重症监护室中危重患者心肺康复管理新策略课件

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,！可怕的惯性思维,患者为何会停留在重症监护室中,？,！可怕的惯性思维患者为何会停留在重症监护室中？,1,重症监护室中危重患者心肺康复管理新策略,ABCDE,模式,重症监护室中危重患者心肺康复管理新策略,2,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,E,evidence,P,practice,T,translation,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,重症患者心肺康复服务所承担的使命EPT为什么会产生ABCDE,3,跨学科的合作,Interdisciplinary,而,非,传统的,多学科交叉,M,ultidisciplinary,跨学科的合作 Interdisciplinary,4,ABCDE,模式的核心,A,：,Awakening,，,促醒,B,：,(Spontaneous),Breathing Trial,，自主呼吸测试,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,ABCDE模式的核心A：Awakening，促醒！请注意,5,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,促醒和镇静剂选择的策略每日戒断的目标：RASS-2 to,6,自主呼吸测试,SBT,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5cmH,2,O,低水平PSV,法模式：换为,PSV，压力支持水平设置在,5,-,7,cmH,2,O,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,自主呼吸测试SBT的策略通过短时间(30min-2Hrs),7,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,重症监护室中的谵妄药物的影响,8,评估工具：,Confusion,Assessment Method for the ICU(CAM-ICU),谵妄的干预策略：,Stop.T.H.I.N.K,T,oxic situations,：有害的情况（,CHF,，休克，脱水，药物，新发的器官衰竭）,H,ypoxemia/Hypotension,：低氧血症,/,低血压,I,nfection/+Sepisis,：感染,/+,败血症,N,on-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,评估工具：Confusion Assessment Met,9,Many patients with respiratory failure,require 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 some degree,of despair,concerning their eventual rehabilitation,.,CHEST,68:4,OCTOBER,1975,Robert,Burns,M.D.,F.C.C.P.,and,Frederick L.Jones,Jr.,M.D.,F.C.C.P.,Department,of Thoracic Medicine,Geisinger Medical Center,Danville,Pa,USA,Early Ambulation Of Patients Requiring Ventilatory Assistance,Many patients with respiratory,10,Muscle Deterioration(Structural And Functional),Occurs Very Rapidly in MV/Critical Illness,The New England Journal Of Medicine,Conclusions,The combination of 18 to 69 hours of complete diaphragmatic inactivity and,mechanical ventilation,results in marked atrophy of human diaphragm,myofibers.,These,findings are consistent with increased diaphragmatic proteolysis during inactivity.,Rapid Disuse Atrophy Of Diaphragm Fibers,In,Mechanically Ventilated Humans,Sanford Levine,M.D.,Taitan Nguyen,B.S.E.,et al,March 27,2008 Vol,.358 No.13:1327-35.,Muscle Deterioration(Structur,11,Goal is not necessarily walking,everyone,but getting them,MOVING,!,Fast,，,NOT RUSH,2-Step Process,Safety Screen+Mobility Protocol,Goal is not necessarily walkin,12,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,%(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 bleeding,；,Active fluid resuscitation,；,Open chest/abdomen,Safety Screen 安全性筛查：MOVENM:M,13,重症患者心肺康复运动,3,阶段策略,LEVEL 1:RASS-5 to+2,Functional level:Total,A,ssist,PROM,Bid,x 10 reps,with NR/CPT,Splinting,and,repositioning every,2 hours by,NR,Bed,in chair position,Bid by NR/CPT greater,than,20 minutes,but less than 2 H,rs,Skilled,therapeutic,interventions by,PT/OT as indicated,重症患者心肺康复运动3阶段策略LEVEL 1:RASS-,14,重症患者心肺康复运动,3,阶段策略,LEVEL 2:RASS-2 to+2,Functional level:Max to Mod,A,ssist,ROM,Ex Bid with family/NR/CPT x,10 reps,Splinting,and,repositioning every,2,Hrs,by,NR,Bed,in chair position,Bid,by,NR/CPT,greater than 20 minutes but,less than,2,Hrs,OOB,to neuro chair greater than,30 minutes,but less than 2,Hrs,Skilled,therapeutic interventions,by CPT/OT,as indicated,Participate,in ADL,重症患者心肺康复运动3阶段策略LEVEL 2:RASS-,15,重症患者心肺康复运动,3,阶段策略,LEVEL 3:RASS-1 to+2,Functional level:Mod Assist to Supervision,Self-care,exercise program,Bid,Reposition,every 2,Hrs while in,bed,OOB,to bedside chair,with NR/CPT Tid,greater than,30 minutes,but less than 2,Hrs,Ambulate,as directed by,CPT/OT,Skilled,therapeutic,interventions by CPT/OT,as indicated,Participate,in ADL,重症患者心肺康复运动3阶段策略LEVEL 3:RASS-,16,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,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,17,诚邀,您与我们一起推进,中国,心肺康复,感谢,聆听,诚邀您与我们一起推进中国心肺康复,18,