外科重症监测治疗

Why are scoring systems needed?
❖ Scoring systems can provide:
-Defining population of critically ill pts
- A tool for comparative audit - A mechanism to decide

ICU收治对象-外科重危病人
❖创伤、大手术 ❖器官移植后监测 ❖循环失代偿者 ❖有呼吸衰竭可能，需呼吸器治疗者 ❖严重水电解质紊乱，酸碱平衡失调者 ❖麻醉意外、心肺复苏后病人 ❖单个或多个器官功能不全者 ❖严重代谢障碍性疾病(甲亢、肾上腺、垂体危象)

Intensive care 外科重症监测治疗
What is ICU?
❖ An intensive care unit (ICU) is a specially staffed and equipped hospital ward dedicated to the management of patients with lifethreatening illnesses,injuries or complications.
❖Hemodynamic support -inotrope and vasoactive medication
❖Mechanical ventilation ❖Organ support (eg.dialysis) ❖Sedation and analgesia ❖Treatment of underlying illnesses ❖Enteral/parenteral nutrition
❖ the MPM (mortality probability model), ❖ the SAPS (simplified acute physiology
score) system. These were all designed to predict outcomes in critical illness and use severity-of-illness scoring systems with common variables. ❖ These include age; vital signs; assessments of respiratory, renal, and neurologic function; and an evaluation of chronic medical illnesses
cost
❖ICU is generally the most expensive, technologically advanced and resource intensive area of medical care. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion accounting for about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004).
❖治疗设备:呼吸机、除颤器、输液泵、注射泵、起 搏器、主动脉内球囊反搏器、血液净化仪、麻醉 机、中心供氧、中心吸引装置、体外膜式肺氧合 (ECMO)装 。

监护仪
❖ 心功能监测系统

心电图机

便携式血气电解质肾功检验仪

铁肺—重症监护病房的最早尝试

呼吸机

Defibrillator 除颤器

制氧机
❖ Pulse Oxymetry ❖ 血氧饱和仪
❖ 1952年夏，丹麦哥本哈根脊灰流行，造成延髓性呼吸麻痹， 多死于呼吸衰竭。病人被集中，通过气管切开保持呼吸道畅 通并进行肺部人工通气，使死亡率显著下降。治疗效果的改 善，使有关医生认识到加强监护和治疗的重要性。

Type of ICU patients
William Osler 1849-1919
History
❖ 1953 – Virginia Apgar ❖ 1974 – Glasgow Coma Scale
❖ APACHE & SAPS – physiologically based classification systems
❖ General severity scores ❖ Aim at stratifying patients based on their severity ❖ 1985 – 1993: general outcome prediction models ❖ 1991 – APACHE III ❖ 1993 – SAPS II ❖ 2005 – SAPS III ❖ 2006 – APACHE IV ❖ During process of evolution of models, main prognostic
Gerneral ICU ward

ICU equipment
❖监测设备monitoring equipment :多功能生
命体征监测仪、呼吸功能监测仪、心脏血流动力 学监测仪、脉搏血氧饱和度仪、血气分析仪、心 电图机。
▪ 监护仪器按系统或器官功能参数分门排列，左 列显示功能参数，右列为治疗参数。
What do we do in ICU?
monitoring ❖ECG heart rate, rhythm, ischemia ❖Blood pressure
non-invasive invasive arterial,central venous, pulmonary artery ❖Hemodynamic measurement
❖ 重症监护病房(intensive care unit, ICU)是将 疑难危重患者集中监测治疗的单位。

History of ICU
❖ICU developed from the poliomyelitis脊 髓灰质炎epidemic in the early 1950s,when the use of long-term artificial ventilation resulted in reduced mortality. Mortality of polio epidemic 87% Dropped to 27% by the use of anesthesia machines for ventilation of pts
Assessment of Severity of Illness--History
❖ APACHE & SAPS – physiologically based classification systems
❖ General severity scores ❖ Aim at stratifying patients based on their severity ❖ 1985 – 1993: general outcome prediction models ❖ 1991 – APACHE III ❖ 1993 – SAPS II ❖ 2005 – SAPS III ❖ 2006 – APACHE IV ❖ During process of evolution of models, main prognostic
resource allocation - An aid for the clinical
management of patients
“It’s more important to know se has, than what sort of disease this person has.”
APACHE
❖William Knaus ❖Initially 34 physiological variables ❖1985 – APACHE II 12 variables ❖APACHE II allows probability of death
before hospital discharge to be estimated ❖Standardised mortality ratio
cardiac output
❖Pulse oxymetry and capnography ❖Intracranial,intraabdominal pressure ❖Many others electrolyte, CNS

What do we do in ICU?--Treatment
❖Terminal illness or irreversible ❖Terminal cancer ❖Permanent brain damage
❖Infectious disease? SARS√ --management of mechanically ventilated
severe acute respiratory syndrome (SARS) patients in the isolation intensive care unit (ICU)--successful
determinants of outcome changed
Scoring System
❖The most commonly utilized scoring systems are
❖the APACHE (acute physiology and chronic health evaluation) system,
❖ Standardised mortality ratio
APACHE
❖acute physiology and chronic health evaluation ❖APACHEⅡ 0～71
. More recently, the APACHE III scoring
system has been released. This scoring system is similar to APACHE II, in that it is based upon age, physiologic abnormalities, and chronic medical comorbidities. The database from which this score was derived is larger
❖ Age, type of ICU admission (after elective surgery vs. nonsurgical or after emergency surgery), a chronic health problem score, and 12 physiologic variables (the most severely abnormal of each in the first 24 h of ICU admission) are used to derive a score. APACHE II allows probability of death before hospital discharge to be estimated
determinants of outcome changed
APACHE-- acute physiology and chronic health evaluation
❖ William Knaus 1985 – APACHE II 12 variables
❖ The APACHE II system is the most commonly used severity-of-illness scoring system in North America.