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Introduction to SICU

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 care ICU : 15 ~ 20 % of hospital cost 15 % x 40 % x 15 ~ 20 % = 0.9 ~ 1.2 % 1 % of GNP. History of ICU.

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Introduction to SICU

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  1. Introduction to SICU 台大醫院 外科加護病房 柯文哲 醫師

  2. The Cost of Health Care Actually, 13.6% in 2000

  3. Economic Impetus of ICU • hospital : 40 % of total health care • ICU : 15 ~ 20 % of hospital cost • 15 % x 40 % x 15 ~ 20 % = 0.9 ~ 1.2 % • 1 % of GNP

  4. History of ICU • 1860+ : Florence Nightingale • 1952 ~ 3 : polio epidemics in Europe • bulbar paralysis ---> resp. failure • formation of modern ICU • 1960+ : open heart surgery • trauma, transplantation

  5. Function of Modern SICU • monitor of high-risk patients • prevention and treatment of post-op complications • pre-op optimization • terminal care

  6. 阿 婆 的 故 事

  7. BP = CO x SVR V= I x R (idea of pre-op optimization)

  8. Function of Modern SICU • monitor of high-risk patients • prevention and treatment of post-op complications • pre-op optimization • terminal care

  9. Multiple Organs Failure (MOF)

  10. 65 yrs , male , CAD - III • PH : NP OP : CABG, CPB : 5 hr • POD 6#: • 1. ARDS (FiO2: 0.8 , PEEP: 10, SaO2: 95%) • 2. ARF : on H/D • 3. paralytic ileus: on TPN • 4. Bil : 12 mg/dl • 5. IABP use • 6. conc : drowsy, but arousable • what is the estimated mortality in this patient ? • (a).20% ,( b).40% ,( c).60% ,(d).80% ,(e).100%

  11. Mortality of MOF

  12. Critical Care State of the Art( USA, 1991) > 3 O.F , > 3 days 99 % mortality

  13. Heart : mechanical circulatory support • Lung : ventilator • Liver : FFP, plasmapheresis • Kidney : P/D, H/D, CVVH • GI : TPN • B.M. : transfusion • Immune: antibiotics

  14. Goal of Modern ICU prevention not treatment of MOF

  15. Three Tasks in SICU • Shock ?  resuscitation 2 underlying problems ?  treatment 3 nutrition ?  support (metabolic support vs nutritional support)

  16. William C. ShoemakerSurgical Clinics of North America (1985) • Survior Vs non-survior • in early ICU period • X : BP , HR , CVP , PAWP , Hct , ABG • O : CI , DO2 , VO2

  17. Basic Model in Critical Care survive success stress => compensation failure death PH in ABG

  18. Inference from Shoemaker's Study • 1. pre- op normal≠post-op normal • 2. what we usually measure in ICU are • useless ( too late to be effective ) • 3. compensation : • major determinant of outcome • 4. survival pattern : the goal of therapy

  19. 1985 William C. ShoemakerSurgical Clinics of North America (1985) × BP, HR, CVP, PAWP, ABG  CI, DO2I, VO2I Stress Compensation↗succeed survival ↘ faildeath × pH in ABG

  20. Inference from Shoemaker's Study • 1. pre- op normal≠post-op normal • 2. what we usually measure in ICU are • useless ( too late to be effective ) • 3. compensation : • major determinant of outcome • 4. survival pattern : the goal of therapy

  21. Therapeutic Goal in SICU Patients(Survival Pattern of SICU Patients) • 1. C.I.＝1.5 x normal • 2. blood volume : 500 ml more than normal • 3. DO2I＞ 600 ml/min/m2 • 4. VO2I＞ 170 ml/min/m2 • 5. BP : normal or higher

  22. But • 1. no one can get the same result • 2. our experience in cardiac surg. patients

  23. Weak Compensation Response • 1. poor compensation mechanism • 2. no stress • ＝＞ optimal supply is determined by need

  24. Basic Model in Critical Care survive success stress => compensation failure death

  25. Modern ICU • optimal environment for patients to recover • prevent complications (esp. iatrogenic ) • early detection and early treatment of pathophysiological process

  26. Summary • critical care begins from pre-op stage • ideal critical care : • continuous monitor • early detection • early intervention • Full time ICU team

  27. Multiple Organs Transplantation

  28. How to develop ICUin my hospital ?

  29. 有沒有比貪污更嚴重的事 ?

  30. 決策錯誤 !

  31. 戲 編劇 , 導演 演員 燈光 , 佈景 , 道具 , 化粧

  32. 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

  33. SICU Patients • CVS , CS • trauma , NS • transplantation • others

  34. 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

  35. 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

  36. 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”

  37. 臺大醫院外科加護病房團隊

  38. 台大外科部 一般外科 SICU 心臟外科 胸腔外科 大腸直腸外科 小兒外科 整形外科 神經外科

  39. SICU 4A1A2 CVS 20 52 1 2 2 4B1B2 NS + CS 11 + 7 40 1 2 2 4C1 GS 14 31 3 2 2 移植小組 周邊血管檢查室 單位 床位 護士 NSP R2 intern VS: 1 + 0.9 + 0.5 Technician: 3 NSP: 5 Tx Nurse: 3 P.S. Ped SICU: 6床, Burn ICU: 4床, 不在管轄內

  40. NTUH SICU Team • VS, R2, Intern • HN, nurse • Clinical pharmacist • CNS (NSP, PA) • PT • RT • ICU technician • Dietitian • Social worker

  41. Date

  42. 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 裝備清單

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