Principles of Critical Care Medicine - Fudan...
Transcript of Principles of Critical Care Medicine - Fudan...
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Principles of
Critical Care Medicine
Bellson 2011 06
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Principles of
Critical Care Medicine
Bellson C
Cellphone number
13564407870
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Direction always goes first
Where to go?
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Principles of
Critical Care Medicine
Scoring system : APACHE II,MPM, SAPS.
Why? What for?
Diaganose and Classification of Shock; Monitoring : Pulmonary Artery Catheter
Respiratory:
a. Four types of Respiratory Failure
b. Endotracheal intubation and Mechanical Ventilatory Support
c. Weaning from Ventilation
d. Monitoring : Pulse Oximetry, Blood gas, Respiratory System Mechanics
Common complications in CCU and the definition of MOFs
NEUROLOGIC DYSFUNCTION IN CRITICALLY ILL PATIENTS Common symptoms
WITHHOLDING AND WITHDRAWING CARE
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Why CCU is a fighting place?
Everything focuses on life.
3 main parts of the treatment in CCU.
Respiratory
Circulation/Shock
Central nervous system
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What does CCU look like?
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What are the stuffs in the CCU?
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Ventilators
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Ventilators
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Ventilators
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Masks
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Who should stay in the CCU?
Scoring system acts as a law.
It is useful in guiding hospital
administrative policies .
It guides hospital administrative
policies, nursing and ancillary care .
It predicts outcomes in critical illness
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the most commonly utilized
scoring systems
APACHE (acute physiology and
chronic health evaluation)
system US
the MPM (mortality probability
model) Europe
the SAPS (simplified acute
physiology score) system
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common variables
age;
vital signs;
assessments of respiratory,
renal, and neurologic function;
and an evaluation of chronic
medical illnesses.
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Shock
What is Shock?
Shock is defined by the
presence of multisystem end-
organ hypoperfusion.
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Classification
Cardiogenic shock
Septic shock
Anaphylactic shock
hypovolemic shock
neurogenic shock
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Diagnose of Shock
1. BP < 90/60 mmHg
2. Why?
3. Clinical indicators :
tachycardia, tachypnea, cool
skin and extremities, acute
altered mental status, and
oliguria.
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Monitoring and Therapy
BP
CVP (central venous pressure)
PAC (Pulmonary Artery Catheter )
Pulse Oximetry, Blood gas
EKG
……
Therapy……
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Respiratory failure:
Four types of Respiratory
Failure
Endotracheal intubation
Mechanical Ventilatory Support
Weaning from Ventilation
Monitoring : Pulse Oximetry,
Blood gas, Respiratory System
Mechanics
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Four types of Respiratory
Failure
Acute Hypoxemic Respiratory Failure
alveolar flooding
and subsequent intrapulmonary shunt
Type II Respiratory Failure
a result of alveolar hypoventilation
-> the inability to effectively eliminate carbon dioxide
Type III Respiratory Failure
a result of lung atelectasis.
Type Iv Respiratory Failure
shock, hypo perfusion -> the weakness of respiratory muscles
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Monitoring
Blood gases analysis
Pulse Oximetry
BP
EKG
……
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Therapy Strategy
Endotracheal intubation
the optimal mean of ventilating unconscious patient
or patient with severe respiratory distress ;
the most reliable but not the only way
Mechanical Ventilatory Support
Care of The Mechanically Ventilated Patient
Weaning from Ventilation
spontaneous respiration for 8 hours;
an acceptable level of arterial blood gases
analysis
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Care of The Mechanically Ventilated
Patient
The management of airway
The management of pain
(Opiates )
The management of anxiety
anxiolysis
Neuromuscular blocking agents
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Care of The Mechanically Ventilated
Patient
pros and cons
patient-ventilator synchrony
less stress/less inflammation reaction
Amnesia / a myopathy known as the postparalytic syndrome
? hepatic and renal function
* So daily interruption of sedative infusions has been shown to prevent excessive drug accumulation and shorten the duration of mechanical ventilation and length of stay in the ICU.
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Weaning from Ventilation
Generally Speaking:
spontaneous respiration for 8 hours;
an acceptable level of arterial blood gases analysis
For All intubated, mechanically ventilated patients :
the screening test and undergo a spontaneous breathing trial are necessary.
In the end, (f/VT) is <105, the patient can be extubated.
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Common complications in CCU
and the definition of MOFs
What is MOSF ?
Severe sepsis, shock of any
kind, severe inflammatory
conditions such as pancreatitis,
and trauma might cause MOSF.
Tips : >24h;
Mortality risk increases ;
SIRS is a common basis
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Mechanism?
Gastrointestinal Tract
bacteria migrating etc.
Lungs
Kidneys
……
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COMPLICATIONS OF
CRITICAL ILLNESS
Sepsis
Ventilator associated pneumonia; ……
Deep Venous Thromboses
Pulmonary embolism
Stress Ulcers
Anemia
AKI
Malnutrition
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NEUROLOGIC DYSFUNCTION
Recognizing:
Common symptoms
Global or Local
MRI/CT
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NEUROLOGIC
DYSFUNCTION
Delirium
(eg. clozapine over the dose)
Anoxic Cerebral Injury
Stroke
Subarachnoid Hemorrhage
Status Epilepticus
Brain Death
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