1、Critical Care Medicine,Dr. Huang Peizhi Zhongshan Hospital of Fudan Universit,What is critical care medicine？,Multidisciplinary healthcare specialty cares for patients with acute, life-threatening illness or injury which including continuum of life support from the scene through discharge Coordinate
2、d care systems, analysis of treatment options, protocols, guidelines for the care of individual patients Monitoring and therapy Intensive care medicine in Europe,What is critical illness ?,A condition where life cannot be sustained without invasive therapeutic interventions Characterized by acute lo
3、ss of physiologic reserve Cardiac arrest, shock, sepsis, severe trauma, coma Dysfunction of one or more organ systems : hemodynamic insufficiency, respiratory failure , abnormalities of fluid and electrolytes,Characters of CCM (1),life support from site of accidentto injury during transportation and
4、management in emergency department (ED) and tosurgical intervation in operating room orin intensive care unit (ICU) Require emergency medicine and Intensive care medicine,Characters of CCM (2),Team action by physicians with various specialty backgrounds Added expertise in resuscitation No focus of i
5、nterest to a single body system, but wide variety of illness Intensivist - ability to provide effective critical care is in all cases,Emergency and critical care medicine (ECCM) system,Pre-hospital care (self-help, help from bystanders, ambulance personnel via transport) life support in Emergency de
6、partment , operation room and ICU EM physician is based in the ED, intensivist remained in ICU,History of CCM,In 1940s: physician sitting at the bedside through the long night 1st ICU opened in Europe in 1950s In 1970： set up society of CCM in USA Since 1991: teaching of CCM in China In 2001: set up
7、 committee of CCM in Shanghai,Intensive Care Unit (ICU),What is ICU ?,Multidisciplinary multi-professional medical/nursing field A very high nurse to patient ratio (3-4:1) The availability of invasive monitoring The use of mechanical and pharmacological life sustaining therapies (mechanical ventilat
8、ion, vasopressors, continuous dialysis, defibrillation, pacemaker),Service in ICU,Elementary service Bedside monitor system Treatment equipment Experiment instrument,Elementary Service,Patient area (special functional bed and bedside monitor) Central monitoring field（central monitor and functional c
9、onnected bedside monitor） Employment area ( placement equipment and therapeutic room,Bedside Monitor System,Non-invasive monitoringInvasive monitoring,Non-invasive Cardiovascular Monitoring,Electrocardiographic monitoring: changes of T waves and ST segment or arrhythmia Echocardiography Non-invasive
10、 blood pressure( NBP ):alarm to higher or lower BP Doppler ultrasound,Non-invasive Respiratory Monitoring,Respiratory rate (RR ), respiratory wave End tidal partial pressure of carbon dioxide (Pet-CO2) : alveolar PCO2 close to PaCO2normal value is 4 5% ( 2835mmHg ) ( 3.74.7 kpa ) Pulse oximetry : pu
11、lse saturation of oxygen (SpO2 ),Invasive Monitoring,Central venous pressure (CVP） ：nearly close right atrium pressure.Invasive blood pressure (IBP ) : SBP40mmHg suggest hypotension . Arterial oxygen saturation (SaO2）：arterial oxygenation , degree of hemoglobin binding to oxygen , 95%97% is normal .
12、 Arterial blood gas analysis (PH、PaO2 、Pa CO2 ). Gastric mucous membran PH(PHi),Pulmonary Arterial Catheterization,Swan-Ganz catheter Right ventricular pressure (RVP) Pulmonary capillary wedge pressure( PCWP） Pulmonary artery wedge pressure( PAWP) Pulmonary arterial pressure (PAP) Cardiac output( CO
13、) Cardiac index (CI) 3.5 L/min/ m2 is normal Oxygen delivery(DO2) :700-1400ml O2/min Oxygen consumption(VO2) ：250 O2/min Mixed venous oxygen saturation(SvO2):7385,Therapeutic Equipment,Mechanical ventilator (respirator) Defibrillator Transcutaneous or transvenous cardiac pacing Cardiopulmonary resus
14、citation machine (Thumpor),Experimental Instrument,Blood gas analyzer An elevated serum lactate level ( 1 mmol/L) identifies tissue hypoperfusion in patient at risk who are not hypotensive Detect meter ：rapidly detect blood sugaror CTnT , CTnI or Brain natriuretic peptide ( BNP),Organ Function Suppo
15、rt in ICU,Respiratory support Circulatory support Renal support Gastrointestinal support Cerebral support,Respiratory Support,Indication: hypoxemia, hypercapmiarespiratory failure, cardiac arrest Monitoring ：arterial blood gas analysisPet-CO2 、 SpO2 Treatment: (1) Oxygen therapy ( when SaO2 90% )con
16、trol inspiratory oxygen ,higher concentration oxygen or hyperbaric oxygen ECMO (extracorpreal membrane oxygenation)(2) Mechanical ventilation,Oxygen Therapy,Inspire oxygen by nasal cannula , face mask , endotracheal intubation , tracheotomy or in hyperbaric oxygen chamber( 2-3 atmospheric pressure)
17、Fraction of inspired oxygen (FiO2) may be used lower (2530) in initial , then middle (4060) or higher ( 60) .,Mechanical Ventilation,A/C( assist-control): no spontaneous breathing IPPV (intermittent positive pressure ventilation) PSV (pressure support ventilation): spontaneous breathing PEEP (positi
18、ve- end expiratory pressure) BiPAP (biphasic positive airway pressure) SIMV (synchronized intermittent mandatory ventilation) CPAP(continuous positive airway pressure) Non-invasive or invasive ventilation,Indication of Circulatory Support,Hypotension Shock Heart failure Arrhythmia,Circulatory Monito
19、ring,Electrocardiogram( ECG) Non-invasive blood pressure( NIBP) Invasive hemodynamic monitory (IHM) : CVP、PAP、PCWP and CO, SvO2, DO2 Ejection fraction (EF) by echocardiography,Circulatory Support,Fluid resuscitation may consist of natural or artificial crystalloids or colloids and transfusion therap
20、y . Supplemental oxygen . Intravenous dopamine or norepinephrine or vasopressin to correct hypotension . Antiarrhythmic drug : amiodarone . Inotropic drug : In patients with low cardiac output despite adequate fluid resuscitation, dobutamine may be used to increase cardiac output .,Gastrointestinal
21、Support,Indication : abdominal pain , diarrhea,dark stools , hematemesis , hematochezia Monitoring ：hematocrit(HCT) , Hb , RBCcomplete blood count (CBC) , occult blood Treatment : H2 receptor antagonistsenteral nutrition Chinese traditional drugs,Renal support,Indication： oliguria , renal failure Mo
22、nitoring: urine volume, urine protein , urinalysis , urine osmolarity blood urea nitrogen(BUN) , creatinine( Cr) , serum electrolytes Management：(1) Caution to renal injury (2) Renal replacement in acute renal failure .Continuous veno-venous hemofiltration or intermittent hemodialysis are considered
23、 equivalent.,Cerebral Support,Indication： ComaConscious disturbance Monitoring: Dimension of pupi Focussing light response Pathologic reflex Intracranial pressure (ICP) Coma score Treatment : Parenteral and enteral nutritionDehydrant or diuretic drugs Hypothermia,Progress and Future,SIRS,Systemic in
24、flammation response syndrome Infection , trauma , ischemic injury Uncontrolled inflammatory reaction Produce and release inflammatory medium Vascular endothelial cell injury Microcircularory disturbance Intracellular oxygen utilization disturbance,Diagnosis of SIRS,Involves two or more of the follow
25、ing findings (1) Temperature 38C or 90 beats/min (3) Tachypnea, with a respiratory rate 20 breaths/min or PaCO2 12 x 109/L or 10% band forms on a peripheral blood smear,Definition of Sepsis,Sepsis = infection plus physiologic changes known as SIRS criteria Severe sepsis = sepsis with acute organ dys
26、function Septic shock = sepsis with shock refractory to fluid resuscitation,Treatment of Severe Sepsis,Recombinant human activated protein C(rhAPC) :anti-coagulant and Anti-inflammatory effect to improve survival in patients with organ dysfunction. Depression apoptosis and induce super expression of
27、 anti-apoptosis protein Bcl-2,MODS,Multiple organ dysfunction syndromethe most cause of death in ICU Origin for dysfunction of intestinal barrier Cell apoptosis Endothelium damage Mitochondrion dysfunction,New Management,Parenteral nutrition for central or peripheral vein administration and enteral for feeding tube positioned in the small bowel , blood substitute New types of respirator New CRRT instrument Hand- carried ultrasound device New non-invasive hemodynamic monitoring Sublingual PH monitoring,Thank you ！,
