1、.,1,.,2,！可怕的慣性思維,患者為何會停留在重癥監(jiān)護室中,？,.,3,重癥監(jiān)護室中危重患者心肺康復管理新策略 ABCDE模式,致謝：李磊先生對運動訓練部分給我的建議 特別感謝：赫萬佳博士和王鵬先生對SBT部分給我的建議,四川大學華西醫(yī)院 四川大學康復醫(yī)學院 喻鵬銘 ,.,4,重癥患者心肺康復服務所承擔的使命 模式的繼承、發(fā)展以及創(chuàng)新,E evidence,P practice,T translation,為什么會產(chǎn)生ABCDE模式,以循證為基礎構(gòu)架的方法 臨床工作團隊成員之間合作改進的結(jié)果 標準化的管理程序 打破了危重患者過度鎮(zhèn)靜和延長戴機的循環(huán),.,5,跨學科的合作 Interdisc

2、iplinary 而非傳統(tǒng)的多學科交叉 Multidisciplinary,.,6,ABCDE模式的核心,A：Awakening，促醒 B：(Spontaneous) Breathing Trial，自主呼吸測試 C：Choice of sedation，鎮(zhèn)靜劑的選擇 D：Delirium monitoring，譫妄的管理 E：Early exercise & mobility，早期的運動和活動,！請注意：讓重癥患者早日安返病房是每一個人的責任,.,7,促醒和鎮(zhèn)靜劑選擇的策略,每日戒斷的目標：RASS -2 to 0；or BIS 60 to 100 (or 遵醫(yī)囑) 咪達唑侖/氯羥去甲安定持

3、續(xù)靜脈滴注 異丙酚靜脈持續(xù)滴注 芬太尼/二氫化嗎啡酮/嗎啡持續(xù)靜脈滴注 右旋美托咪定靜脈持續(xù)滴注,保持鎮(zhèn)靜藥物的持續(xù)靜脈滴注除非患者達到RASS喚醒的目標 使用1/2先前的比率，用最小的劑量達到目標理想的鎮(zhèn)靜指數(shù),.,8,自主呼吸測試SBT的策略,通過短時間(30min-2Hrs) 的動態(tài)觀察, 以評價患者完全耐受自主呼吸的能力, 借此達到預測撤機成功的目的 低水平CPAP法模式：換為CPAP，設置CPAP為5cmH2O 低水平PSV法模式：換為PSV，壓力支持水平設置在5-7cmH2O 脫機試驗方式：T管試驗，并將cuff中氣體抽出,呼吸肌肌力訓練,心理支持,痰液管理,.,9,重癥監(jiān)護室中的

4、譫妄,藥物的影響 睡眠障礙 嘈雜的環(huán)境- BEEP! 身體的不適：疼痛，機械通氣，尿管，鼻飼管 陌生的環(huán)境 晝夜節(jié)律失調(diào) 活動受限,.,10,評估工具： Confusion Assessment Method for the ICU (CAM-ICU),譫妄的干預策略：Stop. T.H.I.N.K,Toxic situations：有害的情況（CHF，休克，脫水，藥物，新發(fā)的器官衰竭） Hypoxemia/Hypotension：低氧血癥/低血壓 Infection/+Sepisis：感染/+敗血癥 Non-pharmacologic Intervention：非藥物的干預（眼鏡，睡眠管理，

5、噪音控制） K+/Electrolyte problems：鉀離子或電解質(zhì)紊亂,FDA并未許可任何一種藥物對譫妄進行治療 所有接受抗精神病藥物治療的患者都應注意它們的副反應，尤其是導致QT間期的延長,.,11,Many patients with respiratory failure require mechanical ventilation for weeks or months before they can breathe unassisted. If such patients are confined to bed or chair simply because they are

6、 tied to their respirators, they are needlessly predisposed to muscular and skeletal wasting, thromboembolism, decubitus ulcers, and to at least some degree of despair concerning their eventual rehabilitation.,CHEST, 68:4, OCTOBER, 1975 Robert Burns, M.D., F.C.C.P. and Frederick L. Jones, Jr., M.D.,

7、 F.C.C.P. Department of Thoracic Medicine Geisinger Medical Center Danville, Pa, USA Early Ambulation Of Patients Requiring Ventilatory Assistance,.,12,Muscle Deterioration (Structural And Functional) Occurs Very Rapidly in MV/Critical Illness,The New England Journal Of Medicine,Conclusions The comb

8、ination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. These findings are consistent with increased diaphragmatic proteolysis during inactivity.,Rapid Disuse Atrophy Of Diaphragm Fibers In Mechanically Ventila

9、ted Humans Sanford Levine, M.D., Taitan Nguyen, B.S.E., et al,March 27, 2008 Vol. 358 No. 13: 1327-35.,.,13,Goal is not necessarily walking everyone, but getting them MOVING!,Fast，NOT RUSH,2-Step Process Safety Screen + Mobility Protocol,.,14,Safety Screen 安全性篩查：MOVEN,M: Myocardial stability，心肌穩(wěn)定 50

10、 HR* 120 ；90 SBP* 200 ；55 MAP* 120 ； *or normal range for pt；No active ischemia x 24 hrs；No new IV antidysrhythmic agents x 24 hrs O: Oxygenation，氧合 FiO2 60%；PEEP 12；SPO292% (88% with activity)；10 RR 35 V: Vasopressor(s) minimal，最小的升壓藥 No increase in vasopressor infusion in last 2 hrs E: Engages to

11、voice ，能夠發(fā)聲 or Pt opens eyes to verbal stimulation N: Neurologic stability，神經(jīng)情況穩(wěn)定 ICP 20mmHg ；Absence of active seizures x 24hrs,CONTRAINDICATIONS: Unstable fx ；Active bleeding ；Active fluid resuscitation ；Open chest/abdomen,.,15,重癥患者心肺康復運動3階段策略,LEVEL 1: RASS -5 to +2 Functional level: Total Assist,

12、PROM Bid x 10 reps with NR/CPT Splinting and repositioning every 2 hours by NR Bed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 Hrs Skilled therapeutic interventions by PT/OT as indicated,.,16,重癥患者心肺康復運動3階段策略,LEVEL 2: RASS -2 to +2 Functional level: Max to Mod Assist,ROM E

13、x Bid with family/NR/CPT x 10 reps Splinting and repositioning every 2 Hrs by NR Bed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 Hrs OOB to neuro chair greater than 30 minutes but less than 2 Hrs Skilled therapeutic interventions by CPT/OT as indicated Participate in ADL,.,17,重癥患者心肺康復運動3階段策略,LEVEL 3: RASS -1 to +2 Functional level: Mod Assist to Supervision,Self-care exercise program Bid Reposition every 2 Hrs while in bed OOB to bedside chair with NR/CPT Tid greater than 30 minutes but