危重医学(英文版).课件.ppt

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

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

3、ysiologic reservenCardiac arrest,shock,sepsis,severe trauma,coma nDysfunction of one or more organ systems:hemodynamic insufficiency,respiratory failure,abnormalities of fluid and electrolytes Characters of CCM(1)nlife support from site of accident to injury during transportation and management in e

4、mergency department(ED)and to surgical intervation in operating room or in intensive care unit(ICU)nRequire emergency medicine and Intensive care medicine Characters of CCM(2)nTeam action by physicians with various specialty backgroundsnAdded expertise in resuscitation nNo focus of interest to a sin

5、gle body system,but wide variety of illness nIntensivist-ability to provide effective critical care is in all cases Emergency and critical care medicine(ECCM)systemnPre-hospital care(self-help,help from bystanders,ambulance personnel via transport)nlife support in Emergency department,operation room

6、 and ICUnEM physician is based in the ED,intensivist remained in ICU History of CCMnIn 1940s:physician sitting at the bedside through the long night n1st ICU opened in Europe in 1950snIn 1970：set up society of CCM in USA nSince 1991:teaching of CCM in ChinanIn 2001:set up committee of CCM in Shangha

7、i Intensive Care Unit(ICU)What is ICU?nMultidisciplinary multi-professional medical/nursing fieldnA very high nurse to patient ratio(3-4:1)nThe availability of invasive monitoringnThe use of mechanical and pharmacological life sustaining therapies(mechanical ventilation,vasopressors,continuous dialy

8、sis,defibrillation,pacemaker)Service in ICUnElementary servicenBedside monitor systemnTreatment equipmentnExperiment instrument Elementary ServicenPatient area(special functional bed and bedside monitor)nCentral monitoring field（central monitor and functional connected bedside monitor）nEmployment ar

9、ea(placement equipment and therapeutic roomBedside Monitor SystemnNon-invasive monitoringnInvasive monitoring Non-invasive Cardiovascular Monitoring nElectrocardiographic monitoring:changes of T waves and ST segment or arrhythmianEchocardiographynNon-invasive blood pressure(NBP):alarm to higher or l

10、ower BPnDoppler ultrasound Non-invasive Respiratory MonitoringnRespiratory rate(RR),respiratory wave nEnd tidal partial pressure of carbon dioxide(Pet-CO2):alveolar PCO2 close to PaCO2 normal value is 4 5%(2835mmHg)(3.74.7 kpa)nPulse oximetry:pulse saturation of oxygen(SpO2 )Invasive Monitoring nCen

11、tral venous pressure(CVP）：nearly close right atrium pressure.n Invasive blood pressure(IBP):SBP90mmHg,or MAP40mmHg suggest hypotension.nArterial oxygen saturation(SaO2）：）：arterial oxygenation,degree of hemoglobin binding to oxygen,95%97%is normal.nArterial blood gas analysis(PH、PaO2、Pa CO2).nGastric

12、 mucous membran PH(PHi)Pulmonary Arterial CatheterizationnSwan-Ganz catheternRight ventricular pressure(RVP)nPulmonary capillary wedge pressure(PCWP）nPulmonary artery wedge pressure(PAWP)nPulmonary arterial pressure(PAP)nCardiac output(CO)nCardiac index(CI)3.5 L/min/m2 is normalnOxygen delivery(DO2)

13、:700-1400ml O2/minnOxygen consumption(VO2)：250 O2/minnMixed venous oxygen saturation(SvO2):7385 Therapeutic EquipmentnMechanical ventilator(respirator)nDefibrillatornTranscutaneous or transvenous cardiac pacingnCardiopulmonary resuscitation machine(Thumpor)Experimental InstrumentnBlood gas analyzern

14、An elevated serum lactate level(1 mmol/L)identifies tissue hypoperfusion in patient at risk who are not hypotensivenDetect meter：rapidly detect blood sugar or CTnT,CTnI or Brain natriuretic peptide(BNP)Organ Function Support in ICU nRespiratory supportnCirculatory supportnRenal supportnGastrointesti

15、nal supportnCerebral support Respiratory SupportnIndication:hypoxemia,hypercapmia respiratory failure,cardiac arrestnMonitoring：arterial blood gas analysis Pet-CO2 、SpO2 nTreatment:(1)Oxygen therapy(when SaO2 38C or 90 beats/minn(3)Tachypnea,with a respiratory rate 20 breaths/min or PaCO2 12 x 109/L

16、 or 10%band forms on a peripheral blood smearDefinition of SepsisnSepsis=infection plus physiologic changes known as SIRS criterianSevere sepsis=sepsis with acute organ dysfunction nSeptic shock=sepsis with shock refractory to fluid resuscitationTreatment of Severe SepsisnRecombinant human activated

17、 protein C(rhAPC):anti-coagulant and Anti-inflammatory effect to improve survival in patients with organ dysfunction.nDepression apoptosis and induce super expression of anti-apoptosis protein Bcl-2 MODSnMultiple organ dysfunction syndromen the most cause of death in ICUnOrigin for dysfunction of in

18、testinal barriernCell apoptosisnEndothelium damagenMitochondrion dysfunction New ManagementnParenteral nutrition for central or peripheral vein administration and enteral for feeding tube positioned in the small bowel ,blood substitutenNew types of respirator nNew CRRT instrumentnHand-carried ultrasound devicenNew non-invasive hemodynamic monitoringnSublingual PH monitoring Thank you！