ICU医师的背景与专业优势课件

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1、ICU医师的背景与专业优势上海复旦大学附属中山医院外科监护病房 诸杜明了 解 ICU的模式和发展背景 ICU常用的诊疗手段 ICU需要什么样的医师ICU的模式和发展背景 最早的ICU其实不是医生发明的，其用途也仅仅是用于手术后恢复，时间是十九世纪中叶 Florence Nightingale wrote about the advantages of establishing a separate area of the hospital for patients recovering from surgery 早在一个多世纪以前，人们即已认识到了给予外科手术病人特别管理的重要性。1863年伟

2、大的护理事业的先驱者南丁格尔就曾撰文提到，其时“在小的乡村医院里，把病人安置在一间由手术在小的乡村医院里，把病人安置在一间由手术室通出的小房间内，直至病人恢复或至少从手术室通出的小房间内，直至病人恢复或至少从手术的即时影响中解脱的情况已不鲜见的即时影响中解脱的情况已不鲜见”。这种专门为术后病人，以后又进一步扩大到为失血、休克等危重外科病人开僻的“小房间”存在相当长的时间，直至本世纪20年代被正式命以“术后恢复室”(recovery room)。南南 丁丁 格格 尔尔 最最 后后 的的 照照 片片提灯女神南丁格尔提灯女神南丁格尔ICU在美国的初创监护单元的出现 时间、地点1923、Johns H

3、opkins Hospital 床位 three-bed unit 负责人 Dr.W.E.Dandy 性质 neurosurgical patients for postoperative 早 期 发 展 1927年，芝加哥的 Sarah Morris Hospital 出现了第一个属于医院管理医院管理的早产儿监护监护中心中心.二战时针对士兵的战伤和随后的手术，出现了用于休克复苏和监护的病房病房 发生于1947的流行性脊髓灰质炎席卷欧美 治疗所用的方法已现呼吸治疗的雏形（manual ventilation was accomplished through a tube placed in t

4、he trachea of polio patients）with respiratory paralysis and/or suffering from acute circulatory failure required intensive nursing nursing care.铁 肺 上世纪五十年代，机械通气技术进一步发展，在欧美国家出现了集中治疗呼吸系统疾病的呼吸呼吸ICU，病人的呼吸治疗得以更有效的进行，同时，针对各种衰竭病人和术后病人的普通普通ICU也应运而生。ICU的模式和发展背景（开放和封闭之争）的模式和发展背景（开放和封闭之争）Dr.Liolios:There is a

5、lot of discussion on the topic of open versus closed ICUs.While many ICUs are closed in Europe,there are still many open ICUs in the United States,with the subspecialists often running the show.How do you respond to that?Do you think it has an impact on outcome?Dr.Vincent:I think it is very importan

6、t to place critically ill patients in the hands of a properly trained,experienced doctor who is part of a team available 24 hours a day.The open ICU design has clearly been shown to provide lower-quality management.In Europe,it is also not uncommon for an ICU physician to have important duties elsew

7、here in the hospital(usually as an anesthesiologist in the operating room,but also as an internist in the outpatient clinic).This is acceptable only in ICUs with a relatively light patient load.In any case,a doctor should be immediately reachable in case of problems.By the way,there are recent data

8、from the IMPACT program suggesting that the closed ICU model may not be better,but it is too early to discuss this new information.在那些科室内部的ICU和部分专科ICU而言，以开放型模式或封闭型管理病人为主。在那些综合型ICU而言，以半开放型为主管理病人因为：病人来自不同科室。美国的第一个 1958年，美国第一个综合性、多学科第一个综合性、多学科ICU在Johns Hopkins Bayview Medical Center at Baltimore City H

9、ospitals成立,也是第一个由麻醉科住院医生担任全天候专职医生的ICU。六十年代，大多数美国医院有了至少一个以上的ICU.1970,28 名志同道合的从事危重病专业的内科医生相聚洛杉矶，发起成立了美国重症医学会（the Society of Critical Care Medicine，SCCM).1986,美国医师委员会开始了针对以下四个专业的危重病专业资格认证：麻醉、内科、儿科和外科 发 展新世纪以来，各种移植手术的开展，促使重症医学在移植领域的进步各种无创技术、微创技术的运用，降低了费用和使用风险（如机械通气、心功能监测、微创气切）对各种药代动力学的研究，各种针对某一特定器官的治疗措

10、施的使用，使得病人的花费和住院天数大大下降。贺贺国外医学国外医学麻醉与复苏分册创刊麻醉与复苏分册创刊 吴珏吴珏麻醉专业百龄过，祖国推迟十年又，世界期刊卅余种，卓著优质实难数。学术登攀广交流，动态进展新貌多，麻醉复苏有分册，综述文摘具规模。编纂印刷事务烦，徐州附院敢承担，举国群英襄盛举，众志成城事不难。全麻伊始惊骇惨，功过莫论后人判，新药争胜年年异，评比参照朝朝唤。局麻普鲁*世纪初，硬外阻滞宜称贺，穿刺敏捷巧妙手，熟练观摩思路宽。静吸复合日月奇，诱导快速效应冀，解痛肌松另用药，镇静安宁全凭依。体外低温心病医，控制降压可显微，监测描记多变革，电子自控莫猜疑。监测描记多变革，电子自控莫猜疑。机械呼吸

11、性能好，血气酸碱共信号，机械呼吸性能好，血气酸碱共信号，扶伤抢救成专职，垂危医学有功劳。扶伤抢救成专职，垂危医学有功劳。边缘学科忆念时，试验探测动物试，阅读思维图书室，猷怀往年辛酸事。事业成长青蓝*共，指引辅导有舵工。不同背景医生的优势麻醉科医师优势 最坐得住，最善于观察生命体征，最多也许还是最早使用监护仪器对各种呼吸、循环监测方法都已掌握或早有所闻 熟练掌握各种抢救技能中心静脉穿刺、气管插管 各种抢救、镇痛所需药物的药理、器官生理功能都有涉猎 吴珏教授言：麻醉科医生是半吴珏教授言：麻醉科医生是半 个外科医生、半个内科医生个外科医生、半个内科医生 熟悉外科手术的主要步骤，十分理解将要处理的外科

12、并发症的难点所在 十分关切病人术后疼痛问题并有能力解决之 多与外科医师保持良好的沟通能力不同背景医生的劣势麻醉科医师 少与病人家属打交道，缺乏相应经验 善于处理问题，但缺少发现问题的能力(检验结果的研判、对影像学结果的研读)全局观念、全身观念有待提高 人无完人人无完人 金无足赤金无足赤不同背景医生的优势内科医师 天然的耐心、细致印象。注重分析、注重检查、注重检验、注重鉴别诊断 在处理下列危重症时，应有相当的功底:急性呼吸功能不全、急性心功能不全、急性心肌梗死、严重心率失常、高血压危象、急性肾功能不全、严重水、电解质紊乱，酸碱平衡失调、急性中毒、DIC、甲亢危象、非酮症性昏迷等 RICU/CCU

13、/EICU/NICU不同背景医生的劣势内科医师 对外科并发症、创伤缺乏深入的理解 动手能力稍弱不同背景医生的优势外科医师 有极强的临床动手能力，在收治外科病人为主的ICU工作，其操作能力游刃有余 对下列疾病和相应并发症的处理有相当的功力 急性重症胰腺炎、大血管病变、严重创伤、烧伤、和外科相关的脓毒症等等 缺陷：诊疗病情直奔主题，缺少分析Pulmonary medicine and(adult)critical care medicine in Europe Eur Respir J 2002;19:12021206There has been growing concern within th

14、eEuropean Respiratory Society(ERS)that pulmonary physicians are becoming less involved in the practise of intensive care medicine Thoracic Society(ATS)expanded its mission statement to include CCM and changed the name of its journal to the American Journal of Respiratory and Critical Care Medicine i

15、n 1994intermediate dependency areas intermediate level of care between the general ward and the ICU,patients with chronic and acute on chronic pulmonary insufficiency and those requiring prolonged mechanical ventilatory support can be managed effectively，support patients with single organ(i.e.pulmon

16、ary)failure,providing an intermediate level of carePulmonary medicine and(adult)critical care medicine in Europe Eur Respir J 2002;19:12021206 In some countries(e.g.Scandinavia,UK),anaesthesiology has dominated ICM from its birth,whereas in others(e.g.the Netherlands),the picture is changing.ICM can

17、 only be practised legally by anaesthesiologists As of March 2001,of the 2,332 members of the European Society of Intensive Care Medicine(ESICM),50.6%counted anaesthesiology and 20.9%internal medicine.Approximately 53%of Society members spend 100%of their time practising ICM;24%spend 5075%of their t

18、ime thus occupied.不同国家的培训时间 In Spain,5 yrs training is required to achieve specialist status,3 yrs of which is in ICM.In France,Germany,Greece and the UK,2 yrs training in ICM is required in addition to that needed for base specialty(usually anaesthesiology,pulmonology or general internal medicine).

19、In Italy,only anaesthesiologists may legally practise ICM.Pulmonary medicine and(adult)critical care medicine in Europe Eur Respir J 2002;19:12021206Spanish model Dr.VincentDr.Vincent Spanish model:a mixture of internal medicine,anesthesiology,surgery,and emergency medicine.It should be 5 years like

20、 the other specialties-that is,1 year less than in the present curriculum(which is 1 primary specialty plus 2 years of additional training,but 1 year is possibly included in the primary specialty).The pulmonary physician in intensive care:practical difficulties Eur Respir J 2002;19:12021206 欧盟内部对ICM

21、的发展政策的制定并不包含肺科学 主流学术组织ESICM其着眼点是在ICM中的多学科建设，而这种多学科建设却不包括对肺科医师的专业培训 在大多数欧盟国家需要至少两年的专业训练时间这两年的时间对一个初级临床医生的培训来说是相当困难或者是不可能的 在一些国家如西班牙，ICM倾向于独立成为学科，让一个医师既接受ICM训练又接受肺科训练并不现实，在意大利，法律禁止肺科医师从事ICM 加拿大的情况 最复杂的病例在ICU中得到治疗，过去，这里的医生来源于麻醉科、外科、内科，但是，现在重症监护成为了一个多学科专业（multidisciplinary specialty），大约30以上的医生是麻醉医师（Abou

22、t thirty percent of intensivists in Canada are anesthesiologists）,这个比例在英国和澳洲还要高展 望美 国1985年到2000年间，美国医院总数下降了8.9%(6,032 to 5,494)内设危重医学科（CCM）的医院，总床位数下降了26.4%(889,600 to 654,400).相反 CCM 床位总数上升了 26.2%(69,300 to 87,400)CCM 床位占用率是65%.CCM 每床每天使用价格上涨了126%($1,185 to$2,674)，尽管CCM总的花费增加了190.4%($19.1 billion to

23、$55.5 billion),但是健康保险部门给CCM的费用配额却下降了5.4%（说明整体医疗费用的上扬更快更多）2000年,CCM 占医院总费用的13.3%,国家健康费用预算的4.2%和国内生产总值的 0.56%结论：CCM在医院持续萎缩的情况下床位总数仍在增加，CCM花费比预想的要低，其占GDP的总量也相应比预想的要低 Critical Care Medicine.32(6):1254-1259,June 2004.Halpern,Neil A.MD,FCCM;Pastores,Stephen M.MD,FCCM;Greenstein,Robert J.MD 国 内 一份最新的调查结果显示

24、，目前我国71.40的医院设立了独立的ICU科室，ICU总床位数已达5424张。2006年全国16631（似乎少了点）人次入住ICU，而仅一年后的2007年,这一数据就翻了一番，达到34344（似乎少了点）人次。急遽的发展也带来了问题。一些医疗机构盲目购置昂贵的先进医疗设备，忽视了专业人员的培训，造成高技术装备与低素质专业人员的尖锐矛盾 医师报2008.11.27Dr.Vincent:怎样的态度面对挑战It is clear that the number of critically ill patients will increase significantly in the years t

25、o come,and the number of ICU doctors may not follow in parallel.We should indeed prepare for this,but as it is a progressive phenomenon,I am sure we will adapt to it.Critical care medicine is the most interesting specialty:I am sure it will continue to raise a lot of interest.The importance of the s

26、pecialty will also increase in the future-we should all be proud to be a part of it.很清楚，危重病人的数量在接下来的数年里将显著增加，但是ICU医生不可能平行增加，我们要为此做好准备，我相信我们会适应这种变化，危重医学是十分有趣的专业，我相信还将有许多有趣点被发现，其重要性也将在将来不断被发掘，我们应该为此自豪一种新的职业hospitalists医院里工作的家庭医生 另一种挑战The hospital,which began tracking data,found that the hospitalists w

27、ere able to decrease the number of code blues by almost 80%.Data also showed that they improved length of stay,cost per case and the rate of ICU bed diversions.“Hospitalists could take care of many ICU patients,with intensivists taking care of the sickest ones,”said Derek C.Angus,MD,chair of critica

28、l care medicine at the University of Pittsburgh,during an SCCM presentation.“Its threatening to intensivists,but frankly I think its the only way if we think we need to keep the same number of ICUs.”Theres another factor:“On any given day,only a fraction of patients cared for in the nations ICUs req

29、uire primary care delivered by physicians with specialized,advanced training in critical care medicine,”says Timothy G.Buchman,MD,professor of surgery,anesthesiology and medicine at Washington University in St.Louis.Stress in UK intensive care unit doctors Br J Anaesth 2002;89:87381 3%were bothered

30、by suicidal thoughts.The most stressful aspects of work were bed allocation,being over-stretched,effect of hours of work and stress on personal/family life,and compromising standards when resources are short.Logistic regression revealed mental health problems were predicted by ve stressors:lack of r

31、ecognition of ones own contribution by others;too much responsibility at times;effect of stress on personal/family life;keeping up to date with knowledge;and making the right decision alone结 语 重症医学需要广泛的临床和基础知识结构，没有个人可以完全掌握，所谓“尺有所短、寸有所长”有志于从事重症医学专业的医师，无论其有着怎样的专业背景，都能在这片广阔的天地里大有作为 中医、西医中医、西医 内科、外科内科、外科 呼吸、麻醉呼吸、麻醉 而我们要做的，只是充分发挥自己的优势，同时，而我们要做的，只是充分发挥自己的优势，同时，汲取身边同事的专长汲取身边同事的专长谢 谢