自普通病房，239例來(lái)自O(shè)R，222例來(lái)自ED。普通病房入ICU患者APACHE II 評(píng)分21，OR 15，ED 19；死亡率分別為47.6%、 OR 19.3%、 ED 31.5%；入ICU前經(jīng)歷的不良事件：普通病房72%、 OR 64.4%、 ED 61.8%。入ICU前8小時(shí)常見(jiàn)的不良事件： hypotension (n=199), tachycardia n=73), tachypnoea (n=64), and sudden change

3、in level of consciousness (n=42).,Intensive Care Med (2002) 28:16291634,危重病的早期預(yù)警,早期預(yù)警（Early warning scoring system，EWS）主要適用于ICU外區(qū)域， 最早由英國(guó)Morgan等提出，并得到廣泛的認(rèn)可與應(yīng)用。也有稱physiological track and trigger warning systems (TTs) 具體評(píng)介方法并未統(tǒng)一，多達(dá)數(shù)十種，但多以簡(jiǎn)單、常用生理參數(shù)為基礎(chǔ)。 MEWS是比較常用的方法之一,Recommendation Multiple-par

4、ameter or aggregate weighted scoring systems used for track and trigger systems should measure: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature.,NICE clinical guideline No. 50. London; 2007,Recommendation In specific clinical circumsta

5、nces, additional monitoring should be considered; for example: hourly urine output biochemical analysis, such as lactate, blood glucose, base deficit, arterial pH pain assessment.,NICE clinical guideline No. 50. London; 2007,危重病的早期預(yù)警,在EWS的基礎(chǔ)上，國(guó)外許多醫(yī)院成立：Critical Care Outreach Service (CCOS)，Medical Em

6、ergency Team (MET)，Rapid Response Teams等以提高危重病人的搶救成功率。,改良早期危險(xiǎn)評(píng)分（MEWS),Journal of Critical Care (2012) 27, 424.e7424.e13,Content of measurements. The combination (in white) of all measurements taken (N = 2688) is shown compared with the measurements with a positive MEWS (3 points) in black (n = 988).

7、 All possible combinations were analyzed, and those with a prevalence of 4% or more were included. BP indicates systolic blood pressure; Resp, respiratory rate; Temp, temperature; Sat, peripheral saturation with supplementary oxygen therapy,Early Warning Score scoring system EWS 3 2 1 0 1 2 3 Pulse

8、rate 51-100 101-110 111-130 130 BP (systolic) 200 Respiratory rate 30 Temperature 37.5 Consciousness A V P U EWS = Early Warning Score; BP = blood pressure; A= alert; V=responsive to voice; P=responsive to pain; U=unresponsive. Worried about patients condition: 1 point; Urine production below 75 ml

9、during previous 4 hours: 1 point; Saturation below 90% despite adequate oxygen therapy: 3 points.,january 2013 , vol . 71, No1,13 months (May 2010-May 2011),71,911 EWS values in the Medical Centre Alkmaar. 56% ( 40,183) on surgical wards, 44% (31,728) on medical wards,Mortality rate as a percentage

10、of admissions each year. Average values pre- and post-MEWS are shown along with P values,M.S. Patel et al. Injury, Int. J. Care Injured 42 (2011) 14551459,The distribution of NEWS values and the relationship with each of the four outcomes studied.,Smith GB, et al. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest