Introduction to SICU

台大醫院 外科加護病房柯文哲 醫師

The Cost of Health Care

Year GNP (%)1965 5.9

1970 7.4

1988 11.12000 15.0

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 1860+ : Florence Nightingale

1952 ~ 3 : polio epidemics in Europe

bulbar paralysis ---> resp. failure

formation of modern ICU

1960+ : open heart surgery

trauma, transplantation

Function of Modern SICU

• monitor of high-risk patients

• prevention and treatment of post-op complications

• pre-op optimization

• terminal care

阿 婆 的 故 事

BP = CO x SVR

V= I x R(idea of pre-op optimization)

Function of Modern SICU

• monitor of high-risk patients

• prevention and treatment of post-op complications

• pre-op optimization

• terminal care

Multiple Organs Failure

(MOF)

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%

Mortality of MOF

Days after last O.FO.F 1 2 3 4 5 6 7

1 22% 31% 34% 35% 40% 42% 41%

2 52% 67% 66% 62% 56% 64% 68%

>3 80% 95% 93% 96% 100% 100% 100%

Critical Care State of the Art( USA, 1991)

> 3 O.F , > 3 days

99 % mortality

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

Goal of Modern ICU

prevention

not treatment of MOF

Three Tasks in SICU1 Shock ? resuscitation

2 underlying problems ? treatment

3 nutrition ? support

(metabolic support vs nutritional support)

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

Basic Model in Critical Care

stress => compensation

success

failure

survive

death

PH in ABG

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

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

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

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

But

1. no one can get the same result

2. our experience in cardiac surg. patients

Weak Compensation Response

1. poor compensation mechanism

2. 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 recover

• prevent complications (esp. iatrogenic )

• early detection and early treatment of pathophysiological process

Summary• critical care begins from pre-op stage

• ideal critical care :– continuous monitor

– early detection

– early intervention

• Full time ICU team

Multiple Organs Transplantation

How to develop ICU

in 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 Patients

• CVS , CS

• trauma , NS

• transplantation

• others

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

4B1B2

NS + CS

11 + 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, Intern• HN, nurse• Clinical pharmacist• CNS (NSP, PA)• PT• RT• ICU technician• Dietitian• Social worker

4A1 4A21 1

2 2

3 3

5 5

6 6

7 7

8 8

9 9

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