外科重症监护与治疗课件.ppt

1、外科重症监护与治疗1外科重症监护与治疗2外科重症监护与治疗3生命：美好，灿烂生命：美好，灿烂外科重症监护与治疗4生命：繁花似锦，春意盎然生命：繁花似锦，春意盎然外科重症监护与治疗5生命：生命：顽强、拼搏顽强、拼搏外科重症监护与治疗6但生命但生命也会被击倒也会被击倒外科重症监护与治疗7生命：生命：甚至是脆弱的甚至是脆弱的外科重症监护与治疗8脆弱的生命脆弱的生命外科重症监护与治疗9外科重症监护与治疗10外科重症监护与治疗11外科重症监护与治疗12外科重症监护与治疗13外科重症监护与治疗14外科重症监护与治疗15外科重症监护与治疗16外科重症监护与治疗17（一）循环功能监测（一）循环功能监测外科重症

2、监护与治疗18外科重症监护与治疗19意义：实时、连续了解循环血压意义：实时、连续了解循环血压外科重症监护与治疗20外科重症监护与治疗21外科重症监护与治疗22外科重症监护与治疗232.中心静脉压监测中心静脉压监测外科重症监护与治疗24外科重症监护与治疗25外科重症监护与治疗26外科重症监护与治疗27外科重症监护与治疗28外科重症监护与治疗29外科重症监护与治疗30外科重症监护与治疗31外科重症监护与治疗32外科重症监护与治疗33外科重症监护与治疗34外科重症监护与治疗35外科重症监护与治疗36外科重症监护与治疗37外科重症监护与治疗38注：注：高于正常，一：正常，：高于正常，一：正常，：低于正

3、常，：两者相等，：前者大于后者，：低于正常，：两者相等，：前者大于后者，RAP：右心房压力，：右心房压力，PADP：肺动脉舒张压：肺动脉舒张压外科重症监护与治疗39外科重症监护与治疗40外科重症监护与治疗41外科重症监护与治疗42外科重症监护与治疗43外科重症监护与治疗44外科重症监护与治疗45外科重症监护与治疗46外科重症监护与治疗47外科重症监护与治疗48外科重症监护与治疗49外科重症监护与治疗50外科重症监护与治疗51外科重症监护与治疗52外科重症监护与治疗53外科重症监护与治疗54外科重症监护与治疗55B、年龄评分、年龄评分外科重症监护与治疗56C.以往健康状况评分以往健康状况评分外科

4、重症监护与治疗57外科重症监护与治疗58外科重症监护与治疗59(1)心搏骤停或电除颤后心搏骤停或电除颤后(48h内内)(2)控制呼吸，用或不用控制呼吸，用或不用PEEP(3)控制呼吸，间断或持续用肌松药控制呼吸，间断或持续用肌松药(4)食管静脉出血，三腔管压迫止血食管静脉出血，三腔管压迫止血(5)持续动脉内输液持续动脉内输液(6)放置肺动脉漂浮导管放置肺动脉漂浮导管(7)心房和心房和(或或)心室起搏心室起搏(8)病情不稳定者行血液透析病情不稳定者行血液透析(9)腹膜透析腹膜透析(10)人工低温人工低温(11)加压输血加压输血(12)抗休克裤抗休克裤(MAST)(13)监测颅内压监测颅内压(14

5、)输血小板输血小板(15)引主动脉球囊反搏引主动脉球囊反搏(IABP)(16)急诊手术急诊手术(24h内内)(17)急性消化道出血灌洗急性消化道出血灌洗(18)急诊行内镜或纤维支气管镜检查急诊行内镜或纤维支气管镜检查(19)应用血管活性药物应用血管活性药物(1种种)4分分外科重症监护与治疗60(1)静脉营养静脉营养(肾、心、肝衰营养液肾、心、肝衰营养液)(2)备用起搏器备用起搏器(3)胸腔引流胸腔引流(4)IMV或辅助通气或辅助通气(5)应用应用CPAP治疗治疗(6)经中心静脉输高浓度钾经中心静脉输高浓度钾(7)经鼻或口气管内插管经鼻或口气管内插管(8)无人工气道者行气管内吸引无人工气道者行气

6、管内吸引(9)代谢失衡，频繁调整出入量代谢失衡，频繁调整出入量(10)频查血气及出凝血频查血气及出凝血(4次次/班班)(11)频繁成分输血频繁成分输血(5U/24h)(12)非常规静脉单次注药非常规静脉单次注药(13)静滴一种血管活性药物静滴一种血管活性药物(14)持续静滴抗心律失常药物持续静滴抗心律失常药物 3分分(15)电转复治疗心律失常电转复治疗心律失常(16)应用降温毯应用降温毯(17)动脉置管测压动脉置管测压(18)48h内快速洋地黄化内快速洋地黄化(19)测定心排出量测定心排出量(20)快速利尿治疗体液超载或脑水肿快速利尿治疗体液超载或脑水肿(21)积极纠正代谢性碱中毒积极纠正代谢

7、性碱中毒(22)积极纠正代谢性酸中毒积极纠正代谢性酸中毒(23)紧急胸腔、腹膜后或心包穿刺紧急胸腔、腹膜后或心包穿刺(24)积极抗凝治疗积极抗凝治疗(最初最初48h)(25)因容量超负荷行静脉放血因容量超负荷行静脉放血(26)静脉应用静脉应用2种以上抗生素种以上抗生素(27)治疗惊厥或代谢性脑病治疗惊厥或代谢性脑病(48h内内)(28)复杂性骨牵引复杂性骨牵引 外科重症监护与治疗61(1)监测监测CVP(2)同时开放同时开放2条静脉输液条静脉输液(3)病情稳定者行血液透析病情稳定者行血液透析(4)48h内的气管切开内的气管切开(5)气管内插管或气管切开者接气管内插管或气管切开者接T形管或面罩自

8、主呼吸形管或面罩自主呼吸(6)鼻饲鼻饲(7)因体液丢失过多行补液治疗因体液丢失过多行补液治疗(8)静脉化疗静脉化疗(9)每小时记录神经、生命体征每小时记录神经、生命体征(10)频繁更换敷料频繁更换敷料(11)静滴垂体后叶素静滴垂体后叶素 2分分 外科重症监护与治疗62(1)监测监测ECG(2)每小时记录生命体征每小时记录生命体征(3)开放开放1条静脉输液条静脉输液(4)慢性抗凝治疗慢性抗凝治疗(5)常规记录常规记录24小时出入量小时出入量(6)急查血常规急查血常规(7)按计划间歇静脉用药按计划间歇静脉用药(8)常规更换敷料常规更换敷料(9)常规骨牵引常规骨牵引(10)气管切开护理气管切开护理(

9、11)褥疮褥疮(12)留置导尿管留置导尿管(13)吸氧治疗吸氧治疗(鼻管或面罩鼻管或面罩)(14)静脉应用抗生素静脉应用抗生素(2种种(15)胸部物理治疗胸部物理治疗(16)伤口、瘘管或肠瘘需加强冲洗、包扎清创伤口、瘘管或肠瘘需加强冲洗、包扎清创(17)胃肠减压胃肠减压(18)外周静脉营养或脂肪乳剂输人外周静脉营养或脂肪乳剂输人 1分分 外科重症监护与治疗63外科重症监护与治疗64外科重症监护与治疗65外科重症监护与治疗66外科重症监护与治疗67外科重症监护与治疗68外科重症监护与治疗69外科重症监护与治疗70外科重症监护与治疗71外科重症监护与治疗72外科重症监护与治疗73外科重症监护与治疗

10、74外科重症监护与治疗75外科重症监护与治疗76外科重症监护与治疗77外科重症监护与治疗78外科重症监护与治疗79外科重症监护与治疗80外科重症监护与治疗81外科重症监护与治疗82外科重症监护与治疗83外科重症监护与治疗84外科重症监护与治疗85外科重症监护与治疗86外科重症监护与治疗87外科重症监护与治疗88外科重症监护与治疗89外科重症监护与治疗90外科重症监护与治疗91肺泡肺泡肺泡肺泡肺毛细血管肺毛细血管肺毛细血管肺毛细血管外科重症监护与治疗92外科重症监护与治疗93外科重症监护与治疗94外科重症监护与治疗95外科重症监护与治疗96外科重症监护与治疗97外科重症监护与治疗98外科重症监护

11、与治疗99外科重症监护与治疗100外科重症监护与治疗101外科重症监护与治疗102外科重症监护与治疗103外科重症监护与治疗104外科重症监护与治疗105外科重症监护与治疗106外科重症监护与治疗107外科重症监护与治疗108CT scan of a 53-yr-old patient with“diffuse”ARDS caused by Pneumocystis carinii.The FRC is 273 mL,and the lung tissue volume is 1404 mL(normal,8001000 mL).A lower inflection point is pres

12、ent on the P-V curve at 12 cm H2O,and the slope is 32 mL/cm H2O.A PEEP of 17 cm H2O induced a lung recruitment of 821 mL without any detectable pulmonary overinflation.Critical Care Medicine 2003;31(4)Supplement:S285-S295外科重症监护与治疗10950-yr-old patient with“lobar”ARDS caused by aspiration pneumonia se

13、condary to a dental cellulitis.FRC is 725 mL,and lung tissue volume is 1486 mL(normal values,8001000 mL).On the P-V curve,the lower inflection point is at 4 cm H2O,and the slope is 42 mL/cm H2O.A PEEP of 10 cm H2O induced a lung recruitment of 275 mL,associated with a lung overinflation of 187 mL.Cr

14、itical Care Medicine 2003;31(4)Supplement:S285-S295外科重症监护与治疗110CT scans obtained in a 74-yr-old patient with“patchy”ARDS caused by severe bronchopneumonia.The FRC is 1486 mL,and the lung tissue volume is 1423 mL(normal,8001000 mL).On the P-V curve,the lower inflection point is at 8 cm H2O,and the sl

15、ope is 46 mL/cm H2O.A PEEP of 15 cm H2O induced a lung recruitment of 478 mL,with a lung overinflation of 92 mL.Critical Care Medicine 2003;31(4)Supplement:S285-S295外科重症监护与治疗111CT scan of a 53-yr-old patient with“diffuse”ARDS caused by Pneumocystis carinii.The FRC is 273 mL,and the lung tissue volum

16、e is 1404 mL(normal,8001000 mL).A lower inflection point is present on the P-V curve at 12 cm H2O,and the slope is 32 mL/cm H2O.A PEEP of 17 cm H2O induced a lung recruitment of 821 mL without any detectable pulmonary overinflation.50-yr-old patient with“lobar”ARDS caused by aspiration pneumonia sec

17、ondary to a dental cellulitis.FRC is 725 mL,and lung tissue volume is 1486 mL(normal values,8001000 mL).On the P-V curve,the lower inflection point is at 4 cm H2O,and the slope is 42 mL/cm H2O.A PEEP of 10 cm H2O induced a lung recruitment of 275 mL,associated with a lung overinflation of 187 mL.CT

18、scans obtained in a 74-yr-old patient with“patchy”ARDS caused by severe bronchopneumonia.The FRC is 1486 mL,and the lung tissue volume is 1423 mL(normal,8001000 mL).On the P-V curve,the lower inflection point is at 8 cm H2O,and the slope is 46 mL/cm H2O.A PEEP of 15 cm H2O induced a lung recruitment

19、 of 478 mL,with a lung overinflation of 92 mL.外科重症监护与治疗112外科重症监护与治疗113外科重症监护与治疗114(二二)心衰的血流动力学改变心衰的血流动力学改变外科重症监护与治疗115外科重症监护与治疗116外科重症监护与治疗117外科重症监护与治疗118外科重症监护与治疗119外科重症监护与治疗120外科重症监护与治疗121外科重症监护与治疗122外科重症监护与治疗123外科重症监护与治疗124外科重症监护与治疗125强强 心心 甙甙 去乙酰毛花甙去乙酰毛花甙C 地高辛地高辛 毒毛花甙毒毛花甙K外科重症监护与治疗126外科重症监护与治疗127外科重症监护与治疗128外科重症监护与治疗129外科重症监护与治疗130外科重症监护与治疗131外科重症监护与治疗132外科重症监护与治疗133