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Principles of

Critical Care Medicine

Bellson 2011 06

Principles of

Critical Care Medicine

Bellson C

xibaishun@126.com

Cellphone number

13564407870

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Where to go?

Principles of

Critical Care Medicine

Scoring system : APACHE II,MPM, SAPS.

Why? What for?

Diaganose and Classification of Shock; Monitoring : Pulmonary Artery Catheter

Respiratory:

a. Four types of Respiratory Failure

b. Endotracheal intubation and Mechanical Ventilatory Support

c. Weaning from Ventilation

d. Monitoring : Pulse Oximetry, Blood gas, Respiratory System Mechanics

Common complications in CCU and the definition of MOFs

NEUROLOGIC DYSFUNCTION IN CRITICALLY ILL PATIENTS Common symptoms

WITHHOLDING AND WITHDRAWING CARE

Why CCU is a fighting place?

Everything focuses on life.

3 main parts of the treatment in CCU.

Respiratory

Circulation/Shock

Central nervous system

What does CCU look like?

What are the stuffs in the CCU?

Ventilators

Ventilators

Ventilators

Masks

Who should stay in the CCU?

Scoring system acts as a law.

It is useful in guiding hospital

administrative policies .

It guides hospital administrative

policies, nursing and ancillary care .

It predicts outcomes in critical illness

the most commonly utilized

scoring systems

APACHE (acute physiology and

chronic health evaluation)

system US

the MPM (mortality probability

model) Europe

the SAPS (simplified acute

physiology score) system

common variables

age;

vital signs;

assessments of respiratory,

renal, and neurologic function;

and an evaluation of chronic

medical illnesses.

Shock

What is Shock?

Shock is defined by the

presence of multisystem end-

organ hypoperfusion.

Classification

Cardiogenic shock

Septic shock

Anaphylactic shock

hypovolemic shock

neurogenic shock

Diagnose of Shock

1. BP < 90/60 mmHg

2. Why?

3. Clinical indicators :

tachycardia, tachypnea, cool

skin and extremities, acute

altered mental status, and

oliguria.

Monitoring and Therapy

BP

CVP (central venous pressure)

PAC (Pulmonary Artery Catheter )

Pulse Oximetry, Blood gas

EKG

……

Therapy……

Respiratory failure:

Four types of Respiratory

Failure

Endotracheal intubation

Mechanical Ventilatory Support

Weaning from Ventilation

Monitoring : Pulse Oximetry,

Blood gas, Respiratory System

Mechanics

Four types of Respiratory

Failure

Acute Hypoxemic Respiratory Failure

alveolar flooding

and subsequent intrapulmonary shunt

Type II Respiratory Failure

a result of alveolar hypoventilation

-> the inability to effectively eliminate carbon dioxide

Type III Respiratory Failure

a result of lung atelectasis.

Type Iv Respiratory Failure

shock, hypo perfusion -> the weakness of respiratory muscles

Monitoring

Blood gases analysis

Pulse Oximetry

BP

EKG

……

Therapy Strategy

Endotracheal intubation

the optimal mean of ventilating unconscious patient

or patient with severe respiratory distress ;

the most reliable but not the only way

Mechanical Ventilatory Support

Care of The Mechanically Ventilated Patient

Weaning from Ventilation

spontaneous respiration for 8 hours;

an acceptable level of arterial blood gases

analysis

Care of The Mechanically Ventilated

Patient

The management of airway

The management of pain

(Opiates )

The management of anxiety

anxiolysis

Neuromuscular blocking agents

Care of The Mechanically Ventilated

Patient

pros and cons

patient-ventilator synchrony

less stress/less inflammation reaction

Amnesia / a myopathy known as the postparalytic syndrome

? hepatic and renal function

* So daily interruption of sedative infusions has been shown to prevent excessive drug accumulation and shorten the duration of mechanical ventilation and length of stay in the ICU.

Weaning from Ventilation

Generally Speaking:

spontaneous respiration for 8 hours;

an acceptable level of arterial blood gases analysis

For All intubated, mechanically ventilated patients :

the screening test and undergo a spontaneous breathing trial are necessary.

In the end, (f/VT) is <105, the patient can be extubated.

Common complications in CCU

and the definition of MOFs

What is MOSF ?

Severe sepsis, shock of any

kind, severe inflammatory

conditions such as pancreatitis,

and trauma might cause MOSF.

Tips : >24h;

Mortality risk increases ;

SIRS is a common basis

Mechanism?

Gastrointestinal Tract

bacteria migrating etc.

Lungs

Kidneys

……

COMPLICATIONS OF

CRITICAL ILLNESS

Sepsis

Ventilator associated pneumonia; ……

Deep Venous Thromboses

Pulmonary embolism

Stress Ulcers

Anemia

AKI

Malnutrition

NEUROLOGIC DYSFUNCTION

Recognizing:

Common symptoms

Global or Local

MRI/CT

NEUROLOGIC

DYSFUNCTION

Delirium

(eg. clozapine over the dose)

Anoxic Cerebral Injury

Stroke

Subarachnoid Hemorrhage

Status Epilepticus

Brain Death

THANKS