Pre-ICU training for R1 Jun 22, 2008

ICU 的重要性 1/3~1/2 的美國人在他們生命的最後一年住過ICU, 而1/4 ~ 1/5 的人死在那兒。 除了死亡，受苦 (suffering)是ICU病人最常遭遇到的 。 ICU病人的家屬及朋友對ICU表示相當的不滿 (dissatisfaction )--- 顯示受苦的不僅僅是病患本身。 ICUI龐大的花費是驚人的。

” Inevitable Surprises “ Peter Schwartz 降低醫療成本最有效方式, 就是不要再將大筆經費耗竭在病人生命結束前的三十天。 今日的醫生, 受到習俗或法律的驅迫,不顧病人自身的利益, 想盡辦法維持他們的生命, 甚至不惜犧牲她們的生活品質。 在生命的最後一個月, 比起加護病房的病患, 安寧療護的病患可以省下至少三千美元。

ICU 的問題 ICU 工作人員之間，缺乏溝通、團隊工作不佳、無法解決問題的情形相當常見。 在護理人員之間的情況，更是常見、重要 。 這些將造成無法有共識，也容易導致病患的不良結果。 ICU 病人或他們的代理人，常常抱怨照護者有關溝通的量質:醫病之間的接觸，常常太遲、太簡短、而導致治療目標的混淆、衝突、乃至於不確定性。

End-of-life Care Pain or symptom control Life sustaining therapy Support for dying patients and their family

End-of-life care (臨終照護) Limitation of Medical Care DNR (拒絕急救) Withhold life sustaining (不給治療) Withdrawal life sustaining (停止治療) Patient-centered care Resource allocation Different Professions: oncology service vs ICU team

Resource Allocation(資源分配) 當2位病患需住進 ICU 時，只有1個空床，誰應該優先住進去？ 預後評分---住院病患嚴重度評估表 解決方法: 增加ICU床數 增加現有ICU的有效利用

加護病房病患收治及轉出標準 收治標準 壹. 優先次序之原則 貳. 疾病診斷之原則 參. 客觀條件之原則

收治標準 必須選擇那些對於重症加護可能受益的病人。 有兩類不同情況的病人，在一般治療之下另施予重症加護治療，並無太大助益。 「病況太輕而無助益 (too well to benefit)」或是 「病況太重而無助益 (too sick to benefit)」。 加護病房之重症治療的目的，在改善極為危險和不穩定病況病患的預後。 在決定病況的好與壞而有無實質助益時，是主觀的判斷。 醫師必須去評估重症病患的疾病嚴重度和預後。結合臨床判斷，以最好的方式決定預後。 重症加護病房的轉入，決定必須根據不同的情況，給予優先順序(priority)，利用不同診斷和客觀的分析。

重症加護病房轉出條件 所有重症/加護病房的住院病患，必須持續地評估，直到不再需要重症加護治療。 當病患的生理狀態穩定，而加護觀察不再需要時， 當病患的生理狀態已退化，而不再考慮積極治療，可轉介至次階的照護時。

Technology changes what is today Conflicts: Multiple members of the different healthcare teams may be confronted. Eroded Trust: With the increasing technology and multi-specialty, the “sacred trust” between patient and physician has eroded. Dysfunction : between oncology services and ICU teams

ICU照護 生活品質 尊嚴 自主權 資源分配 充分告知 臨終照護

ICU 的目標 ICU的臨床醫師，傳統上，認為他們的目標是治療疾病、恢復身體健康和功能。 必要時，這些目標也應該包括保障病患的好死(good death)。 Robert D. Crit Care Med 2001; 29: 2332

撤除維生治療 first blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, finally tube feedings

結論 重症醫學早期 近年來逐漸發現 重大的發現與發明，降低了疾病的罹病率和死亡率。 重症醫師逐漸認知對病人的責任，必須超越 “治療疾病”，而包括提供病人有尊嚴而可忍受的死亡。

結論 以痊癒模式的醫療: (curative model) 常以診斷性的檢查與治療性的介入，來達到病情的治癒。 以緩和模式的醫療: (palliative model) 以症狀解除、改善身體功能及減緩情緒上、心理上、靈性上的痛楚為主 。 前者強調疾病的治療，後者則以症狀的治療為主。

Procedure Note

Critical Care Physical Examination Vital signs: Temperature, pulse, respiratory rate, BP (vital signs should be given in ranges) Input/Output: IV fluid volume/urine output. Special parameters: Oxygen saturation, pulmonary artery wedge pressure (PAWP), systemic vascular resistance (SVR), ventilator settings, impedance cardiography. General: Mental status, Glasgow coma score, degree ofdistress. HEENT: PERRLA, EOMI, carotid pulse. Lungs: Inspection, percussion, auscultation for wheezes, crackles. Cardiac: Lateral displacement of point of maximal impulse; irregular rate,, irregular rhythm (atrial fibrillation); S3gallop (LV dilation), S4 (myocardial infarction), holosystolicapex murmur (mitral regurgitation). Cardiac murmurs: 1/6 = faint; 2/6 = clear; 3/6 - loud; 4/6= palpable; 5/6 = heard with stethoscope off the chest; 6/6= heard without stethoscope. Abdomen: Bowel sounds normoactive, abdomen soft andnontender. Extremities: Cyanosis, clubbing, edema, peripheral pulses2+. Skin: Capillary refill, skin turgor.

Critical Care Physical Examination Neuro Deficits in strength, sensation. Deep tendon reflexes: 0 = absent; 1 = diminished; 2 = normal; 3 = brisk; 4 = hyperactive clonus. Motor Strength: 0 = no contractility; 1 = contractility but no joint motion; 2 = motion without gravity; 3 = motion against gravity; 4 = motion against some resistance; 5 = motion against full resistance (normal). Labs: CBC, INR/PTT; chem 7, chem 12, Mg,pH/pCO2/pO2. CXR, ECG, impedance cardiography, otherdiagnostic studies.

Impression/Problem list Discuss diagnosis and plan for each problem by system. Neurologic Problems: List and discuss neurologic problems Pulmonary Problems: Ventilator management. Cardiac Problems: Arrhythmia, chest pain, angina. GI Problems: H2 blockers, nasogastric tubes, nutrition. Renourinary Problems: Fluid status: IV fluids, electrolyte therapy. Check BUN, creatinine. Monitor fluids and electrolytes. Monitor inputs and outputs. Hematologic Problems: Blood or blood products, DVT prophylaxis, check hematocrit/hemoglobin. Infectious Disease: Plans for antibiotic therapy; antibiotic day number, culture results. Endocrine/Nutrition: Serum glucose control, parenteral or enteral nutrition, diet.

Admission Check List 1. Call and request old chart, ECG, and x-rays. 2. Stat labs: CBC, Biochem, cardiac enzymes (myoglobin, troponin, CPK), INR, PTT, C&S, ABG, UA, cardiac enzymes (myoglobin, troponin, CPK). 3. Labs: Toxicology screens and drug levels. 4. Cultures: Blood culture x 2, urine and sputum culture (before initiating antibiotics), sputum Gram stain, urinalysis. ........... 5. CXR, ECG, diagnostic studies. 6. Discuss case with resident, attending, and family.

Critical Care Progress Note ICU Day Number: Antibiotic Day Number: Subjective: Patient is awake and alert. Note any events that occurred overnight. Objective: Temperature, maximum temperature, pulse, respiratory rate, BP, 24- hr input and output, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output. Lungs: Clear bilaterally Cardiac: Regular rate and rhythm, no murmur, no rubs. Abdomen: Bowel sounds normoactive, soft-nontender. Neuro: No local deficits in strength, sensation. Extremities: No cyanosis, clubbing, edema, peripheral pulses 2+. Labs: CBC, ABG, Biochemistry ECG: Chest x-ray: Impression and Plan: overall impression, and discuss impression and plan: Cardiovascular: Pulmonary: Neurological: Gastrointestinal: Renal: Infectious: Endocrine: Nutrition: