休克定义及分型的再思考

休克, 已被临床认识和治疗多年, 是常见的危及生命的疾病状态。近些年, 随着血流动力学理论及认知内涵的发展, 人们对于休克的评估与认识不断深入。在此基础上, 中国的重症医学专家们尝试提出休克的中国定义:各种原因引起全身灌注流量改变, 导致组织器官氧输送不足与氧代谢异常的急性循环综合征。同时根据血流动力学特点及临床应用, 休克的分型依然是:分布性、低血容量性、梗阻性、心源性。当不同类型的休克同时存在时, 可以称之为混合性休克。由此, 以更好地理解休克、评估休克、管理休克, 使更多的临床休克患者从中获益。     

床旁即时超声在新生儿休克诊疗中的应用进展

新生儿休克是新生儿重症监护病房患者住院和死亡的主要原因之一。根据血流动力学分型将休克分为四种类型,不同原因的休克在同一个患者中可能会同时出现并可能互相转换,因此,快速明确休克类型对休克治疗至关重要。床旁超声技术作为一种对各重症单元可视化动态检查的评估手段,在成人重症监护领域必不可少。近年来,重症超声技术在新生儿科的应用越来越广泛,床旁即时超声(POCUS)技术可对心肺氧输送器官进行实时动态评估,可明确休克的病理生理机制。本文结合国内外床旁超声的发展现状和新生儿休克特点,阐述POCUS在新生儿休克及治疗中的应用价值。     

休克复苏:血流至上，氧流至优

人类对重症认知的重要里程碑是从对休克的血流动力学精细化理解开始。经过几十年的发展,血流动力学治疗理念更加完善,休克的治疗既有依托于指南的群体化治疗,又有具体到床旁每一位患者的个体化策略。血流的龙头效应早已深入人心,而血流中的氧流更是休克血流动力学复苏的目的性指标。本文对血流及血流中的氧流进行进一步追踪探讨,并将血流与氧流的影响因素、监测与复苏导向治疗进行拆分,提出基于血流-氧流的休克新分型,以期在器官化血流动力学治疗理念之下开启更精准的血流动力学治疗时代。     

重症肾脏超声:肾脏血流动力学评估

器官的血流动力学评估逐渐成为热门话题。肾脏作为最易受休克影响的器官之一,其血流动力学评估也备受重视。重症超声由于具有动态、实时、可重复的特点,能兼顾结构与血流灌注的结合,更是为重症患者的器官血流动力学评估提供了新的理念和方法。本文重点阐述重症超声在肾脏血流动力学评估中的应用及意义,主要包括脉冲多普勒肾血管阻力指数测定、彩色多普勒血流显像结合彩色血流定量技术和超声造影成像等内容。     

重症超声在重症患者循环管理中的作用

重症超声在重症患者循环管理中有着重要的价值和作用,可以对心脏骤停、急性循环衰竭患者进行快速病因诊断,对重症患者进行重症超声导向的连续、动态循环精细化管理,对全身多个器官的灌注情况进行评估,是重症医生管理重症患者的有力武器。     

PiCCO系统临床应用进展

血流动力学监测是危重症患者病情评估及抢救治疗中一项重要监测手段。近年来危重症患者血流动力学监测技术不断发展,临床应用的血流动力学监测技术各有优势,但对手术室及ICU重症患者应用PiCCO系统监测血流动力学变化仍是首要选择。     

超声评估急重症患者容量状态研究进展

循环不稳定是急重症患者常见急症之一,快速评估其容量状态是指导治疗的关键。检测中心静脉压（CVP）是目前临床评估容量负荷的较常用方法,但为有创操作,且存在较多近远期并发症。超声作为无创检查已广泛应用于监测血流动力学,近年来,采用急诊超声评估患者容量状态并指导液体治疗日益普及。本文对超声评估急重症患者容量状态的应用进展进行综述。     

床边超声技术在重症医学科中的应用

<正>由于危重病患者,多半存在血流动力学不稳定,且可能进行持续机械通气或血液净化治疗,不适宜搬动,这给危重病患者的进一步明确诊断和治疗带来诸多不便。床边超声检查作为一种无创、可重复的检查技术,尤其对于心脏功能、液体反应性等血流动力学评估作用越来越重要。现就床边超声技术在重症医学科的应用综述如下。1血流动力学及心功能变化的评估血流动力学不稳定患者的管理,重要的是以提高心排出量和改善组织灌注为目的的血管内容量的     

重症超声在重症患者护理中的作用

重症超声具有问题导向、实时动态、既可重复检查也可连续监测的特点,是确定患者治疗方向,尤其是指导血流动力学治疗精细调整的重要手段。然而目前,超声在重症患者护理中的应用处于起步阶段。超声具有独特的可视化视角,可定性和(或)定量的评估肉眼无法观察的护理指标,有助于解决临床中护理工作的难题。本文就超声引导下血管穿刺技术、超声引导下空肠营养管置入技术、超声在肺脏护理评估中的应用以及在压疮评估与预防中的应用进行探讨和阐述。     

颗粒化多模态监测与血流动力学研究

血流动力学优化是重症医学危重患者复苏的关键,处理延迟或不当将不可避免地造成机体灌注不足、组织缺氧和多器官功能障碍,从而影响患者结局。血流动力学管理的关键原则是根据当前组织代谢情况优化血流及氧流。要实现这一目标需要获取并监测血压、心输出量、器官特异性自动调节和组织微循环等参数。鉴于指标的多样性和连续性,通过临床监测提供的数据十分庞大,同一时段可有近百项数据客观呈现患者的病理生理状态,而不同时段的数据变化可为患者的病情进展描述提供理论支撑。因此,基于毫秒级高分辨率数据的时域/频域整合分析,即颗粒化多模态监测,将促进血流动力学认知与实践迈入微观化,有助于更清晰地判断患者病情并进行更精准的治疗。     

Red cell transfusion therapy in the critical care setting

According to our own experience and published reports the frequency of red cell transfusion in intensive care units is in the range of 0.2 to 0.4 units per patient per day and is dependent upon the local strategy, the patients involved and the kind of surgery performed. The rationale for red cell transfusion is to maintain or restore the oxygen carrying capacity of the blood to avoid tissue hypoxia which occurs when oxygen delivery drops below a certain critical value. Besides bleeding, phlebotomy is also a significant source of blood loss in critically ill patients. According to several recent reviews and consensus articles there is no basis for a fixed indicator for transfusion, such as a haemoglobin concentration of < 100 gL-1. The decision to transfuse has to be made according to the patients individual status. The major adaptive mechanism in response to acute anaemia is an increase in cardiac output and hence blood flow to tissues. As a consequence even moderate degrees of acute anaemia may not be tolerated by patients with cardiac disease, whilst marked anaemia carries a considerable risk of ischaemia in patients with brain lesions or cerebral arterial stenoses. In critically ill patients it has been postulated that supply dependency of oxygen consumption occurs over a wide range of oxygen delivery, far above the critical values of oxygen delivery seen under normal conditions. Maximising oxygen delivery was therefore formulated as a goal in these patients. However, whether pathological supply dependency of oxygen delivery really exists in critically ill patients is still under discussion and recent studies found no benefit in maximising oxygen delivery to this patient group. However, individualised triggers for red blood cell transfusion are adequate for critically ill patients considering their co-morbidities and severity of disease. Finally, the decision to transfuse must also take into account the potential risks (infectious and non-infectious), as well as benefits for the individual patient. In the future, the level of transfusions may be reduced by using blood sparing techniques such as blood withdrawal in closed systems, bedside microchemistry, intravascular monitors, or autotransfusion of drainage blood in intensive care units.     

Intestinal ischemic reperfusion syndrome: pathophysiology, clinical significance, therapy]

Gut ischemia-reperfusion injury is a serious condition in intensive care patients. Activation of immune cells within the huge endothelial surface area of gut microcirculation may initiate a systemic inflammatory response with secondary injury to distant organs. Translocation of bacteria and toxins through a leaky gut mucosa may amplify or perpetuate systemic inflammation, leading to multiple organ dysfunction syndrome and death in critically ill patients. Gut ischemia promotes regional production of inflammatory mediators, expression of cell adhesion molecules on endothelial and immune cell surfaces and increases the procoagulatory properties of vascular endothelial cells. During reperfusion, gut injury may be amplified by increased production of oxygen radicals and exhaustion of endogenous antioxidant defence mechanisms. Although several therapeutic strategies to interrupt the pathophysiology of ischemia-reperfusion have been shown to be beneficial in animal experiments, none of these interventions has gained clinical relevance. After initial hemodynamic and respiratory stabilisation of critically ill patients, strategies to prevent secondary gut injury by increasing splanchnic oxygen delivery or augment mucosal cell regeneration may be the only therapeutic options for intensive medical specialists at the present time. Early enteral nutrition and treatment with specific vasoactive drugs may reduce morbidity and costs of treatment in certain critically ill patients. However definitive evidence of a reduction in mortality with these therapies has still not be provided.     

Hemodynamic responses to gram-positive versus gram-negative sepsis in critically ill patients with and without circulatory shock

OBJECTIVE: To examine the hemodynamic patterns of critically ill patients with septicemia to evaluate their relationship to blood bacteriology. DESIGN: Retrospective study. SETTING: Medical ICUs of a tertiary care medical center. PATIENTS: Total of 59 critically ill patients with bacteremia: 33 with Gram-positive and 26 with Gram-negative bacteremia. MEASUREMENTS: Hemodynamic variables and mixed venous oxygen saturation (SvO2) measurements associated with the highest cardiac index measured within 72 hrs of positive blood cultures. MAIN RESULTS: No significant differences in cardiac index, mean arterial pressure, systemic vascular resistance, oxygen extraction ratio, or SvO2 were observed comparing the two groups. CONCLUSION: We were unable to demonstrate clinically important differences between the hemodynamic responses to Gram-positive vs. Gram-negative sepsis.     

超声造影在重症监护病房中的应用现状

常规超声监测在危重症患者中已广泛应用,但在某些特殊情况如器官血流灌注下易出现误诊和漏诊。超声造影可以反映器官组织的血流灌注情况,特别是微灌注情况,在监测危重症患者时可弥补常规超声血流灌注的不足。本文初步总结超声造影在重症监护病房中的应用现状及进展。     

Community-acquired pneumonia in the emergency department: a practical approach to diagnosis and management

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.     

The critical care literature 2019

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments across the United States has steadily increased. From 2006 to 2014, emergency department (ED) visits for critically ill patients increased approximately 80%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the ICU remain in the ED for more than 6 h. Prolonged ED wait times for critically ill patients to be transferred to the ICU is associated with increased hospital, 30-day, and 90-day mortality. It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2019 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to emergency medicine. The following topics are covered: sepsis, rapid sequence intubation, mechanical ventilation, neurocritical care, post-cardiac arrest care, and ED-based ICUs.     

The critical care literature 2017

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. Between 2001 and 2009, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased >200% [1]! This trend has persisted since then. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, >33% of critically ill patients who are brought to an ED remain there for >6?h [1]. Longer ED boarding times for critically ill patients have been associated with a negative impact on inpatient morbidity and mortality [2]. During these crucial early hours of illness, detrimental pathophysiologic processes begin to take hold. It is during these early hours of illness where lives can be saved, or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2017 pertaining to the resuscitation and care of select critically ill patients in the ED. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care. The following topics are covered: sepsis, vasolidatory shock, cardiac arrest, post-cardiac arrest care, post-intubation sedation, and pulmonary embolism.     

The critical care literature 2018

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased more than 200% (Herring et al., 2013). In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the intensive care unit (ICU) remain in the ED for more than 6 h (Rose et al., 2016). Longer ED boarding times for critically ill patients is associated with a negative impact on inpatient morbidity and mortality (Mathews et al., 2018). It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2018 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to clinical care in the ED. The following topics are covered: cardiac arrest, post-arrest care, septic shock, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and metabolic acidosis.     

Scope of the problem: epidemiology of anemia and use of blood transfusions in critical care

Anemia is a common problem in critically ill patients. It is caused, in part, by blood loss related to phlebotomy for diagnostic testing, occult gastrointestinal bleeding, renal replacement therapies, surgical intervention, and traumatic injuries. Reduced red cell life span and nutritional deficiencies (iron, folate, vitamin B12) may be other contributing factors. In addition, critically ill patients have impaired erythropoiesis because of blunted endogenous erythropoietin production and the direct inhibitory effects of inflammatory cytokines on red blood cell production by the bone marrow. Blood transfusions are commonly utilized for treatment of anemia in critical care, resulting in high use of blood transfusions in the intensive care unit (ICU). The percentage of patients transfused in the ICU is inversely related to admission hemoglobin and directly related to age and severity of illness. Patients with an increased length of stay in the ICU are also at increased risk for receiving blood transfusions. Studies are needed to improve our understanding of the pathophysiology of ICU-acquired anemia, to determine the efficacy of blood transfusions in critical care, and to investigate alternatives to blood transfusion for the treatment of anemia in the ICU.