外科重症监护与治疗教学课件.ppt

1、123生命：美好，灿烂生命：美好，灿烂4生命：繁花似锦，春意盎然生命：繁花似锦，春意盎然5生命：生命：顽强、拼搏顽强、拼搏6但生命但生命也会被击倒也会被击倒7生命：生命：甚至是脆弱的甚至是脆弱的8脆弱的生命脆弱的生命91011121314151617（一）循环功能监测（一）循环功能监测1819意义：实时、连续了解循环血压意义：实时、连续了解循环血压202122232.中心静脉压监测中心静脉压监测242526272829303132333435363738注：注：高于正常，一：正常，：高于正常，一：正常，：低于正常，：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

2、房压力，：右心房压力，PADP：肺动脉舒张压：肺动脉舒张压3940414243444546474849505152535455B、年龄评分、年龄评分56C.以往健康状况评分以往健康状况评分575859(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(

3、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)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

4、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

5、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 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(

6、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 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)

7、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(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 6364656667686970717273747576777879808182838485868788899091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92

8、93949596979899100101102103104105106107108CT 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 present on the P-V curve at 12 cm H2O,and the slope is 32 mL/cm H2O.A PEEP o

9、f 17 cm H2O induced a lung recruitment of 821 mL without any detectable pulmonary overinflation.Critical Care Medicine 2003;31(4)Supplement:S285-S29510950-yr-old patient with“lobar”ARDS caused by aspiration pneumonia secondary to a dental cellulitis.FRC is 725 mL,and lung tissue volume is 1486 mL(no

10、rmal 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.Critical Care Medicine 2003;31(4)Supplement:S285-S295110CT scans obtained in a 74-y

11、r-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 of 478 mL,with a lung o

12、verinflation of 92 mL.Critical Care Medicine 2003;31(4)Supplement:S285-S295111CT 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 present on the P-V curve at 12 cm H2O,a

13、nd 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 secondary to a dental cellulitis.FRC is 725 mL,and lung tissue volume is 1486 mL(normal values,8001000

14、 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 scans obtained in a 74-yr-old patient with“patchy”ARDS caused by severe bronchopneumonia.The FRC is

15、 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 of 478 mL,with a lung overinflation of 92 mL.112113114(二二)心衰的血流动力学改变心衰的血流动力学改变115116117118119120121122123124125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K126127128129130131132133个人观点供参考，欢迎讨论！