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1、ICU=重症医学？ 危重病的早期预警,浙江省人民医院ICU 孙仁华,内容,背景 危重病的早期预警 小结,什么叫重症医学?,早期发现并积极处理危重症-提高抢救成功率的关键,ARDS ALI ARF AKI MOF MODS,病情的突然变化-病情变化被突然发现,研究显示：那些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,从不同部门入ICU患者死亡率的差别,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、恰当的治疗可以有效提高抢救成功率，降低致残率
2、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,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
3、in level of consciousness (n=42).,Intensive Care Med (2002) 28:16291634,危重病的早期预警,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,Recommendation 1.2.2.5 Multiple-par
4、ameter 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,Recommendation 1.2.2.6 In specific clinical circumsta
5、nces, 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,危重病的早期预警,在EWS的基础上，国外许多医院成立：Critical Care Outreach Service (CCOS)，Medical Em
6、ergency Team (MET)，Rapid Response Teams等以提高危重病人的抢救成功率。,改良早期危险评分（MEWS),Journal of Critical Care (2012) 27, 424.e7424.e13,Content of measurements. The combination (in white) of all measurements taken (N = 2688) is shown compared with the measurements with a positive MEWS (3 points) in black (n = 988).
7、 All possible combinations were analyzed, and those with a prevalence of 4% or more were included. BP indicates systolic blood pressure; Resp, respiratory rate; Temp, temperature; Sat, peripheral saturation with supplementary oxygen therapy,Early Warning Score scoring system EWS 3 2 1 0 1 2 3 Pulse
8、rate 51-100 101-110 111-130 130 BP (systolic) 200 Respiratory rate 30 Temperature 37.5 Consciousness A V P U EWS = Early Warning Score; BP = blood pressure; A= alert; V=responsive to voice; P=responsive to pain; U=unresponsive. Worried about patients condition: 1 point; Urine production below 75 ml
9、during previous 4 hours: 1 point; Saturation below 90% despite adequate oxygen therapy: 3 points.,january 2013 , vol . 71, No1,13 months (May 2010-May 2011),71,911 EWS values in the Medical Centre Alkmaar. 56% ( 40,183) on surgical wards, 44% (31,728) on medical wards,Mortality rate as a percentage
10、of admissions each year. Average values pre- and post-MEWS are shown along with P values,M.S. Patel et al. Injury, Int. J. Care Injured 42 (2011) 14551459,The distribution of NEWS values and the relationship with each of the four outcomes studied.,Smith GB, et al. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation (2013),小结,早期发现、恰当处理是提高危重病人抢救成功率的关键 早期预警系统能及早提醒医务人员可能的病情恶化，以便采取干预措施，降低死亡率 ICU医生要开阔思路，放眼全院,