危重病的早期预警

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,ICU=,重症医学？,危重病的早期,(zoq),预警,浙江省人民,(rnmn),医院,ICU,孙仁华,第一页，共二十七页。,内容,(nirng),背景,危重病的早期,(zoq),预警,小结,第二页，共二十七页。,什么,(shn me),叫重症医学,?,第三页，共二十七页。,早期发现并积极,(jj),处理危重症,-,提高抢救成功率的关键,ARDS ALI,ARF AKI,MOF MODS,第四页，共二十七页。,病情的突然,(trn),变化,-,病情变化被突然发现,研究显示：那些,(nxi),没有经过心肺复苏就死亡的住院患者中，约一半的患者在死亡前的,24 h,内具有可逆的生命体征异常；,80,的院内心脏骤停的患者在发生事件前,8 h,内已经出现了严重的生命体征的异常,第五页，共二十七页。,从不同部门入,ICU,患者,(hunzh),死亡率的差别,普通病房入,ICU,患者的死亡率高于从急诊室、手术室、麻醉复苏室入,ICU,者,早期,(zoq),、恰当的治疗可以有效提高抢救成功率，降低致残率,现代医学专业细分化与患者高龄化和复杂化的矛盾,-,发现延误、处理不当,第六页，共二十七页。,Hillman KM,等前瞻性研究了,551,例从不同科室入,ICU,患者情况：,90,例来自普通病房，,239,例来自,OR,，,222,例来自,ED,。普通病房入,ICU,患者,APACHE II,评分,(png fn),21,，,OR 15,，,ED 19,；死亡率分别为,47.6%,、,OR 19.3%,、,ED 31.5%,；入,ICU,前经历的不良事件：普通病房,72%,、,OR 64.4%,、,ED 61.8%,。入,ICU,前,8,小时常见的不良事件：,hypotension(,n=199),tachycardia n=73),tachypnoea(n=64),and sudden,change in level of consciousness(,n=42).,Intensive Care Med(2002)28:16291634,第七页，共二十七页。,危重病的早期,(zoq),预警,早期预警（,Early warning scoring system,，,EWS,）主要适用于,ICU,外区域，,最早由英国,Morgan,等提出，并得到广泛的认可,(rnk),与应用。也有称,physiological track and trigger warning systems(TTs),具体评介方法并未统一，多达数十种，但多以简单、常用生理参数为基础。,MEWS,是比较常用的方法之一,第八页，共二十七页。,Multiple-parameter or aggregate weighted scoring systems used for track and,trigger systems should measure:,heart rate,respiratory rate,systolic blood pressure,level of consciousness,oxygen saturation,temperature.,NICE clinical guideline No.50.London;2007,第九页，共二十七页。,In specific clinical circumstances,additional monitoring should be considered;,for example:,hourly urine output,biochemical analysis,such as lactate,blood glucose,base deficit,arterial pH,pain assessment.,NICE clinical guideline No.50.London;2007,第十页，共二十七页。,危重病,的,的早期,(zoq),预警,在,EWS,的基础,上,上，国,外,外许多,(xdu),医院成,立,立：,CriticalCare Outreach Service(CCOS),，,Medical EmergencyTeam(MET),，,RapidResponseTeams,等以提,高,高危重,病,病人的,抢,抢救成,功,功率。,第十一,页,页，共,二,二十七,页,页。,改良早,期,期危险,(wixi,n),评分（,MEWS),第十二,页,页，共,二,二十七,页,页。,Journal of Critical Care(2012)27,424.e7,424.e13,第十三,页,页，共,二,二十七,页,页。,第十四,页,页，共,二,二十七,页,页。,Content of measurements.The combination(inwhite)ofall measurementstaken(N=2688)is shown compared withthe measurementswith apositiveMEWS(3points)inblack(n=988).Allpossiblecombinationswereanalyzed,and those withaprevalence of 4%or morewereincluded.BPindicates systolic blood pressure;Resp,respiratoryrate;Temp,temperature;Sat,peripheral saturationwithsupplementary oxygentherapy,第十五页,，,，共二十,七,七页。,第十六页,，,，共二十,七,七页。,第十七页,，,，共二十,七,七页。,Early Warning Scorescoringsystem,EWS3210123,Pulse rate51-100101-110111-130130,BP(systolic)200,Respiratoryrate30,Temperature37.5,ConsciousnessAVPU,EWS=EarlyWarningScore;BP=blood pressure;A=alert;V=responsive to voice;P=responsive topain;U=unresponsive.Worried aboutpatient,s,condition:1point;Urine productionbelow 75 mlduringprevious4 hours:1point;Saturation below90%despiteadequateoxygentherapy:3 points,.,january2013,vol.71,No1,第十八页,，,，共二十,七,七页。,13 months(May 2010-May2011),71,911EWSvaluesintheMedicalCentre Alkmaar.56%(40,183)on surgical wards,44%(31,728)on medical wards,第十九页,，,，共二十,七,七页。,第二十页,，,，共二十,七,七页。,Mortality rate as apercentage of admissionseach year.Averagevalues pre-andpost-MEWS are shownalong with Pvalues,M.S.Patel et al.Injury,Int.J.CareInjured42(2011)14551459,第二十一,页,页，共二,十,十七页。,第二十二,页,页，共二,十,十七页。,ThedistributionofNEWSvaluesandtherelationshipwith each of the four outcomesstudied,.,Smith GB,etal.TheabilityoftheNationalEarly Warning Score(NEWS)to discriminatepatientsatriskofearly cardiac arrest,unanticipatedintensive care unitadmission,and death.Resuscitation(2013),第二十三,页,页，共二,十,十七页。,第二十四,页,页，共二,十,十七页。,小结,(xioji),早期发现,、,、恰当处,理,理是提高,危,危重病人,抢,抢救成功,率,率的关键,早期预警,系,系统能及,早,早提醒医,务,务人员可,能,能的病情,恶,恶化，以,便,便采取,(ciq),干预措施,，,，降低死,亡,亡率,ICU,医生要开,阔,阔思路，,放,放眼全院,第,二,二,十,十,五,五,页,页,，,，,共,共,二,二,十,十,七,七,页,页,。,。,第,二,二,十,十,六,六,页,页,，,，,共,共,二,二,十,十,七,七,页,页,。,。,内,容,容,(n,ir,ng),总,结,结,ICU=,重,重,症,症,医,医,学,学,。,。HillmanKM,等,等,前,前,瞻,瞻,性,性,研,研,究,究,了,了551,例,例,从,从,不,不,同,同,科,科,室,室,入,入ICU,患,患,者,者,情,情,况,况,(q,ngku,ng),：90,例,例,来,来,自,自,普,普,通,通,病,病,房,房,，,，239,例,例,来,来,自,自OR,，,，222,例,例,来,来,自,自ED,。,。,具,具,体,体,评,评,介,介,方,方,法,法,并,并,未,未,统,统,一,一,，,，,多,多,达,达,数,数,十,十,种,种,，,，,但,但,多,多,以,以,简,简,单,单,、,、,常,常,用,用,生,生,理,理,参,参,数,数,为,为,基,基,础,础,。,。,早,早,期,期,预,预,警,警,系,系,统,统,能,能,及,及,早,早,提,提,醒,醒,医,医,务,务,人,人,员,员,可,可,能,能,的,的,病,病,情,情,恶,恶,化,化,，,，,以,以,便,便,采,采,取,取,干,干,预,预,措,措,施,施,，,，,降,降,低,低,死,死,亡,亡,率,率,。,。ICU,医,医,生,生,要,要,开,开,阔,阔,思,思,路,路,，,，,放,放,眼,眼,全,全,院,院,第,二,二,十,十,七,七,页,页,，,，,共,共,二,二,十,十,七,七,页,页,。,。,