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1、Introduction to SICU,臺大醫(yī)院 外科加護病房柯文哲 醫(yī)師,The Cost of Health Care,,Actually, 13.6% in 2000,Economic Impetus of ICU,hospital : 40 % of total health careICU : 15 ~ 20 % of hospital cost15 % x 40 % x 15 ~ 20 % =

2、 0.9 ~ 1.2 %1 % of GNP,History of ICU,1860+ : Florence Nightingale1952 ~ 3 : polio epidemics in Europe bulbar paralysis ---> resp. failure formation of modern ICU1960+ : open heart surgery

3、 trauma, transplantation,Function of Modern SICU,monitor of high-risk patientsprevention and treatment of post-op complicationspre-op optimizationterminal care,阿 婆 的 故 事,,BP = C

4、O x SVR,V= I x R(idea of pre-op optimization),Function of Modern SICU,monitor of high-risk patientsprevention and treatment of post-op complicationspre-op optimizationterminal care,M

5、ultiple Organs Failure,(MOF),65 yrs , male , CAD - III,PH : NP OP : CABG, CPB : 5 hrPOD 6# :1. ARDS (FiO2: 0.8 , PEEP: 10, SaO2: 95%)2. ARF : on H/D3. paralytic ileus: on TPN4. Bil : 12 mg/dl5. IABP use6.

6、 conc : drowsy, but arousablewhat is the estimated mortality in this patient ?(a).20% ,( b).40% ,( c).60% ,(d).80% ,(e).100%,Mortality of MOF,,Critical Care State of the Art( USA, 1991),> 3 O.F , > 3 days

7、 99 % mortality,,,Heart : mechanical circulatory supportLung : ventilator Liver : FFP, plasmapheresisKidney : P/D, H/D, CVVH GI : TPNB.M. : transfusionImmune: antibiotics,Goal of Modern ICU,prevention

8、 not treatment of MOF,Three Tasks in SICU,Shock ? ? resuscitation2 underlying problems ? ? treatment3 nutrition ? ? support (metabolic support vs nutritional support),William C. ShoemakerSurgical Clinics of Nort

9、h America (1985),Survior Vs non-survior in early ICU period X : BP , HR , CVP , PAWP , Hct , ABGO : CI , DO2 , VO2,Basic Model in Critical Care,stress => compensation,success,,failure,,,,survive,death,PH in

10、ABG,Inference from Shoemaker's Study,1. pre- op normal≠post-op normal 2. what we usually measure in ICU are useless ( too late to be effective )3. compensation : major determinant of outcome4. survival pattern

11、 : the goal of therapy,1985 William C. ShoemakerSurgical Clinics of North America (1985),× BP, HR, CVP, PAWP, ABG ? CI, DO2I, VO2IStress ? Compensation ↗ succeed ? survival

12、 ↘ fail ? death × pH in ABG,Inference from Shoemaker's Study,1. pre- op normal≠post-op normal 2. what we usually measure in ICU are useless ( too late to be effective )3. compensation

13、 : major determinant of outcome4. survival pattern : the goal of therapy,Therapeutic Goal in SICU Patients(Survival Pattern of SICU Patients),1. C.I.＝1.5 x normal2. blood volume : 500 ml more than normal 3. DO2I＞ 6

14、00 ml/min/m24. VO2I＞ 170 ml/min/m25. BP : normal or higher,But,1. no one can get the same result2. our experience in cardiac surg. patients,Weak Compensation Response,1. poor compensation mechanism2. no stress＝＞ o

15、ptimal supply is determined by need,Basic Model in Critical Care,stress => compensation,success,,failure,,,,survive,death,Modern ICU,optimal environment for patients to recoverprevent complications (esp. iatrogen

16、ic )early detection and early treatment of pathophysiological process,Summary,critical care begins from pre-op stageideal critical care :continuous monitorearly detection early interventionFull time ICU team,Mult

17、iple Organs Transplantation,,How to develop ICUin my hospital ?,,有沒有比貪污更嚴重的事 ?,,決策錯誤 !,,戲,編劇 , 導演演員燈光 , 佈景 , 道具 , 化粧,外科加護病房之特色,1.基本設備投資大2.人員養(yǎng)成慢3.難以轉用其他用途4.發(fā)展決策更需慎重,SICU Patients,CVS , CStrauma , NS transplanta

18、tionothers,外科加護病房發(fā)展之考慮因素,病人種類與數量現有的人員裝備未來的發(fā)展→領導者的責任,外科加護病房之重要性,“白飯” 理論 * CVS ICU * Trauma ICU產業(yè)升級 擺脫競爭最好的方法總後勤支援,加護病房設立之考慮順序,軟體 > 硬體 先決定運作方式, 再決定人員 設備營運成本 > 設備成本經濟規(guī)模留 “空白

19、”,臺大醫(yī)院外科加護病房團隊,,,,,,,,,,,,,,,,,,,SICU,,心臟外科,,胸腔外科,,一般外科,,大腸直腸外科,,小兒外科,,整形外科,,神經外科,,臺大外科部,,,,,,,,,,,,4A1A2CVS2052122,,4B1B2NS + CS11 + 740122,,4C1GS1431322,,移植小組,周邊血管檢查室,,SICU,,,,單位床位護士NSPR2int

20、ern,VS: 1 + 0.9 + 0.5 Technician: 3 NSP: 5 Tx Nurse: 3P.S. Ped SICU: 6床, Burn ICU: 4床, 不在管轄內,,NTUH SICU Team,VS, R2, InternHN, nurseClinical pharmacistCNS (NSP, PA)PTRTICU technicianDietitianSocial worker

21、,Date,裝備清單,ECMO ? 4臺IABP ? 5臺VAD (Heartmate 1臺, Thoratec 1臺)Metabolic cart 1臺Tonometry 1臺COLD 1臺Dialysis (HD ? 1, CVVH ? 3),全身超音波 ? 1 血管超音波 ? 1, IPG ? 1 Continuous cardiac output ? 3 ABG 全套手術裝備 ? 2 (頭燈, 電刀,