What is Critical Care Medicine? Xixiuming ICU Fu Xing Hospital 2012

ICU 概念的起源 …… 英国护士 Florence Nightingale 被认为是第一个使用 ICU 概 念的人 Crimean War,1854 to 1856 她 把最终的伤员集中在护士站 周围，以便看到患者病情变 化，可以迅速提供所需的医 疗服务

Intensive care medicine owes its roots to the support of failing ventilation 呼吸支持 Intensive Care Medicine 的根 呼吸支持 脊髓灰质炎导致的呼吸衰竭 吸入麻醉后的呼吸管理 RICU SICU Crit Care Clin 25 (2009) 239–250 General ICU 多器官生命支持

呼吸 ICU 的开始

历史回顾 -The first ICU in the world Acta Anaesthesiol Scand 2003;47: Bjorn Ibsen 第一次使用正压通气治疗 呼吸衰竭的医生 （ In the first ICU in the world ） 这项新技术的应用是病死率从 的 87% 下降到 的 15% 因此 1953 年 3 月是机械通气的生日

Controlled Respiration by Means of Special Automatic Machines as Used in Sweden and Denmark The treatment of ventilatory insufficiency after pulmonary resection with tracheostomy and prolonged artificial ventilation J Thorac Surg 1955;30(3):356–67 Engstrom had already demonstrated the advantage of his ventilator in the treatment of totally paralyzed polio victims during the Copenhagen epidemic Acta Anaesthesiol Scand 1963;(Suppl 13) McKesson machine with Trier Moerch's "Respirator". Proc R Soc Med August; 40(10): 603–607.

1929 when Dr. Walter Dandy of the Johns Hopkins Hospital in Baltimore described the use of a special postoperative unit for his neurosurgical Anesthesiology 2001;95(3):781–8.

Peter Safar- 现代 CPR 58 年美国巴的摩尔医院 safar 建立了一个多学科、专业性 ICU

机械通气患者病死率的比较（ vs 1969 on RICU) 综合医院 1965 － 1968 RICU 1969 病人死亡病死率病人数死亡病死率 COPD11655%27519% 神经疾病 ％ ％ 肺炎 ％ ％ 药物中毒 ％ ％ 其他 ％ ％ 总数 ％ ％ Chest 1972 ； 62 ： 94-97

ICU 床位与医院床位 Crit Care Med 2008; 36:2787–2793

ICU in Beijing 2009

危重病医学是一门学科 Specialty or Subspecialty?

Specialty or Subspecialty Crit Care Med 1978, 6:355–359

Intensive care medicine comes of age Julian Bion and Timothy Evans  Sub-specialty of one or more disciplines  ‘Supra-specialty’ (an add-on with common skills across all)  Primary specialty There is considerable overlap in content between the supra-specialty and primary specialty models Clinical Medicine 2011,vol 11,6:519-20

Specialty or Subspecialty  Primary specialty ？ Italy 、 Spain (Southern European) Australia/Newseland Southern American China  Subspecialty ？ US/Canada(Northern American) European(Most anesthesiology) Crit Care Med 1981, 9:117–125.

Specialty Association of SCCM Members US Crit Care Med 1981, 9:117–125.

美国 7800 个注册 CCM 会员中专科的分布 Anesthesiology 2001; 95:781–8

Cardiothoracic ICU or Cardiac ICU or CCU

美国综合 ICU 与专科 ICU 的分布 Crit Care Med 2006; 34:1016–1024

Do we need specific cardiac ICU? James B Herrick (1861–1954) “The importance of absolute rest in bed for several days is clear.” Lancet 1988; 352: 1771–74

The first CICU in the world First CICU description was suggested by D.J. Julian in 1961 to the British Thoracic Society monitoring patients with acute myocardial infarction (AMI) for the early diagnosis and treatment of ventricular fibrillation Julian DG. Treatment of cardiac arrest in acute myocardial ischemia and infarction Lancet 1961;ii:840-4

Treatment of myocardial infarction in a coronary care unit A Two year experience with 250 patients Am J Cardiol 1967;20:457– 64

Evidence That Hospital Care for Acute Myocardial Infarction Has Not Contributed to the Decline in Coronary Mortality Between and Circulation. 1982;65:

Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003 Admission wards for patients with acute myocardial infarction(n=58263) Q J Med 2005; 98:797–802

Location of cardiac arrests within hospital during the first 4 h after admission 76.2% 60.4%46.9% Q J Med 2005; 98:797–802

Evolution of the coronary care unit Crit Care Med 2010; 38:375–381

a blue baby with a heart malformation was considered "beyond the reach of surgical aid." Helen Taussig, Drs. Alfred Blalock, Helen Taussig, and Vivien Thomas. Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945;128:

The evolution of cardiothoracic critical care Cardiothoracic (CT) critical care has 2 goals: To facilitate a rapid recovery To prevent or effectively treat complications J Thorac Cardiovasc Surg 2011;141:3-6

The evolution of cardiothoracic critical care CT critical care teams CT surgeons, intensivists, anesthesiologists, hospitalists, critical care nurses, nurse practitioners, physician assistants, perfusionists, respiratory therapists, pharmacists, and nutritionists. J Thorac Cardiovasc Surg 2011;141:3-6

Development of CT Critical Care as a Subspecialty of Thoracic Surgery Cardiovascular–Thoracic Critical Care 2008 Conference American College of Chest Physicians Society of Critical Care Medicine

The recent evolution of coronary care units into intensive cardiac care units: the experience of a tertiary center in Florence Major complications observed during intensive cardiac care unit (ICCU) stay in the 1397 consecutive patients included in the study Complication n (%) Ventricular fibrillation14/1397 (1.0%) Complete AV block9/1397 (0.6%) Pulmonary edema12/1397 (0.9%) Cardiogenic shock on ICCU admission43/1397 (3.1%) Cardiogenic shock developed during ICCU stay 13/1397 (0.9%) Post-procedural complications observed during intensive cardiac care unit stay in all patients submitted to coronary angiography and intervention Complicationn (%) Acute renal failure requiring ultrafiltration 56/1265 (4.4%) Vascular and hemorrhagic complications54/1265 (4.3%) Cardiac tamponade7/1265 (0.6%) Mechanical complications6/1265 (0.5%) Mechanical ventilation15/219 (6.8%) Journal of Cardiovascular Medicine 2007, 8:181–187

Trends in CICU J Am Coll Cardiol 2007;49:1279–82

Clinical and Echocardiographic Correlates of Symptomatic Tachydysrhythmias After Noncardiac Thoracic Surgery 100 肺切除患者室上速的发生率 SVTNo SVT p Value ICU admission 4/181/82<0.004 Hospital stay, d 22.4± ±3.6< d mortality 3/181/82< 肺切除患者室上速的危险因素 Chest 1995;108;

Impact of 24-Hour In-House Intensivists on a Dedicated Cardiac Surgery Intensive Care Unit SICUCICUP ValueOR(95% CI) 机械通气数 620(66.5%)408(43.7%)< (0.33,0.47) ICU 住院天（中 位数） 0.96 (0.82, 1.83)0.98 (0.85, 1.93)0.02 ICU 再住院数 38 (4.07%)29 (3.11%) (0.46, 1.24) ICU 病死率 14 (1.50%)12 (1.29%) (0.39, 1.86) 30 天病死率 20 (2.14%)16 (1.71%) (0.41, 1.55) 住院天数（中位 数） 7.0 (5.0, 9.0)6.0 (5.0, 8.0) Ann Thorac Surg 2009;88:1153– 61

Impact of 24-Hour In-House Intensivists on a Dedicated Cardiac Surgery Intensive Care Unit Ann Thorac Surg 2009;88:1153– 61

The evolution of cardiothoracic critical care CT-ICU/CICU 非心脏的器官功能衰竭增多 Sepsis/Septic shock 增加 机械通气和肾脏替代治疗增加 机械的循环辅助生命支持增加 GICU 非心脏手术围手术期心脏并发症增 加 心脏结构和功能监测增加（心脏超 声） 循环机械支持技术增加

治疗的强度与获益的程度