醫(yī)技學院華盛頓醫(yī)療手冊培訓重癥監(jiān)護

1、Contents Respiratory Failure Shock Respiratory Failure General Principles Hypercapnic respiratory failure may produce a respiratory acidosis (pH 7.35). Hypoxic respiratory failure can result in hypoxemia (arterial oxygen tension PaO2 60 mm Hg or arterial oxygen saturation SaO2 90%). The acute respir

2、atory distress syndrome (ARDS) is a form of hypoxic respiratory failure caused by acute lung injury. The common end result is disruption of the alveolar capillary membrane, leading to increased vascular permeability and accumulation of inflammatory cells and protein-rich edema fluid within the alveo

3、lar space. The American-European Consensus Conference has defined ARDS as follows: (a) acute bilateral pulmonary infiltrates, (b) ratio of PaO2 to inspired oxygen concentration (FIO2) 90%, PaO260mmHg Minute Volume of Ventilation Determined by Vt and f In COPD patients, the goal of PaCO2 is the basel

4、ine level, not the normal level Ventilator Management PEEP: Positive End-Expiratory Pressure Increase the risk of barotrauma and cardiovascular compromise Initial: 3-5cmH2O Incerments: 3-5cmH2O High level: 20-25cmH2O Goal 1: PaO255-60mmHg Goal 2: FiO260% Goal 3: Avoid CV compromise Ventilator Manage

5、ment Inspiratory Flow 40-80L/min for adult pts Trigger Sensitivity -2-5cmH2O or 3-5L/min Flow-by In flow-triggered system Decrease pts work of breathing Problems and Complications Worsening respiratory distress NOTE alarm, Vt, airway pressure Disconnected ventilator circuit Ventilate manually Suctio

6、n if manual ventilation is difficult Check vital sign and rapid physical examination Ventilator is never used again unless making sure its working properly Problems and Complications High PIP Pneumothorax, hemothorax, or hydropneumothorax Airway occlusion Bronchospasm Increased accumulation of conde

7、nsate in the ventilator circuit tubing Main-stem intubation Worsening pulmonary edema Development of gas trapping with auto-PEEP Problems and Complications Loss of Vt Leakage: circuit, tube or patient Asynchronous Breathing Unmet respiratory demands Inappropriate setting of ventilation Patients cond

8、ition worsening Hypotension Due to positive inspiratory pressure Increase preload Administration of dobutamine Problems and Complications Auto-PEEP Gas trapped of pts due to airway diseases or inadequate expiratory time Adjust ventilation parameter, increase PEEP Barotrauma or Volutrauma Associated

9、with high PIP, PEEP, or Pplat subcutaneous emphysema, pneumoperitoneum, pneumomediastinum, pneumopericardium, air embolism, and pneumothorax Maybe life-threatening Reduce inspiratory pressure Problems and Complications Positive fluid balance Cardiac arrhythmias Aspiration Ventilator-Associated Pneum

10、onia (VAP) Upper gastrointestinal hemorrhage Acid-base complications Oxygen toxicity Weaning from Mechanical Ventilation Gradual withdrawal of mechanical ventilatory support, depending on the condition of the patient and on the status of the cardiovascular and respiratory systems Methods SIMV T-tube

11、 PSV Protocol-guided weaning is safe and successful Extubation Should be performed early in the day Patient educated about the necessity of extubation, the need of cough, and the possibility of reintubation Extubated after the cuff is deflated completely Encourage the patient for cough and deep brea

12、thing, and vital sign should be monitered Extubation should not be reattempted for 24 to 72 hours after reintubation SHOCK General Principles Oxygen DeliveryBlood Flow Tissue Hypoxia Organ Malfuction Cellular Metabolism OliguriaUnconsciousPulse General Principles Classification HemodynamicHemodynami

13、c Bleeding Mass fluid loss Myocarditis AMI Cardiomyo- pathy Pericardial Tamponade Pulmonary Embolism Septic Allergic Neurogenic Hemodynamic patterns Type of ShockCISVRPVRSvO2RAPRVPPAPPAOP CardiogenicN HypovolemicN DistributiveN-NN-N-N-N-N- Obstructive-NN-N- Cardiogenic Shock Mostly followed by acute

14、 myocardial infarction (AMI) due to pump failure BP60mmHg CO18mmHg SVR Hypoperfusion Cardiogenic Shock Certain Concern PaO260mmHg Hct30% Non-invasive or invasive ventilation Necessary fluid management Pharmacological treatment Inotropes and vasopressors Vasodilators not used in severe hypotensive pt

15、s. DOPAMINE used as the first-line drug (BP60mmHg) An PAC maybe help for inotropes and fluid infusion Cardiogenic Shock Mechanically Circulatory Assist Devices In pts. not respond to medical therapy IABP is controlled electronically for synchronizing with the pts ECG Definitive treatment must be con

16、sidered including non-invasive or invasive procedures Septic Shock Septic Shock SIRSSEPSIS SEVERE SEPSIS SEPTIC SHOCK Resuscitative Principles Fluid Resuscitation Initial IV fluid challenge The amount of fluid based on clinical parameters Arterial BP, Urine Output, Cardiac filling pressure, CO Cryst

17、alloid fluid solutions prefer to colloid fluid Hematocrits of 20% to 25% for the young, and 30% for the older Resuscitative Principles Vesopressors and inotropes Dopamine 10mcg/kg/minincrease BP Dobutamine Epinephrine Norepinephrine Vasopressin Milrinone Hemodynamic Monitoring Pulmonary artery cathe

18、terization Pulmonary Artery Catheterization Indication Allows to measure intravascualr and intracardiac pressure (CVP, RAP, PAP, PAWP), CO, PvO2 Differentiate cardiogenic or noncardiogenic pulmonary edema Identify the etiology of shock Evaluate acute renal failure or unexplained acidosis Evaluate ca

19、rdiac disorders Monitor high-risk surgical patients in the perioperative setting Pulmonary Artery Catheterization Method Interpretation of Hemodynamic Parameters PAOP used as the left ventricular filling (preload) and the propensity of pulmonary edema Optimize cardiac function Optimize preload Inotr

20、opes or vasodilators followed Fluid bolus and followed by repeated measurements of PAOP, CI, SV, HR, etc. PAOP 5mmHg as cutoff for additional fluid bolus Interpretation of Hemodynamic Parameters Reduce unnecessary lung water Differentiating hydrostatic from nonhydrostatic pulmonary edema Adequacy of

21、 organ perfusion Noninvasive hemodynamic monitoring Esophageal Doppler Aortic blood flow velocity CO, SV, SVR can be calculated Correlate well with thermodilution values Contents Respiratory Failure Shock General Principles Hypercapnic respiratory failure may produce a respiratory acidosis (pH 7.35)

22、. Hypoxic respiratory failure can result in hypoxemia (arterial oxygen tension PaO2 60 mm Hg or arterial oxygen saturation SaO2 90%). The acute respiratory distress syndrome (ARDS) is a form of hypoxic respiratory failure caused by acute lung injury. The common end result is disruption of the alveolar capillary membrane, leading to increased vascular permeability and accumulation of inflammatory cells and protei