医、技学院(华盛顿医疗手册培训-重症监护)PPT资料.ppt

医、技学院(华盛顿医疗手册培训-重症监护)PPT资料.ppt

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THEWASHINGTONMANUALOFMEDICALTHERAPEUTICS-CRITICALCAREDepartmentofCriticalCareCuiWeiContentsRespiratoryFailureShockRespiratoryFailureGeneralPrinciplesHypercapnicrespiratoryfailuremayproducearespiratoryacidosis（pH7.35）.Hypoxicrespiratoryfailurecanresultinhypoxemia（arterialoxygentensionPaO260mmHgorarterialoxygensaturationSaO290%）.Theacuterespiratorydistresssyndrome（ARDS）isaformofhypoxicrespiratoryfailurecausedbyacutelunginjury.Thecommonendresultisdisruptionofthealveolarcapillarymembrane,leadingtoincreasedvascularpermeabilityandaccumulationofinflammatorycellsandprotein-richedemafluidwithinthealveolarspace.TheAmerican-EuropeanConsensusConferencehasdefinedARDSasfollows:

@#@（a）acutebilateralpulmonaryinfiltrates,（b）ratioofPaO2toinspiredoxygenconcentration（FIO2）90%,PaO260mmHgMinuteVolumeofVentilationDeterminedbyVtandfInCOPDpatients,thegoalofPaCO2isthebaselinelevel,notthenormallevelVentilatorManagementPEEP:

@#@PositiveEnd-ExpiratoryPressureLungLungComplanceComplanceOxygenationOxygenationShuntShuntFractionFractionWorkofWorkofBreathingBreathingIncreasetheriskofbarotraumaandcardiovascularcompromiseInitial:

@#@3-5cmH2OIncerments:

@#@3-5cmH2OHighlevel:

@#@20-25cmH2OGoal1:

@#@PaO255-60mmHgGoal2:

@#@FiO260%Goal3:

@#@AvoidCVcompromiseVentilatorManagementInspiratoryFlow40-80L/minforadultptsTriggerSensitivity-2-5cmH2Oor3-5L/minFlow-byInflow-triggeredsystemDecreaseptsworkofbreathingProblemsandComplicationsWorseningrespiratorydistressNOTEalarm,Vt,airwaypressureDisconnectedventilatorcircuitVentilatemanuallySuctionifmanualventilationisdifficultCheckvitalsignandrapidphysicalexaminationVentilatorisneverusedagainunlessmakingsureitsworkingproperlyProblemsandComplicationsHighPIPPneumothorax,hemothorax,orhydropneumothoraxAirwayocclusionBronchospasmIncreasedaccumulationofcondensateintheventilatorcircuittubingMain-stemintubationWorseningpulmonaryedemaDevelopmentofgastrappingwithauto-PEEPProblemsandComplicationsLossofVtLeakage:

@#@circuit,tubeorpatientAsynchronousBreathingUnmetrespiratorydemandsInappropriatesettingofventilationPatientsconditionworseningHypotensionDuetopositiveinspiratorypressureIncreasepreloadAdministrationofdobutamineProblemsandComplicationsAuto-PEEPGastrappedofptsduetoairwaydiseasesorinadequateexpiratorytimeAdjustventilationparameter,increasePEEPBarotraumaorVolutraumaAssociatedwithhighPIP,PEEP,orPplatsubcutaneousemphysema,pneumoperitoneum,pneumomediastinum,pneumopericardium,airembolism,andpneumothoraxMaybelife-threateningReduceinspiratorypressureProblemsandComplicationsPositivefluidbalanceCardiacarrhythmiasAspirationVentilator-AssociatedPneumonia（VAP）UppergastrointestinalhemorrhageAcid-basecomplicationsOxygentoxicityWeaningfromMechanicalVentilationGradualwithdrawalofmechanicalventilatorysupport,dependingontheconditionofthepatientandonthestatusofthecardiovascularandrespiratorysystemsMethodsSIMVT-tubePSVProtocol-guidedweaningissafeandsuccessfulExtubationShouldbeperformedearlyinthedayPatienteducatedaboutthenecessityofextubation,theneedofcough,andthepossibilityofreintubationExtubatedafterthecuffisdeflatedcompletelyEncouragethepatientforcoughanddeepbreathing,andvitalsignshouldbemoniteredExtubationshouldnotbereattemptedfor24to72hoursafterreintubationSHOCKGeneralPrinciplesOxygenDeliveryBloodFlowTissueHypoxiaOrganMalfuctionCellularMetabolismOliguriaUnconsciousPulseGeneralPrinciplesSurvivalofShockFluidFluidAdministraionAdministraionDegreeofDegreeofOrganOrganDysfunctionDysfunctionReversalofReversalofEtiologicEtiologicProcessProcessClassificationHemodynamicHemodynamicHypovolemicHypovolemicHypovolemicHypovolemicBleedingMassfluidlossCardiogenicCardiogenicCardiogenicCardiogenicMyocarditisAMICardiomyo-pathyObstructiveObstructiveObstructiveObstructivePericardialTamponadePulmonaryEmbolismDistributiveDistributiveDistributiveDistributiveSepticAllergicNeurogenicHemodynamicpatternsTypeofShockCISVRPVRSvO2RAPRVPPAPPAOPCardiogenicNHypovolemicNDistributiveN-NN-N-N-N-N-Obstructive-NN-N-CardiogenicShockMostlyfollowedbyacutemyocardialinfarction（AMI）duetopumpfailureBP60mmHgCO18mmHgSVRHypoperfusionCardiogenicShockCertainConcernPaO260mmHgHct30%Non-invasiveorinvasiveventilationNecessaryfluidmanagementPharmacologicaltreatmentInotropesandvasopressorsVasodilatorsnotusedinseverehypotensivepts.DOPAMINEusedasthefirst-linedrug（BP60mmHg）AnPACmaybehelpforinotropesandfluidinfusionCardiogenicShockMechanicallyCirculatoryAssistDevicesInpts.notrespondtomedicaltherapyIABPiscontrolledelectronicallyforsynchronizingwiththeptsECGDefinitivetreatmentmustbeconsideredincludingnon-invasiveorinvasiveproceduresSepticShockSepticShockSIRSSEPSISSEVERESEPSISSEPTICSHOCKFLUIDFLU