Critical Care Medicine Dr. Huang Peizhi Zhongshan Hospital of Fudan Universit What is critical care medicine ？Multidisciplinary healthcare specialty cares for patients with acute, life-threatening illness or injury which including continuum of life support from the scene through discharge Coordinated care systems, analysis of treatment options, protocols, guidelines for the care of individual patients Monitoring and therapy Intensive care medicine in Europe What is critical illness ? A condition where life cannot be sustained without invasive therapeutic interventions Characterized by acute loss of physiologic reserve Cardiac arrest, shock, sepsis, severe trauma, coma Dysfunction of one or more organ systems : hemodynamic insufficiency, respiratory failure , abnormalities of fluid and electrolytes Characters of CCM (1) life support from site of accident to injury during transportation and  management in emergency department (ED)  and to  surgical intervation in operating room  or in intensive care unit (ICU) Require emergency medicine and Intensive care medicine Characters of CCM (2) Team action by physicians with various specialty backgrounds Added expertise in resuscitation No focus of interest to a single body system, but wide variety of illness Intensivist - ability to provide effective critical care is in all cases Emergency and critical care medicine (ECCM) system Pre-hospital care (self-help, help from bystanders, ambulance personnel via transport) life support in Emergency department , operation room and ICU EM physician is based in the ED,  intensivist remained in ICU History of CCM In 1940’s: physician sitting at the bedside through the long night 1st ICU opened in Europe in 1950’s In 1970 ：set up society of CCM in USA Since 1991: teaching of CCM in China In 2001: set up committee of CCM in Shanghai  Intensive Care Unit (ICU) What is ICU ? Multidisciplinary multi-professional medical/nursing field A very high nurse to patient ratio (3-4:1) The availability of invasive monitoring The use of mechanical and pharmacological life sustaining therapies (mechanical ventilation, vasopressors, continuous dialysis, defibrillation, pacemaker)  Service in ICU Elementary service Bedside monitor system Treatment equipment Experiment instrument   Elementary Service Patient area (special functional bed and bedside monitor) Central monitoring field （central monitor and functional connected bedside monitor ）Employment area ( placement equipment and therapeutic room Bedside Monitor System Non-invasive monitoring Invasive monitoring Non-invasive  Cardiovascular Monitoring  Electrocardiographic monitoring:  changes of T waves and ST segment or  arrhythmia Echocardiography Non-invasive blood pressure( NBP ):  alarm to higher or lower BP Doppler ultrasound Non-invasive  Respiratory Monitoring Respiratory rate (RR ), respiratory wave End tidal partial pressure of carbon dioxide (Pet-CO2) : alveolar PCO2 close to PaCO2  normal value is 4 ～5% ( 28 ～35mmHg )  ( 3.7 ～4.7 kpa ) Pulse oximetry : pulse saturation of oxygen (SpO2  ) Invasive Monitoring Central venous pressure (CVP ）：nearly close right atrium pressure. Invasive blood pressure (IBP ) : SBP<90mmHg, or MAP<70mmHg, or SBP decreased>40mmHg suggest hypotension . Arterial oxygen saturation (SaO2 ）：arterial oxygenation , degree of hemoglobin binding to oxygen , 95%—97% is normal . Arterial blood gas analysis (PH 、PaO2 、Pa CO2 ). Gastric mucous membran PH(PHi) Pulmonary Arterial  Catheterization Swan-Ganz catheter Right ventricular pressure (RVP) Pulmonary capillary wedge pressure( PCWP ）Pulmonary artery wedge pressure( PAWP) Pulmonary arterial pressure (PAP) Cardiac output( CO) Cardiac index (CI) > 3.5 L/min/ m2 is normal Oxygen delivery(DO2) :700-1400ml O2/min Oxygen consumption(VO2) ：250 O2/min Mixed venous oxygen saturation(SvO2):73 －85 ％Therapeutic Equipment Mechanical ventilator (respirator) Defibrillator Transcutaneous or transvenous cardiac pacing Cardiopulmonary resuscitation machine (Thumpor) Experimental Instrument Blood gas analyzer An elevated serum lactate level (> 1 mmol/L) identifies tissue hypoperfusion in patient at risk who are not hypotensive Detect meter ：rapidly detect blood sugar or  CTnT , CTnI  or  Brain natriuretic peptide ( BNP)	 Organ Function Support in ICU Respiratory support Circulatory support Renal support Gastrointestinal support Cerebral support  Respiratory Support Indication: hypoxemia, hypercapmia  respiratory failure, cardiac arrest Monitoring ：arterial blood gas analysis  Pet-CO2 、SpO2 Treatment: (1) Oxygen therapy ( when SaO2 < 90% ) control inspiratory oxygen , higher concentration oxygen or hyperbaric oxygen ECMO (extracorpreal membrane oxygenation) (2) Mechanical ventilation  Oxygen Therapy Inspire oxygen by nasal cannula , face mask , endotracheal intubation , tracheotomy or in hyperbaric oxygen chamber( 2-3 atmospheric pressure) Fraction of inspired oxygen (FiO2)  may be used lower (25 ％～30 ％) in initial , then middle (40 ％～60 ％) or higher ( 60 ％) .  Mechanical Ventilation A/C( assist-control):  no spontaneous breathing IPPV (intermittent positive pressure ventilation) PSV (pressure support ventilation): spontaneous breathing PEEP (positive- end expiratory pressure) BiPAP (biphasic positive airway pressure) SIMV (synchronized intermittent mandatory ventilation) CPAP(continuous positive airway pressure) Non-invasive or invasive ventilation Indication of Circulatory Support Hypotension Shock Heart failure Arrhythmia Circulatory Monitoring Electrocardiogram( ECG) Non-invasive blood pressure( NIBP) Invasive hemodynamic monitory (IHM) :  CVP 、PAP 、PCWP and CO, SvO2, DO2 Ejection fraction (EF) by echocardiography  Circulatory Support Fluid resuscitation may consist of natural or artificial crystalloids or colloids and transfusion therapy . Supplemental oxygen . Intravenous dopamine or norepinephrine or vasopressin to correct hypotension . Antiarrhythmic drug : amiodarone . Inotropic drug : In patients with low cardiac output despite adequate fluid resuscitation, dobutamine may be used to increase cardiac output .  Gastrointestinal Support Indication :  abdominal pain ,  diarrhea, dark stools , hematemesis , hematochezia Monitoring ：hematocrit(HCT) , Hb ,  RBC complete blood count (CBC) , occult blood Treatment :  H2 receptor antagonists enteral nutrition Chinese traditional drugs Renal support Indication ：oliguria ,  renal failure Monitoring: urine volume, urine protein , urinalysis , urine osmolarity blood urea nitrogen(BUN) , creatinine( Cr) ,  serum electrolytes Management ：(1) Caution to renal injury (2) Renal replacement in acute renal failure . Continuous veno-venous hemofiltration or intermittent hemodialysis are considered equivalent. Cerebral Support Indication ：Coma  Conscious disturbance Monitoring: Dimension of pupi Focussing light response  Pathologic reflex  Intracranial pressure (ICP) Coma score Treatment : Parenteral and enteral nutrition Dehydrant or diuretic drugs  Hypothermia Progress and Future  SIRS Systemic inflammation response syndrome  Infection , trauma , ischemic injury Uncontrolled inflammatory reaction Produce and release inflammatory medium Vascular endothelial cell injury Microcircularory disturbance Intracellular oxygen utilization disturbance  Diagnosis of SIRS Involves two or more of the following findings (1) Temperature > 38°C or < 36°C (2) Heart rate > 90 beats/min (3) Tachypnea, with a respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg (4.25 kPa) (4) WBC count > 12 x 109/L or < 4 x 109/L, or > 10% band forms on a peripheral blood smear Definition of Sepsis Sepsis = infection plus physiologic changes known as SIRS criteria Severe sepsis = sepsis with acute organ dysfunction Septic shock = sepsis with shock refractory to fluid resuscitation  Treatment of Severe Sepsis Recombinant human activated protein C(rhAPC) : anti-coagulant and Anti-inflammatory effect to improve survival in patients with organ dysfunction. Depression apoptosis and induce super expression of anti-apoptosis protein Bcl-2  MODS Multiple organ dysfunction syndrome the most cause of death in ICU Origin for dysfunction of intestinal barrier Cell apoptosis Endothelium damage Mitochondrion dysfunction New Management Parenteral nutrition for central or peripheral vein administration and enteral for feeding tube positioned in the small bowel , blood substitute New types of respirator New CRRT instrument Hand- carried ultrasound device New non-invasive hemodynamic monitoring Sublingual PH monitoring * *