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1、！可怕的惯性思维,患者为何会停留在重症监护室中,？,重症监护室中危重患者心肺康复管理新策略ABCDE模式,重症患者心肺康复服务所承担的使命模式的继承、发展以及创新,Eevidence,Ppractice,Ttranslation,为什么会产生ABCDE模式,以循证为基础构架的方法临床工作团队成员之间合作改进的结果标准化的管理程序打破了危重患者过度镇静和延长戴机的循环,跨学科的合作 Interdisciplinary而非传统的多学科交叉 Multidisciplinary,ABCDE模式的核心,A：Awakening，促醒B：(Spontaneous) Breathing Trial，自主呼吸测
2、试 C：Choice of sedation，镇静剂的选择D：Delirium monitoring，谵妄的管理E：Early exercise & mobility，早期的运动和活动,！请注意：让重症患者早日安返病房是每一个人的责任,促醒和镇静剂选择的策略,每日戒断的目标：RASS -2 to 0；or BIS 60 to 100 (or 遵医嘱)咪达唑仑/氯羟去甲安定持续静脉滴注异丙酚静脉持续滴注芬太尼/二氢化吗啡酮/吗啡持续静脉滴注右旋美托咪定静脉持续滴注,保持镇静药物的持续静脉滴注除非患者达到RASS唤醒的目标使用1/2先前的比率，用最小的剂量达到目标理想的镇静指数,自主呼吸测试SBT
3、的策略,通过短时间(30min-2Hrs) 的动态观察, 以评价患者完全耐受自主呼吸的能力, 借此达到预测撤机成功的目的低水平CPAP法模式：换为CPAP，设置CPAP为5cmH2O低水平PSV法模式：换为PSV，压力支持水平设置在5-7cmH2O脱机试验方式：T管试验，并将cuff中气体抽出,呼吸肌肌力训练,心理支持,痰液管理,重症监护室中的谵妄,药物的影响睡眠障碍嘈杂的环境- BEEP!身体的不适：疼痛，机械通气，尿管，鼻饲管陌生的环境昼夜节律失调活动受限,评估工具： Confusion Assessment Method for the ICU (CAM-ICU),谵妄的干预策略：Sto
4、p. T.H.I.N.K,Toxic situations：有害的情况（CHF，休克，脱水，药物，新发的器官衰竭）Hypoxemia/Hypotension：低氧血症/低血压Infection/+Sepisis：感染/+败血症Non-pharmacologic Intervention：非药物的干预（眼镜，睡眠管理，噪音控制）K+/Electrolyte problems：钾离子或电解质紊乱,FDA并未许可任何一种药物对谵妄进行治疗所有接受抗精神病药物治疗的患者都应注意它们的副反应，尤其是导致QT间期的延长,Many patients with respiratory failure requ
5、ire mechanical ventilation for weeks or months before they can breathe unassisted. If such patients are confined to bed or chair simply because they are tied to their respirators, they are needlessly predisposed to muscular and skeletal wasting, thromboembolism, decubitus ulcers, and to at least som
6、e degree of despair concerning their eventual rehabilitation.,CHEST, 68:4, OCTOBER, 1975Robert Burns, M.D., F.C.C.P.and Frederick L. Jones, Jr., M.D., F.C.C.P.Department of Thoracic MedicineGeisinger Medical CenterDanville, Pa, USAEarly Ambulation Of Patients Requiring Ventilatory Assistance,Muscle
7、Deterioration (Structural And Functional)Occurs Very Rapidly in MV/Critical Illness,The New England Journal Of Medicine,ConclusionsThe combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. These findings
8、are consistent with increased diaphragmatic proteolysis during inactivity.,Rapid Disuse Atrophy Of Diaphragm Fibers In Mechanically Ventilated HumansSanford Levine, M.D., Taitan Nguyen, B.S.E., et al,March 27, 2008 Vol. 358 No. 13: 1327-35.,Goal is not necessarily walking everyone, but getting them
9、MOVING!,Fast，NOT RUSH,2-Step ProcessSafety Screen + Mobility Protocol,Safety Screen 安全性筛查：MOVEN,M: Myocardial stability，心肌稳定 50 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%
10、 (88% with activity)；10 RR 35 V: Vasopressor(s) minimal，最小的升压药 No increase in vasopressor infusion in last 2 hrs E: Engages to voice ，能够发声 or Pt opens eyes to verbal stimulation N: Neurologic stability，神经情况稳定 ICP 20mmHg ；Absence of active seizures x 24hrs,CONTRAINDICATIONS: Unstable fx ；Active bleed
11、ing ；Active fluid resuscitation ；Open chest/abdomen,重症患者心肺康复运动3阶段策略,LEVEL 1: RASS -5 to +2Functional level: Total Assist,PROM Bid x 10 reps with NR/CPTSplinting and repositioning every 2 hours by NRBed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 HrsSkilled therapeutic int
12、erventions by PT/OT as indicated,重症患者心肺康复运动3阶段策略,LEVEL 2: RASS -2 to +2Functional level: Max to Mod Assist,ROM Ex Bid with family/NR/CPT x 10 repsSplinting and repositioning every 2 Hrs by NRBed in chair position Bid by NR/CPT greater than 20 minutes but less than 2 HrsOOB to neuro chair greater tha
13、n 30 minutes but less than 2 HrsSkilled therapeutic interventions by CPT/OT as indicatedParticipate in ADL,重症患者心肺康复运动3阶段策略,LEVEL 3: RASS -1 to +2Functional level: Mod Assist to Supervision,Self-care exercise program BidReposition every 2 Hrs while in bedOOB to bedside chair with NR/CPT Tid greater than 30 minutes but less than 2 HrsAmbulate as directed by CPT/OTSkilled therapeutic interventions by CPT/OT as indicatedParticipate in ADL,综合的ABCDE模式能让您的患者获得最大益处,别害怕！您的患者会比您期望的做得更好,请记住！这是跨学科合作才能完成的任务,诚邀您与我们一起推进中国心肺康复感谢聆听,
