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1、ICU护士应当掌握的知识,1,ICU护士应当了解的知识,循环系统血流动力学基本理论不同疾病的特点血管活性药物抗心律失常药物呼吸系统氧疗机械通气模式和特点不同疾病机械通气原则,肾脏急性肾损伤(AKI)定义和诊断标准利尿药物肾脏替代治疗IHDCRRT水电平衡酸碱平衡,2,ICU护士应当具备的技能,CPR气道管理氧疗呼吸机无创通气有创通气血流动力学监测PACPiCCOCRRT,血气分析电解质紊乱鉴别诊断患者转运患者评估,3,Obamas Intensive Care,4,血流动力学中的欧姆定律,R=P/flow,Pin,Pout,flow,R,5,器官灌注压,肾脏灌注RPP=MAP IAPFG=GF
2、P PTP=MAP IAP x 2,脑灌注CPP=MAP ICP,6,健康与疾病时的自身调节,0,150,50,100,Organ blood flow(%Baseline),0,100,20,40,60,80,Organ artery pressure(mmHg),Autoregulatory threshold,Subautoregulatory slope,7,疾病时的自身调节机制,0,150,50,100,Organ blood flow(%Baseline),0,100,20,40,60,80,Organ artery pressure(mmHg),control,3 weeks,1
3、 week,8,无创血压监测,9,无创血压监测,普遍应用低血压71%(105/149)高血压73%(108/149)应用升压药47%(70/149)局限性高血压时低估低血压时高估心律失常时准确性下降,Chatterjee A,DePriest K,Blair R,et al.Results of a survey of blood pressure monitoring by intensivists in critically ill patients:a preliminary study.Crit Care Med 2010;38:2335-2338,10,无创血压监测,from Bar
4、bara Bates:A Guide to Physical Examination,11,有创压力监测,12,有创血压监测 衰减,13,有创血压监测 真实收缩压,真实收缩压,14,有创血压的测量,15,什么血压?,收缩压活动性出血舒张压急性冠脉综合征平均压器官灌注,16,血流动力学监测:技巧,确认患者的平均动脉压家属病历记录检查患者平均动脉压的测定方法无创 vs.有创确定无创血压与有创血压的差值,17,中心静脉压监测,Why?How?上腔静脉 vs.下腔静脉平卧位 vs.半卧位多腔中心静脉插管通过哪个腔测量如果同时输液随呼吸周期呈显著波动,18,危重病患者的容量不足,19,容量负荷试验:判断
5、标准,心率改变血压改变CVP/PAWP改变CO/SV改变,20,容量负荷试验:判断标准,每10分钟测定CVPCVP 2 mmHg继续快速补液CVP 2 5 mmHg暂停快速补液,等待10分钟后再次评估CVP 5 mmHg停止快速补液,每10分钟测定PAWPPAWP 3 mmHg继续快速补液PAWP 3 7 mmHg暂停快速补液,等待10分钟后再次评估PAWP 7 mmHg停止快速补液,Weil MH,Henning RJ:New concepts in the diagnosis and fluid treatment of circulatory shock.Anesth Analg 197
6、9;58:124-132,容量负荷试验：结果判断的影响因素,输液速度各种操作翻身吸痰改变维持液输液速度改变血管活性药物剂量改变呼吸机条件,22,血管活性药物的使用,标准配制DA:3 x BWt/50 mlNE:.3 x BWt/50 ml抽药量需要计算剂量调整方便不同患者间不可互换更换频繁,非标准配制DA:10 mg/mlNE:1 mg/ml抽药量无需计算剂量调整需要计算不同患者间可互换无需频繁更换,23,血管活性药物的使用：多巴胺(10 mg/ml),24,输液速度与微量泵阻塞报警,Ilan R,Fowler RA,Ferguson ND,et al.Prolonged time to al
7、arm in infusion devices operated at low flow rates.Crit Care Med 2008;36:2763-2765,25,第一阶段：对照,经中心静脉输注血管活性药物儿茶酚胺最低输注速度2 ml/hr不规定更换注射器的方法,第二阶段：干预,双泵更换接近输注完毕前，将配好药物的注射器放在另一微量泵上，预冲管路使用快速推注功能直至管路开口处看到液体流出设置新微量泵的输注速度(与原有微量泵相同)新微量泵开始输注关闭原有微量泵,Argaud L,Cour M,Martin O,et al.Changeovers of vasoactive drug in
8、fusion pumps:impact of a quality improvement program.Crit Care 2007;11:R133,血管活性药物：注射器更换方法,26,血管活性药物：更换注射器方法,更换血管活性药物相关事件(CVIP)换泵后15分钟内收缩压变化 20 mmHg换泵后15分钟内心率变化 20 bpm出现房性或室性心律失常,Argaud L,Cour M,Martin O,et al.Changeovers of vasoactive drug infusion pumps:impact of a quality improvement program.Crit
9、 Care 2007;11:R133,27,血管活性药物：更换注射器方法,Argaud L,Cour M,Martin O,et al.Changeovers of vasoactive drug infusion pumps:impact of a quality improvement program.Crit Care 2007;11:R133,28,血管活性药物：更换注射器方法,Argaud L,Cour M,Martin O,et al.Changeovers of vasoactive drug infusion pumps:impact of a quality improvem
10、ent program.Crit Care 2007;11:R133,29,定容通气,30,I,吸气峰压(PIP),平台压(Pplat),机械通气 传统模式,定容通气气道压力不恒定潮气量吸气流量气道阻力呼吸系统顺应性吸气潮气量恒定,定压通气吸气相气道压力恒定吸气潮气量不恒定吸气力量压力控制/支持水平吸气时间气道阻力呼吸系统顺应性,31,机械通气 传统模式,定容通气监测指标：压力定压通气监测指标：容量（潮气量）,32,机械通气 新模式的理解,Pressure regulated volume control(PRVC)Simens Servo 300/300A,ServoiAdaptive pr
11、essure ventilation(APV)Hamilton GalileoAuto-FlowDrger Savina,Evita 2 dura,Evita 4Variable Pressure ControlCardiopulmonary Corporation Venturi,33,机械通气 新模式的理解,压力控制通气(PC)通气量会随着肺的顺应性变化而变化，有可能出现通气不足容量控制(VC)模式，通气量虽有保证，却易引起气压伤PRVC就是综合PC和 VC的优点而开发出的一种新的控制通气模式其独特之处是在确保预先设置的潮气量参数的基础上，呼吸机能自动连续监测胸肺顺应性和容积压力关系，并据
12、此反馈调节下一次通气的吸气压水平，使气道压尽可能降低，以减少正压通气的气压伤,34,机械通气 新模式的理解,The ventilator is continuously,breath by breath,adapting the inspiratory pressure to changes in the volume/pressure relationship.When the target volume has been achieved and the measured volume increases above or decreases below the preset tidal
13、volume,the pressure level is regulated in small steps of max 3 cmH2O until preset volumes are delivered.,max 3 cmH2O,机械通气 新模式的理解,压力控制/支持通气目标：潮气量500 mlVt 500 ml?Vt 500 ml?监测指标Vt?PIP?,36,肾脏功能,少尿(0.5 ml/kg/hr)组织灌注不足的标志若不及时纠正可能导致急性肾功能衰竭连续2小时尿量减少必须给予紧急处理,37,正常,少尿缺血加剧,急性肾小管坏死,此时开始治疗,组织灌注不足的临床表现,皮肤花斑四肢冰冷毛细
14、血管再充盈时间延长尿量减少意识障碍代谢性酸中毒乳酸酸中毒ScvO2 70%,38,医院获得性肺炎 发病机制,改变胃排空及胃液pH值的药物,有生物膜的装置(气管插管,鼻胃管),既往应用抗生素,宿主因素(免疫抑制,烧伤),消化道细菌定植,细菌误吸,细菌吸入,医院获得性肺炎,水,药物溶液及呼吸治疗装置污染,感染控制措施不够(洗手,隔离衣,手套),医务人员不足,经胸种植原发性菌血症胃肠道细菌移位,医院获得性肺炎 发病机制,平卧位是医院获得性肺炎的危险因素,Drakulovic MB,Torres A,Bauer TT,et al.Supine body position as a risk facto
15、r for nosocomial pneumonia in mechanically ventilated patients:a randomised trial.Lancet 1999;354:1851-1858,医院获得性肺炎 预防指南,42,医院获得性肺炎 预防指南,43,床头抬高 现状,床头抬高角度19.2 13.4(中位数19,范围0-90)机械通气患者16.8非机械通气患者23.1大多数患者(71%)处于平卧位,Grap MJ,Munro CL,Bryant S,et al.Predictors of backrest elevation in critical care.Inte
16、nsive Crit Care Nurs 2003;19:68-74,估测HOB角度的准确性,Awan N,Seneviratne C,Ceniza Z,et al.Accuracy of clinical evaluation of head of bed elevation.Chest 2005;128(Suppl):304S,估测HOB角度的准确性,McMullin JP,Cook DJ,Meade MO,et al.Clinical estimation of trunk position among mechanically ventilated patients.Intensive
17、 Care Med 2002;28:304-309,33名患者,12名医生,28名护士,估测HOB角度的准确性,估测角度与实测角度的相关系数为0.8488未发现估测角度准确性的相关因素年龄从事护理工作年限教育程度从事危重病护理工作年限担任当前职务年限,Dillon A,Munro Cl,Grap MJ.Nurses accuracy in estimating backrest elevation.Am J Crit Care 2002;11(1):34-37,床头抬高 问题何在,病床配备的角度指示器小,位于床下方难以辨别,容易忘记病床常保持在轻度Trendelenburg体位以防止患者下滑影
18、响某些病床角度指示器的准确性估测床头角度过高影响依从性护士的知识并非重要因素94%的受访者了解指南以及保持床头抬高的重要性,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,床头抬高 影响实施的主要障碍,护士医嘱中没有对体位进行特别说明,医生护理人员的喜好,Cook DJ,Meade MO,Han
19、d LE,et al.Toward understanding evidence uptake:semirecumbency for pneumonia prevention.Crit Care Med 2002;30:1472-1477,床头抬高 标准化医嘱的作用,Helman DL,Sherner JH,Fitzpatrick TM,et al.Effect of standardized orders and provider education on head-of-bed positioning in mechanical ventilated patients.Crit Care
20、Med 2003;31(9):2285-2290,床头抬高 标准化医嘱的作用,Helman DL,Sherner JH,Fitzpatrick TM,et al.Effect of standardized orders and provider education on head-of-bed positioning in mechanical ventilated patients.Crit Care Med 2003;31(9):2285-2290,床头抬高 护理工作的障碍,Helman DL,Sherner JH,Fitzpatrick TM,et al.Effect of stand
21、ardized orders and provider education on head-of-bed positioning in mechanical ventilated patients.Crit Care Med 2003;31(9):2285-2290,床头抬高 临床试验,目的:评价ICU患者实施半卧位的可行性及其对VAP的影响设计:前瞻多中心临床试验半卧位组:床头角度目标45平卧位组:床头角度目标10预后指标床头抬高角度VAP罹患率,Van Nieuwenhoven CA,Vandenbroucke-Grauls C,van Tiel FH,et al.Feasibility
22、and effects of the semirecumbent position to prevent ventilator-associated pneumonia:a randomized study.Crit Care Med 2006;34:396-402,床头抬高 临床试验,Van Nieuwenhoven CA,Vandenbroucke-Grauls C,van Tiel FH,et al.Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumoni
23、a:a randomized study.Crit Care Med 2006;34:396-402,螺母,丝线,30,30,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,床头抬高 如何实施,床头抬高 如何实施,试验为期4周初期提醒护士保持床头抬高 30随后2周,测定插管患者床头抬高角度最后2
24、周,将角度提示装置放置在床档,并测定床头抬高角度对护理人员进行调查,以了解对该装置的满意度,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in m
25、aintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,床头抬高 如何实施,依从定义为床头角度 28,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,床头抬
26、高 如何实施,32名护士完成调查问卷 回收率100%该装置改进现有方法72%该装置有助于监测床头抬高情况88%希望该装置永久使用84%既往了解ICU中床头抬高指南94%改进了对于抬高床头重要性的认识66%,Williams Z,Chan R,Kelly E.A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients.Crit Care Med 2008;36:1155-1157,每日清单,59,每日提醒导管留置时间,60
27、,Seguin P,Laviolle B,Isslame S,et al.Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization.Intensive Care Med 2010;36:1202-1206,每日提醒导管留置时间,61,Seguin P,Laviolle B,Isslame S,et al.Effectiveness of simple daily sensitization of phy
28、sicians to the duration of central venous and urinary tract catheterization.Intensive Care Med 2010;36:1202-1206,每日提醒导管留置时间,62,Seguin P,Laviolle B,Isslame S,et al.Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization.Intensive C
29、are Med 2010;36:1202-1206,每日目标清单,Hartford医院800张床位的I级创伤中心教学医院12张床外科ICU查房时的目标清单源自Baltimore的Johns Hopkins医院清单列举了各种方面的目标临床治疗安全性每日两次查房时使用,http:/access on July 8,2008,63,每日目标清单,患者为何住ICU?镇静水平是否适当?疼痛控制水平是否适当?床头是否抬高30度?是否进行脱机/拔管评估?Current vent support needed RWP candidate?组织灌注是否充分?心律失常得到治疗/控制?BP控制适当?容量状态适当?I
30、V液体适当?营养支持充分?肠道?PUD预防?电解质WNL?血糖控制?,血色素/血球压积(H/H)正常?凝血指标正常?DVT预防?培养结果已核对?伤口已检查?皮肤完整?抗生素适当?各种管路的必要性?化验检查/操作已开医嘱?化验检查结果已查验?DELTA PO药物剂量调整?已经联系会诊医生?Patient mobilized,OT/PT/ST?Primary service/consults contacted,plan discussed?医疗团队了解终末期治疗计划?已与家属沟通?,http:/access on July 8,2008,64,每日目标清单,结果对治疗目标的了解明显改善护士:50%98 100%LOS缩短约1.5天机械通气时间缩短约1.0天ICU病死率从11.5%下降至8.3%,http:/access on July 8,2008,65,护士培训计划 BASIC讲座,护士培训计划 BASIC技能操作,总结,68,
