2022醫(yī)學課件危重病的早期預警

1、ICU=重癥醫(yī)學？ 危重病的早期預警浙江省人民醫(yī)院ICU 孫仁華第一頁，共二十七頁。內(nèi)容背景危重病的早期預警小結第二頁，共二十七頁。 什么叫重癥醫(yī)學?第三頁，共二十七頁。早期發(fā)現(xiàn)并積極處理危重癥-提高搶救成功率的關鍵ARDS ALIARF AKIMOF MODS第四頁，共二十七頁。病情的突然變化-病情變化被突然發(fā)現(xiàn)研究顯示：那些沒有經(jīng)過心肺復蘇就死亡的住院患者中，約一半的患者在死亡前的24 h內(nèi)具有可逆的生命體征異常；80的院內(nèi)心臟驟停的患者在發(fā)生事件前8 h內(nèi)已經(jīng)出現(xiàn)了嚴重的生命體征的異常第五頁，共二十七頁。從不同部門入ICU患者死亡率的差異普通病房入ICU患者的死亡率高于從急診室、手術室、

2、麻醉復蘇室入ICU者早期、恰當?shù)闹委熆梢杂行岣邠尵瘸晒β?，降低致殘率現(xiàn)代醫(yī)學專業(yè)細分化與患者高齡化和復雜化的矛盾-發(fā)現(xiàn)延誤、處理不當?shù)诹?，共二十七頁?Hillman KM等前瞻性研究了551例從不同科室入ICU患者情況：90例來自普通病房，239例來自OR，222例來自ED。普通病房入ICU患者APACHE II 評分21，OR 15，ED 19；死亡率分別為47.6%、 OR 19.3%、 ED 31.5%；入ICU前經(jīng)歷的不良事件：普通病房72%、 OR 64.4%、 ED 61.8%。入ICU前8小時常見的不良事件： hypotension (n=199), tachycardia

3、 n=73), tachypnoea (n=64), and sudden change in level of consciousness (n=42). Intensive Care Med (2002) 28:16291634第七頁，共二十七頁。危重病的早期預警早期預警Early warning scoring system，EWS主要適用于ICU外區(qū)域， 最早由英國Morgan等提出，并得到廣泛的認可與應用。也有稱physiological track and trigger warning systems (TTs)具體評介方法并未統(tǒng)一，多達數(shù)十種，但多以簡單、常用生理參數(shù)為根底。

4、MEWS是比較常用的方法之一第八頁，共二十七頁。Recommendation Multiple-parameter or aggregate weighted scoring systems used for track andtrigger systems should measure: heart rate respiratory rate systolic blood pressure level of consciousness oxygen saturation temperature.NICE clinical guideline No. 50. London; 2007第九頁，共

5、二十七頁。Recommendation In specific clinical circumstances, additional monitoring should be considered;for example: hourly urine output biochemical analysis, such as lactate, blood glucose, base deficit, arterial pH pain assessment. NICE clinical guideline No. 50. London; 2007第十頁，共二十七頁。危重病的早期預警在EWS的根底上，

6、國外許多醫(yī)院成立：Critical Care Outreach Service (CCOS)，Medical Emergency Team (MET)，Rapid Response Teams等以提高危重病人的搶救成功率。第十一頁，共二十七頁。改進早期危險評分MEWS)第十二頁，共二十七頁。Journal of Critical Care (2022) 27, 424.e7424.e13第十三頁，共二十七頁。第十四頁，共二十七頁。Content of measurements. The combination (in white) of all measurements taken (N =

7、2688) is shown compared with the measurements with a positive MEWS (3 points) in black (n = 988). All possible combinations were analyzed, and those with a prevalence of 4% or more were included. BP indicates systolic blood pressure; Resp, respiratory rate; Temp, temperature; Sat, peripheral saturat

8、ion with supplementary oxygen therapy第十五頁，共二十七頁。第十六頁，共二十七頁。第十七頁，共二十七頁。 Early Warning Score scoring system EWS 3 2 1 0 1 2 3Pulse rate 51-100 101-110 111-130 130BP (systolic) 200Respiratory rate 30Temperature 37.5Consciousness A V P UEWS = Early Warning Score; BP = blood pressure; A= alert; V=respons

9、ive to voice; P=responsive to pain; U=unresponsive. Worried about patientscondition: 1 point; Urine production below 75 ml during previous 4 hours: 1 point; Saturation below 90% despite adequate oxygen therapy: 3 points. january 2022 , vol . 71, No1 第十八頁，共二十七頁。 13 months (May 2022-May 2022),71,911 E

10、WS values in the Medical Centre Alkmaar. 56% ( 40,183) on surgical wards, 44% (31,728) on medical wards第十九頁，共二十七頁。第二十頁，共二十七頁。Mortality rate as a percentage of admissions each year. Average values pre- and post-MEWS are shown along with P valuesM.S. Patel et al. Injury, Int. J. Care Injured 42 (2022)

11、 14551459第二十一頁，共二十七頁。第二十二頁，共二十七頁。The distribution of NEWS values and the relationship with each of the four outcomes studied. Smith GB, et al. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation (2022) 第二十三頁，共二十七頁。第二十四頁，共二十七頁。小結早期發(fā)現(xiàn)、恰當處理是提高危重病人搶救成功率的關鍵早期預警系統(tǒng)能及早提醒醫(yī)務人員可能的病情惡化，以便采取干預措施，降低死亡率ICU醫(yī)生要開闊思路，放眼全院第二十五頁，共二十七頁。第二十六頁