1、Introduction to SICU,台大醫院 外科加護病房柯文哲 醫師,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 % = 0.9 1.2 %1 % of GNP,History of ICU,1860+ : Florence Nightingale1952 3 : polio epidemics in Europe b
2、ulbar paralysis - resp. failure formation of modern ICU1960+ : open heart surgery 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 = CO x SVR,V= I x R(idea of pre-op optimizatio
3、n),Function of Modern SICU,monitor of high-risk patientsprevention and treatment of post-op complicationspre-op optimizationterminal care,Multiple 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
4、ileus: on TPN4. Bil : 12 mg/dl5. IABP use6. 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 99 % mortality,Heart : mechanical circulatory supportLun
5、g : ventilator Liver : FFP, plasmapheresisKidney : P/D, H/D, CVVH GI : TPNB.M. : transfusionImmune: antibiotics,Goal of Modern ICU,prevention not treatment of MOF,Three Tasks in SICU,Shock ? resuscitation2 underlying problems ? treatment3 nutrition ? support (metabolic support vs nutritional support
6、),William C. ShoemakerSurgical Clinics of North 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 ABG,Inference from Shoemakers Study,1. pre- op norma
7、lpost-op normal 2. what we usually measure in ICU are useless ( too late to be effective )3. compensation : major determinant of outcome4. survival pattern : the goal of therapy,1985 William C. ShoemakerSurgical Clinics of North America (1985), BP, HR, CVP, PAWP, ABG CI, DO2I, VO2IStress Compensatio
8、n succeed survival fail death pH in ABG,Inference from Shoemakers Study,1. pre- op normalpost-op normal 2. what we usually measure in ICU are useless ( too late to be effective )3. compensation : major determinant of outcome4. survival pattern : the goal of therapy,Therapeutic Goal in SICU Patients(
9、Survival Pattern of SICU Patients),1. C.I.1.5 x normal2. blood volume : 500 ml more than normal 3. DO2I 600 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 mechanis
10、m2. no stress optimal 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. iatrogenic )early detection and early treatment of pathophysiological process,Summary,
11、critical care begins from pre-op stageideal critical care :continuous monitorearly detection early interventionFull time ICU team,Multiple 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.人員養成慢3.難以轉用其他用途4.發展決策更需慎重,SICU P
12、atients,CVS , CStrauma , NS transplantationothers,外科加護病房發展之考慮因素,病人種類與數量現有的人員裝備未來的發展領導者的責任,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 設備成本經濟規模留 “空白”,臺大醫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,台大外科部,4A1A2CVS2052122,4B1B2NS + CS11 +
13、740122,4C1GS1431322,移植小組,周邊血管檢查室,SICU,單位床位護士NSPR2intern,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,Date,裝備清單,ECMO 4台IABP 5台VAD (Heartmate 1台, Thoratec 1台)Metabolic cart 1台Tonometry 1台COLD 1台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, 器械, 手術衣, 布單) BiPAP NO inhalation,作業原則,擴大戰區統一指揮減少指揮層級,制度化職業化組織化,SICU Meeting,
