introduction to sicu 台大醫院 外科加護病房 柯文哲 醫師. the cost of health care...
TRANSCRIPT
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Introduction to SICU
台大醫院 外科加護病房柯文哲 醫師
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The Cost of Health Care
Year GNP (%)1965 5.9
1970 7.4
1988 11.12000 15.0
Actually, 13.6% in 2000
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Economic Impetus of ICU hospital : 40 % of total health care
ICU : 15 ~ 20 % of hospital cost
15 % x 40 % x 15 ~ 20 % = 0.9 ~ 1.2 %
1 % of GNP
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History of ICU 1860+ : Florence Nightingale
1952 ~ 3 : polio epidemics in Europe
bulbar paralysis ---> resp. failure
formation of modern ICU
1960+ : open heart surgery
trauma, transplantation
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Function of Modern SICU
• monitor of high-risk patients
• prevention and treatment of post-op complications
• pre-op optimization
• terminal care
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阿 婆 的 故 事
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BP = CO x SVR
V= I x R(idea of pre-op optimization)
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Function of Modern SICU
• monitor of high-risk patients
• prevention and treatment of post-op complications
• pre-op optimization
• terminal care
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Multiple Organs Failure
(MOF)
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65 yrs , male , CAD - III PH : NP OP : CABG, CPB : 5 hr
POD 6# : 1. ARDS (FiO2: 0.8 , PEEP: 10, SaO2: 95%) 2. ARF : on H/D 3. paralytic ileus: on TPN 4. Bil : 12 mg/dl 5. IABP use 6. conc : drowsy, but arousable
what is the estimated mortality in this patient ?
(a).20% ,( b).40% ,( c).60% ,(d).80% ,(e).100%
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Mortality of MOF
Days after last O.FO.F 1 2 3 4 5 6 7
1 22% 31% 34% 35% 40% 42% 41%
2 52% 67% 66% 62% 56% 64% 68%
>3 80% 95% 93% 96% 100% 100% 100%
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Critical Care State of the Art( USA, 1991)
> 3 O.F , > 3 days
99 % mortality
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• Heart : mechanical circulatory support• Lung : ventilator • Liver : FFP, plasmapheresis• Kidney : P/D, H/D, CVVH • GI : TPN• B.M. : transfusion• Immune: antibiotics
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Goal of Modern ICU
prevention
not treatment of MOF
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Three Tasks in SICU1 Shock ? resuscitation
2 underlying problems ? treatment
3 nutrition ? support
(metabolic support vs nutritional support)
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William C. ShoemakerSurgical Clinics of
North America (1985)
Survior Vs non-survior
in early ICU period
X : BP , HR , CVP , PAWP , Hct , ABG
O : CI , DO2 , VO2
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Basic Model in Critical Care
stress => compensation
success
failure
survive
death
PH in ABG
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Inference from Shoemaker's Study
1. pre- op normal≠post-op normal
2. what we usually measure in ICU are
useless ( too late to be effective )
3. compensation :
major determinant of outcome
4. survival pattern : the goal of therapy
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1985 William C. ShoemakerSurgical Clinics of North America (1985)
× BP, HR, CVP, PAWP, ABG
CI, DO2I, VO2I
Stress Compensation ↗ succeed survival
↘ fail death
× pH in ABG
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Inference from Shoemaker's Study
1. pre- op normal≠post-op normal
2. what we usually measure in ICU are
useless ( too late to be effective )
3. compensation :
major determinant of outcome
4. survival pattern : the goal of therapy
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Therapeutic Goal in SICU Patients(Survival Pattern of SICU Patients)
1. C.I. = 1.5 x normal
2. blood volume : 500 ml more than normal
3. DO2I > 600 ml/min/m2
4. VO2I > 170 ml/min/m2
5. BP : normal or higher
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But
1. no one can get the same result
2. our experience in cardiac surg. patients
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Weak Compensation Response
1. poor compensation mechanism
2. no stress
=> optimal supply is determined by need
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Basic Model in Critical Care
stress => compensation
success
failure
survive
death
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Modern ICU• optimal environment for patients
to recover
• prevent complications (esp. iatrogenic )
• early detection and early treatment of pathophysiological process
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Summary• critical care begins from pre-op stage
• ideal critical care :– continuous monitor
– early detection
– early intervention
• Full time ICU team
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Multiple Organs Transplantation
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How to develop ICU
in my hospital ?
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有沒有比貪污更嚴重的事 ?
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決策錯誤 !
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戲• 編劇 , 導演• 演員• 燈光 , 佈景 , 道具 , 化
粧
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外科加護病房之特色
1. 基本設備投資大
2. 人員養成慢
3. 難以轉用其他用途
4. 發展決策更需慎重
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SICU Patients
• CVS , CS
• trauma , NS
• transplantation
• others
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外科加護病房發展之考慮因素
•病人種類與數量•現有的人員裝備•未來的發展→領導者的責任
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外科加護病房之重要性• “ 白飯” 理論 * CVS ICU
* Trauma ICU
• 產業升級 擺脫競爭最好的方法• 總後勤支援
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加護病房設立之考慮順序
• 軟體 > 硬體 先決定運作方式 , 再決定人員 設
備• 營運成本 > 設備成本• 經濟規模• 留 “空白”
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臺大醫院外科加護病房團隊
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SICU
心臟外科
胸腔外科
一般外科
大腸直腸外科
小兒外科
整形外科
神經外科
台大外科部
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4A1A2CVS2052122
4B1B2
NS + CS
11 + 740122
4C1GS1431322
移植小組
周邊血管檢查室
SICU
單位床位護士NSPR2intern
VS: 1 + 0.9 + 0.5 Technician: 3 NSP: 5 Tx Nurse: 3P.S. Ped SICU: 6床 , Burn ICU: 4床 , 不在管轄內
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NTUH SICU Team• VS, R2, Intern• HN, nurse• Clinical pharmacist• CNS (NSP, PA)• PT• RT• ICU technician• Dietitian• Social worker
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4A1 4A21 1
2 2
3 3
5 5
6 6
7 7
8 8
9 9
Date
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裝備清單• ECMO 4 台• IABP 5 台• VAD • (Heartmate 1 台 , Thoratec 1 台 )
• Metabolic cart 1 台• Tonometry 1 台• COLD 1 台• Dialysis (HD 1, CVVH 3)
• 全身超音波 1• 血管超音波 1, IPG 1• Continuous cardiac output
3• ABG• 全套手術裝備 2 • ( 頭燈 , 電刀 , 器械 , 手術
衣 , 布單 )• BiPAP• NO inhalation
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作業原則• 擴大戰區• 統一指揮• 減少指揮層級
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制度化職業化組織化
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SICU Meeting
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