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1、ICU病人常见心血管危急重症处理,ICU主要收治病症,重大复杂手术后重症或有并发症(心血管并发症) 重要器官急性功能不全或衰竭(如急性心力衰竭、严重心律失常、急性肾功能不全或衰竭、急性呼吸衰竭、急性肝功能衰竭及胃肠功能衰竭) 心、肺、脑复苏及高级生命支持 各类休克 严重多发伤、复合伤需器官功能支持及严密监护 急性严重中毒 急性大出血或DIC 严重代谢障碍 严重复合感染 器官移植术后(常为独立性移植监护病房),ICU病人常见心血管危急重症,Acute heart failure Arrythmias Acute coronary syndrome Acute PE/DVT Cardiac arr
2、est Cardiogenic shock Perioperative hypertension,Acute Heart Failure,Outline Definition Epidemiology Prognosis Diagnosis Treatment,Heart Failure = pump failure,“Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of
3、 the ventricle to fill with or eject blood.” ACC/AHA Guideline 2005“the inability of the heart to pump blood with normal efficiency. The cardinal manifestations of heart failure are dyspnea and fatigue.”,Felker GM et al. Am Heart J 2001 Gheorghiade, M et al. Circulation 2006,Definition,Flavors of he
4、art failure,Definition,急性 心 力 衰竭(AH F)通常指的是由于心脏功能异常所致的急性发作的以肺水肿及或心源性休克为典型临床表现的临床综合征,既往有或无心脏病史均可发作AHF,其中一部分人为首次发作AHF,但大部分AHF发作系慢性心力衰竭失代偿所致; 急性 心 力 衰竭(AHF)作为临床上最常见的心脏急危重症之一,越来越成为临床研究的热点。临床上AHF包括新出现的急性心力衰竭(既往无明确的心功能不全病史)和慢性心力衰竭(CHF)急性失代偿,其中大多数为CHF急性失代偿所致,两种情况急性期处理原则是相同的。,流行病学资料: 美国:1.5-2.0%,65岁6-10%,五年
5、生存率 70%,与恶性肿瘤严重患者相仿。 中国:0.9%(男0.7%,女1.0%) 北方: 1.4%, 南方: 0.5% 城市: 1.1%, 农村: 0.8% 住院率: 20%, 死亡率:40% 急诊就诊率:11.8-21%,Epidemiology,Acute Heart Failure: A Neglected Epidemic?,Adapted from Felker GM et al. Am Heart J 2001,AHA 2006 Heart and Stroke Statistical Update,Heart failure Discharges in US,Outcomes
6、in Patients Hospitalized With HF,Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3 Jong P et al. Arch Intern Med. 2002;162:1689,0,25,50,75,100,20%,50%,30 Days,6 Months,Hospital Readmissions,0,25,50,75,100,12%,50%,30 Days,12 Months,Mortality,33%,5 Years,Mean LOS: 6.5 days,Prognosis,No Progress in A
7、HF Outcomes,Lee DS, et al Am J Med 2004,Prognosis,Proposed causes of AHF due to LV dysfunction,Primary cardiac Progressive cardiomyopathy Acute cardiomyopathy (myocarditis, postpartum CM) Myocardial ischemia Arrhythmia (tachy- or brady) Valvular dysfunction Pericardial syndrome (tamponade, constrict
8、ion) Pressure overload Hypertensive urgency or emergency Volume overload Sodium or volume load Decreased compliance with diuretics Renal dysfunction Hepatic dysfunction,High output Shunt (intra- or extracardiac) Anemia Septicemia Thyroid disease Other Inflammation or infection Major surgery Lack of
9、compliance with heart failure medications New medications (excess -blockade) Substance abuse (alcohol, stimulants),Causes,Killip分级,4级I:无心衰。II:有心衰。 S3奔马律、肺充血,啰音局限在双下1/2肺野 III:严重心衰。 明显的肺水肿,伴满肺湿啰音。 IV:心源性休克。 低血压(SBP90mmHg) 外周血管收缩表现:少尿、紫绀、发汗,Classification,型,型,型,型,临床严重程度分级,分级I级:为肢体温暖和肺部干净II级:为肢体温暖和肺部湿啰音
10、 III级:肢体冷和肺部干净 IV级:肢体冷和肺部啰音,Tests helpful in diagnosis and treatment of AHF, Chest radiography Electrocardiography Measurement of BNP and NT-BNP levels Other laboratory tests (complete blood count, renal function tests, measurement of electrolyte levels, glucose level, transaminase levels, prothromb
11、in time, troponin level, D-dimer level and arterial blood gas pressure, thyroid function tests and urinalysis) Transthoracic echocardiography Central venous line or pulmonary artery catheter,Diagnosis,Symptoms,Left-Sided DOE Orthopnea PND Nocturnal cough Nocturnal awakening Palpitations Exertional f
12、atigue Nocturia Hemoptysis,Right-sided Abdominal bloating Hiccups Anorexia Weight loss,Diagnosis,Signs,Diagnosis,Diagnostic Evaluation,Basic:Chemistry panel Cardiac enzymes Lipids ECG CXR Echocardiogram ? BNP,Other:Thyroid functions Liver function tests Ferritin ANA HIV SPEP, UPEP,Diagnosis,Chest x-
13、ray,Normal,CHF and cardiomegaly,Diagnosis,BNP = b-type natriuretic peptide,Validated as a marker of CHF Strong negative predictive value BNP150 pg/mL: specific for CHF BNP should not supplant clinical evaluation (or echo),McCullough, Nowak, et al. Circulation 2002. 106:416. Morrison, Harrison, et al
14、. JACC 2002. 39:202.,Diagnosis,HF: Differential Diagnosis,Leading etiologies: IHD 36% Idiopathic 34% HTN 14% Valvular disease 7% Atrial fibrillation 5% Other causes 5%,Types of heart failure: Dilated (low output vs. high output) Restrictive (infiltrative) Hypertrophic Constrictive (pericardial),Cowi
15、e, Wood, et al. Eur Heart J 1999. 20:421.,Diagnosis,急性心力衰竭的诊断步骤,Diagnosis,治疗目标,临床: 症状减轻(呼吸困难和/或疲乏),体征改善,体重下降,尿量增加,氧合增加 实验室: BUN/Cr、胆红素、BNP下降,血电介质、血糖正常 血流动力学: 肺毛细血管楔压下降18mmHg,心输出量/每搏射血量增加 结果: ICU治疗时间缩短,住院时间缩短,再入院间期延长,死亡率下降,Treatment,一 般处理,控制感染 短效胰岛素:控制血糖,保证能量和氮平衡 保存肾功能 氧疗: 将SaO2维持在95%98%水平 提高吸氧浓度;,通气
16、支持: 无创通气: 急性肺水肿时,CPAP、NIPPV能显著减少气管插管机械通气的需要 有创通气: 仅用于AHF导致的呼吸肌疲劳,以及AHF对扩管剂、给氧、和(或CPAP或NIPPV无反应时 可肺水肿继发于ACS。,Treatment,药物治疗,吗啡: 急性肺水肿时可首选,首剂吗啡3mg-IV,必要时可重复一次 血管扩张剂: 硝酸盐 硝普钠:从最小剂量开始,滴度0.3-5ug/kgmin 奈西立肽:重组人脑钠肽 CCB:高血压性AHF,Treatment,急性心衰患者血管扩张剂的应用指征和剂量,Treatment,ACE-I: 并不适用于AHF患者的早期稳定治疗 应避免静脉使用ACE抑制剂。最初剂量应较低,发病48小时内监测血压和肾功能。治疗期限至少持续6周 利尿剂: AHF和失代偿心衰的急性发作,伴有液体潴留的情况 AHF优先考虑使用静脉使用袢利尿剂,呋塞米、托拉塞米 根据利尿效果和淤血症状的缓解情况来调整用药 开始负荷剂量,继续静滴呋塞米或托拉塞米,静滴比静注更有效 袢利尿剂+噻嗪类/螺内酯 袢利尿剂+多巴酚丁胺、多巴胺 袢利尿剂+硝酸盐 增加利尿效果,减少副反应,