呼吸重症监护初级读本1.pptVIP

PICU Primer I Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC The Primer Outline Physiology Hypoxia / Hypoxemia ABG’s and Acidosis Sodium and H2O metabolism Hemodynamics and Cardiopulmonary interactions ICU Care Common Problems Head trauma Toxicology Postoperative issues Mechanical Ventilation Oxygen and Hypoxemia Define Hypoxemia Hypoxia Hypoxemia Ventilation/Perfusion mismatch Hypoventilation Shunt Diffusion Decreased Ambient O2 Oxyhemoglobin Curve Shunt / Dead Space Spectrum V/Q = 0 V/Q = infinity No amount of ? O2 ? difference will fix between EtCO2 and PaCO2 Ventilation / Perfusion mismatch Blood Pus Air Water Atalectasis Quantitate using A – a Gradient A – a Gradient (Pb-PH2O) x FIO2 - (PCO2/.8) - PaO2 Other useful equations Dead Space = 1 - (EtCO2/PaCO2) OI = (Paw x FIO2 x 100)/ PaO2 Positive vs. negative pressure Cause for desaturations Anesthesia – hypoventilation Atalectasis – V/Q mismatch Edema - V/Q mismatch Asthma– dead space/ V/Q mismatch Dysfunctional Hemoglobin You may need a CXR and or ABG in addition to H+P to answer the question Hypoxia Hypoxic - ex. pulmonary disease Anemic – ex. low CaO2 , CO poisoning Distributive - ex. sepsis, emboli Histotoxic – ex. cyanide Oxygen Debt/ Oxygen Deficit Oxygen Content Which has the biggest impact on O2 delivery to the tissues? Hemoglobin, Sat, Cardiac Output, or PaO2 Which patient has more oxygen in the blood? Patient A, PaO2 89, Sat% 97%, Hg 9.8 Patient B, PaO2 60, Sat% 85%, Hg 13.1 “Normal” Values CaO2 = (Hg X 1.34 X Sat%) + (PaO2 X 0.003) 17-20cc O2 /dL DO2 = CI X CaO2 400-600 ml X min / M2 VO2 = CI X avDo2 140-160 ml X min / M2 Oxygen Rules of Thumb Give enough high flow non-rebreather if needed Look for a reason for low Saturations Postop Posterior Spinal Fusion Pt with Sats 88% Don’t be fooled by a little 5 kg baby , RR 40, I:E 1:2, on 2L NC What’s the FiO2? Questions? NEXT UP ABG’s and acidosis A