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CriticalCareMedicine
Dr.HuangPeizhiZhongshanHospitalofFudanUniversitCriticalCareMedicine
D1Whatiscriticalcaremedicine？Multidisciplinaryhealthcarespecialtycaresforpatientswithacute,life-threateningillnessorinjury
whichincludingcontinuumoflifesupport
fromthescenethroughdischargeCoordinatedcaresystems,analysisoftreatmentoptions,protocols,guidelinesforthecareofindividualpatientsMonitoringandtherapyIntensivecaremedicineinEurope
Whatiscriticalcaremedicine2
Whatiscriticalillness?Aconditionwherelifecannotbesustained
withoutinvasivetherapeuticinterventionsCharacterizedbyacutelossofphysiologicreserveCardiacarrest,shock,sepsis,severetrauma,coma
Dysfunctionofoneormoreorgansystems:hemodynamicinsufficiency,respiratoryfailure,abnormalitiesoffluidandelectrolytesWhatiscriticalillness?A3CharactersofCCM(1)lifesupportfromsiteofaccidenttoinjuryduringtransportationandmanagementinemergencydepartment(ED)andtosurgicalintervationinoperatingroomorinintensivecareunit(ICU)RequireemergencymedicineandIntensivecaremedicineCharactersofCCM(1)life4CharactersofCCM(2)TeamactionbyphysicianswithvariousspecialtybackgroundsAddedexpertiseinresuscitation
Nofocusofinteresttoasinglebodysystem,butwidevarietyofillness
Intensivist-abilitytoprovideeffectivecriticalcareisinallcases
CharactersofCCM(2)Team5Emergencyandcriticalcaremedicine(ECCM)systemPre-hospitalcare(self-help,helpfrombystanders,ambulancepersonnelviatransport)lifesupportinEmergencydepartment,operationroomandICUEMphysicianisbasedintheED,intensivistremainedinICUEmergencyandcriticalcarem6
HistoryofCCMIn1940’s:physiciansittingatthebedsidethroughthelongnight1stICUopenedinEuropein1950’sIn1970：setupsocietyofCCMinUSASince1991:teachingofCCMinChinaIn2001:setupcommitteeofCCMinShanghaiHistoryofCCMIn1940’s:ph7
IntensiveCareUnit(ICU)
IntensiveCareUnit(ICU)8WhatisICU?Multidisciplinarymulti-professionalmedical/nursingfieldAveryhighnursetopatientratio(3-4:1)TheavailabilityofinvasivemonitoringTheuseofmechanicalandpharmacologicallifesustainingtherapies(mechanicalventilation,vasopressors,continuousdialysis,defibrillation,pacemaker)WhatisICU?Multidisci9ServiceinICUElementaryserviceBedsidemonitorsystemTreatmentequipmentExperimentinstrumentServiceinICUElementary10
ElementaryServicePatientarea(specialfunctionalbedandbedsidemonitor)Centralmonitoringfield（centralmonitorandfunctionalconnectedbedsidemonitor）Employmentarea(placementequipmentandtherapeuticroom
ElementaryServicePatie11BedsideMonitorSystemNon-invasivemonitoringInvasivemonitoringBedsideMonitorSystemNon-inva12Non-invasive
CardiovascularMonitoringElectrocardiographicmonitoring:changesofTwavesandSTsegmentorarrhythmiaEchocardiographyNon-invasivebloodpressure(NBP):alarmtohigherorlowerBPDopplerultrasoundNon-invasive
Cardiov13Non-invasive
RespiratoryMonitoringRespiratoryrate(RR),respiratorywaveEndtidalpartialpressureofcarbondioxide(Pet-CO2):alveolarPCO2closetoPaCO2normalvalueis4～5%(28～35mmHg)(3.7～4.7kpa)Pulseoximetry:pulsesaturationofoxygen(SpO2
)
Non-invasive
14InvasiveMonitoringCentralvenouspressure(CVP）：nearlycloserightatriumpressure.Invasivebloodpressure(IBP):SBP<90mmHg,orMAP<70mmHg,orSBPdecreased>40mmHgsuggesthypotension.Arterialoxygensaturation(SaO2）：arterialoxygenation,degreeofhemoglobinbindingtooxygen,95%—97%isnormal.Arterialbloodgasanalysis(PH、PaO2、PaCO2).GastricmucousmembranPH(PHi)InvasiveMonitoringCe15PulmonaryArterial
CatheterizationSwan-GanzcatheterRightventricularpressure(RVP)Pulmonarycapillarywedgepressure(PCWP）Pulmonaryarterywedgepressure(PAWP)Pulmonaryarterialpressure(PAP)Cardiacoutput(CO)Cardiacindex(CI)>3.5L/min/m2isnormalOxygendelivery(DO2):700-1400mlO2/minOxygenconsumption(VO2)：250O2/minMixedvenousoxygensaturation(SvO2):73－85％PulmonaryArterial
16TherapeuticEquipmentMechanicalventilator(respirator)DefibrillatorTranscutaneousortransvenouscardiacpacingCardiopulmonaryresuscitationmachine(Thumpor)TherapeuticEquipmentMechani17ExperimentalInstrumentBloodgasanalyzerAnelevatedserumlactatelevel(>1mmol/L)identifiestissuehypoperfusioninpatientatriskwhoarenothypotensiveDetectmeter：rapidlydetectbloodsugaror
CTnT,CTnIorBrainnatriureticpeptide(BNP) ExperimentalInstrumentBloodg18OrganFunctionSupportinICU
RespiratorysupportCirculatorysupportRenalsupportGastrointestinalsupportCerebralsupportOrganFunctionSupportinICU19RespiratorySupportIndication:hypoxemia,hypercapmiarespiratoryfailure,cardiacarrestMonitoring：arterialbloodgasanalysisPet-CO2、SpO2Treatment:(1)Oxygentherapy(whenSaO2
<90%)controlinspiratoryoxygen,higherconcentrationoxygenorhyperbaricoxygenECMO(extracorprealmembraneoxygenation)(2)MechanicalventilationRespiratorySupportIndica20OxygenTherapyInspireoxygenbynasalcannula,facemask,
endotrachealintubation,tracheotomyorinhyperbaricoxygenchamber(2-3atmosphericpressure)Fractionofinspiredoxygen(FiO2)maybeusedlower(25％～30％)ininitial,thenmiddle(40％～60％)orhigher(60％).OxygenTherapyInspireox21MechanicalVentilationA/C(assist-control):nospontaneousbreathingIPPV(intermittentpositivepressureventilation)PSV(pressuresupportventilation):spontaneousbreathing
PEEP(positive-endexpiratorypressure)BiPAP(biphasicpositiveairwaypressure)SIMV(synchronizedintermittentmandatoryventilation)CPAP(continuouspositiveairwaypressure)Non-invasiveorinvasiveventilationMechanicalVentilationA/C22IndicationofCirculatorySupportHypotensionShockHeartfailureArrhythmiaIndicationofCirculatory23CirculatoryMonitoringElectrocardiogram(ECG)Non-invasivebloodpressure(NIBP)Invasivehemodynamicmonitory(IHM):CVP、PAP、PCWPandCO,SvO2,DO2Ejectionfraction(EF)byechocardiographyCirculatoryMonitoring24
CirculatorySupportFluidresuscitationmayconsistofnaturalorartificialcrystalloidsorcolloidsandtransfusiontherapy.Supplementaloxygen.Intravenousdopamineornorepinephrineorvasopressintocorrecthypotension.Antiarrhythmicdrug:amiodarone.Inotropicdrug:Inpatientswithlowcardiacoutputdespiteadequatefluidresuscitation,dobutaminemaybeusedtoincreasecardiacoutput.
CirculatorySupportFluid25
GastrointestinalSupportIndication:abdominalpain,diarrhea,darkstools,hematemesis,hematocheziaMonitoring：hematocrit(HCT),Hb,RBCcompletebloodcount(CBC),occultblood
Treatment:
H2receptorantagonistsenteralnutrition
Chinesetraditionaldrugs
GastrointestinalSupport26Renalsupport
Indication：oliguria,renalfailure
Monitoring:urinevolume,urineprotein,urinalysis,urineosmolarity
bloodureanitrogen(BUN),creatinine(Cr),serumelectrolytesManagement：(1)Cautiontorenalinjury
(2)Renalreplacementinacuterenalfailure.
Continuousveno-venoushemofiltrationorintermittenthemodialysisareconsideredequivalent.RenalsupportI27CerebralSupportIndication：ComaConsciousdisturbanceMonitoring:DimensionofpupiFocussinglightresponsePathologicreflexIntracranialpressure(ICP)ComascoreTreatment:ParenteralandenteralnutritionDehydrantordiureticdrugs
HypothermiaCerebralSupportIndicati28ProgressandFuture
ProgressandFuture29SIRSSystemicinflammationresponsesyndromeInfection,trauma,ischemicinjuryUncontrolledinflammatoryreactionProduceandreleaseinflammatorymediumVascularendothelialcellinjuryMicrocircularorydisturbanceIntracellularoxygenutilizationdisturbanceSIRSSystemicinf30
DiagnosisofSIRS
Involvestwoormoreofthefollowingfindings(1)Temperature>38°Cor<36°C
(2)Heartrate>90beats/min(3)Tachypnea,witharespiratoryrate>20breaths/minorPaCO2
<32mmHg(4.25kPa)(4)WBCcount>12x109/Lor<4x109/L,or>10%bandformsonaperipheralbloodsmearDiagnosisofSIRSInvolv31
DefinitionofSepsis
Sepsis=infectionplusphysiologicchangesknownasSIRScriteriaSeveresepsis=sepsiswithacuteorgandysfunctionSepticshock=sepsiswithshockrefractorytofluidresuscitation
DefinitionofSepsis
Sepsis=32TreatmentofSevereSepsisRecombinanthumanactivatedproteinC(rhAPC):anti-coagulantandAnti-inflammatoryeffecttoimprovesurvivalinpatientswithorgandysfunction.Depressionapoptosisandinducesuperexpressionofanti-apoptosisproteinBcl-2TreatmentofSevereSepsisReco33MODSMultipleorgandysfunctionsyndrome
themostcauseofdeathinICUOriginfordysfunctionofintestinalbarrierCellapoptosisEndotheliumdamageMitochondriondysfunctionMODSMultipleorgand34NewManagementParenteralnutritionforcentralorperipheralveinadministrationandenteralforfeedingtubepositionedinthesmallbowel,bloodsubstituteNewtypesofrespiratorNewCRRTinstrumentHand-carriedultrasounddeviceNewnon-invasivehemodynamicmonitoringSublingualPHmonitoringNewManagementParenteralnu35
Thankyou！
36CriticalCareMedicine
Dr.HuangPeizhiZhongshanHospitalofFudanUniversitCriticalCareMedicine
D37Whatiscriticalcaremedicine？Multidisciplinaryhealthcarespecialtycaresforpatientswithacute,life-threateningillnessorinjury
whichincludingcontinuumoflifesupport
fromthescenethroughdischargeCoordinatedcaresystems,analysisoftreatmentoptions,protocols,guidelinesforthecareofindividualpatientsMonitoringandtherapyIntensivecaremedicineinEurope
Whatiscriticalcaremedicine38
Whatiscriticalillness?Aconditionwherelifecannotbesustained
withoutinvasivetherapeuticinterventionsCharacterizedbyacutelossofphysiologicreserveCardiacarrest,shock,sepsis,severetrauma,coma
Dysfunctionofoneormoreorgansystems:hemodynamicinsufficiency,respiratoryfailure,abnormalitiesoffluidandelectrolytesWhatiscriticalillness?A39CharactersofCCM(1)lifesupportfromsiteofaccidenttoinjuryduringtransportationandmanagementinemergencydepartment(ED)andtosurgicalintervationinoperatingroomorinintensivecareunit(ICU)RequireemergencymedicineandIntensivecaremedicineCharactersofCCM(1)life40CharactersofCCM(2)TeamactionbyphysicianswithvariousspecialtybackgroundsAddedexpertiseinresuscitation
Nofocusofinteresttoasinglebodysystem,butwidevarietyofillness
Intensivist-abilitytoprovideeffectivecriticalcareisinallcases
CharactersofCCM(2)Team41Emergencyandcriticalcaremedicine(ECCM)systemPre-hospitalcare(self-help,helpfrombystanders,ambulancepersonnelviatransport)lifesupportinEmergencydepartment,operationroomandICUEMphysicianisbasedintheED,intensivistremainedinICUEmergencyandcriticalcarem42
HistoryofCCMIn1940’s:physiciansittingatthebedsidethroughthelongnight1stICUopenedinEuropein1950’sIn1970：setupsocietyofCCMinUSASince1991:teachingofCCMinChinaIn2001:setupcommitteeofCCMinShanghaiHistoryofCCMIn1940’s:ph43
IntensiveCareUnit(ICU)
IntensiveCareUnit(ICU)44WhatisICU?Multidisciplinarymulti-professionalmedical/nursingfieldAveryhighnursetopatientratio(3-4:1)TheavailabilityofinvasivemonitoringTheuseofmechanicalandpharmacologicallifesustainingtherapies(mechanicalventilation,vasopressors,continuousdialysis,defibrillation,pacemaker)WhatisICU?Multidisci45ServiceinICUElementaryserviceBedsidemonitorsystemTreatmentequipmentExperimentinstrumentServiceinICUElementary46
ElementaryServicePatientarea(specialfunctionalbedandbedsidemonitor)Centralmonitoringfield（centralmonitorandfunctionalconnectedbedsidemonitor）Employmentarea(placementequipmentandtherapeuticroom
ElementaryServicePatie47BedsideMonitorSystemNon-invasivemonitoringInvasivemonitoringBedsideMonitorSystemNon-inva48Non-invasive
CardiovascularMonitoringElectrocardiographicmonitoring:changesofTwavesandSTsegmentorarrhythmiaEchocardiographyNon-invasivebloodpressure(NBP):alarmtohigherorlowerBPDopplerultrasoundNon-invasive
Cardiov49Non-invasive
RespiratoryMonitoringRespiratoryrate(RR),respiratorywaveEndtidalpartialpressureofcarbondioxide(Pet-CO2):alveolarPCO2closetoPaCO2normalvalueis4～5%(28～35mmHg)(3.7～4.7kpa)Pulseoximetry:pulsesaturationofoxygen(SpO2
)
Non-invasive
50InvasiveMonitoringCentralvenouspressure(CVP）：nearlycloserightatriumpressure.Invasivebloodpressure(IBP):SBP<90mmHg,orMAP<70mmHg,orSBPdecreased>40mmHgsuggesthypotension.Arterialoxygensaturation(SaO2）：arterialoxygenation,degreeofhemoglobinbindingtooxygen,95%—97%isnormal.Arterialbloodgasanalysis(PH、PaO2、PaCO2).GastricmucousmembranPH(PHi)InvasiveMonitoringCe51PulmonaryArterial
CatheterizationSwan-GanzcatheterRightventricularpressure(RVP)Pulmonarycapillarywedgepressure(PCWP）Pulmonaryarterywedgepressure(PAWP)Pulmonaryarterialpressure(PAP)Cardiacoutput(CO)Cardiacindex(CI)>3.5L/min/m2isnormalOxygendelivery(DO2):700-1400mlO2/minOxygenconsumption(VO2)：250O2/minMixedvenousoxygensaturation(SvO2):73－85％PulmonaryArterial
52TherapeuticEquipmentMechanicalventilator(respirator)DefibrillatorTranscutaneousortransvenouscardiacpacingCardiopulmonaryresuscitationmachine(Thumpor)TherapeuticEquipmentMechani53ExperimentalInstrumentBloodgasanalyzerAnelevatedserumlactatelevel(>1mmol/L)identifiestissuehypoperfusioninpatientatriskwhoarenothypotensiveDetectmeter：rapidlydetectbloodsugaror
CTnT,CTnIorBrainnatriureticpeptide(BNP) ExperimentalInstrumentBloodg54OrganFunctionSupportinICU
RespiratorysupportCirculatorysupportRenalsupportGastrointestinalsupportCerebralsupportOrganFunctionSupportinICU55RespiratorySupportIndication:hypoxemia,hypercapmiarespiratoryfailure,cardiacarrestMonitoring：arterialbloodgasanalysisPet-CO2、SpO2Treatment:(1)Oxygentherapy(whenSaO2
<90%)controlinspiratoryoxygen,higherconcentrationoxygenorhyperbaricoxygenECMO(extracorprealmembraneoxygenation)(2)MechanicalventilationRespiratorySupportIndica56OxygenTherapyInspireoxygenbynasalcannula,facemask,
endotrachealintubation,tracheotomyorinhyperbaricoxygenchamber(2-3atmosphericpressure)Fractionofinspiredoxygen(FiO2)maybeusedlower(25％～30％)ininitial,thenmiddle(40％～60％)orhigher(60％).OxygenTherapyInspireox57MechanicalVentilationA/C(assist-control):nospontaneousbreathingIPPV(intermittentpositivepressureventilation)PSV(pressuresupportventilation):spontaneousbreathing
PEEP(positive-endexpiratorypressure)BiPAP(biphasicpositiveairwaypressure)SIMV(synchronizedintermittentmandatoryventilation)CPAP(continuouspositiveairwaypressure)Non-invasiveorinvasiveventilationMechanicalVentilationA/C58IndicationofCirculatorySupportHypotensionShockHeartfailureArrhythmiaIndicationofCirculatory59CirculatoryMonitoringElectrocardiogram(ECG)Non-invasivebloodpressure(NIBP)Invasivehemodynamicmonitory(IHM):CVP、PAP、PCWPandCO,SvO2,DO2Ejectionfraction(EF)byechocardiographyCirculatoryMonitoring60
CirculatorySupportFluidresuscitationmayconsistofnaturalorartificialcrystalloidsorcolloidsandtransfusiontherapy.Supplementaloxygen.Intravenousdopamineornorepinephrineorvasopressintocorrecthypotension.Antiarrhythmicdrug:amiodarone.Inotropicdrug:Inpatientswithlowcardiacoutputdespiteadequatefluidresuscitation,dobutaminemaybeusedtoincreasecardiacoutput.
CirculatorySupportFluid61
GastrointestinalSupportIndication:abdominalpain,diarrhea,darkstools,hematemesis,hematocheziaMonitoring：hematocrit(HCT),Hb,RBCcompletebloodcount(CBC),occultblood
Treatment:
H2receptorantagonistsenteralnutrition
Chinesetraditionaldrugs
GastrointestinalSupport62Renalsupport
Indication：oliguria,renalfailure
Monitoring:urinevolume,urineprotein,urinalysis,urineosmolarity
bloodureanitrogen(BUN),creatinine(Cr),serumelectrolytesManagement：(1)Cautiontorenalinjury
(2)Renalreplacementinacuterenalfailure.
Continuousveno-venoushemofiltrationorintermittenthemodialysisareconsideredequivalent.RenalsupportI63CerebralSupportIndication：ComaConsciousdisturbanceMonitoring:DimensionofpupiFocussinglightresponsePathologicref
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