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
Thank you ！
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
Thank you ！
