tata S 14'0016'00

1
??tat???????a ????S???? 14.00-16.00

• ??t?ß???? 5,12,19,26
• ???µß???? 2,9,16,23,30
• ?e??µß???? 7,14,21
• ?a???????? 2008 11
• ??d?s???te?
• G.?pa?t?p?????, ?.G?????????, ?.????a??e??,
  G.F???t?s?? ???? t?? ????????
• ??ß??a
• CURRENT ??????????G?? ??????s? Te?ape?a
• Frederic S.Bongard, Darryl Y.Sue, Ge?????? ?.
  ?pa?t?p?????
• ?s??s? (07.00-14.00)
• ?µ?da ? ?e?t??a, ???t?, ?et??t?
• ap? 8/10 - 22/10 (8,9,10,15,16,17, 22/10/06)
• ?µ?da ? ???t?, ?et??t?
• ap? 23/10-13/11 (23,24, 30,31/10/07 6,7,13
  /11/07)
• ??et?se??
• ???t?se?? p???ap??? apa?t?se??

?a????t?? G.?.?pa?t?p????? ??e????t??
?a?ep?st?µ?a??? ???????? ??tat???? ??s??e?a? st?
G.?. ??? 5 ??t?ß???? 2007
2

• F???s?f?a ?a? a???? ??tat???? ?e?ape?a?
• ? e??????? p?a?µat???t?ta
• ????? ?a? ??µ??? ??µata st? ??T
• ???????a???? a?ep???e?a
• ????at???? p??ß??µata

3
??tat???????a-??tat??? Te?ape?a?a?a?t???st???

• ? e?tat??? ?e?ape?a e??a? µ??ad??? a??µesa st??
  e?d???t?te?.
• ??d???t?ta est?a e?d?af????t?? t??
• ??a µ??? s?st?µa t?? s?µat??
• µ?a s???e???µ??? ?e?ape?a
• µ?a s???e???µ??? ?????a?? ?µ?da
• ??tat??? ?e?ape?a ape????eta? se as?e?e?? µe µ?a
  µe???? p??????a ??s??
• ???? ????? e?a??et??? s?ßa?? ??s? ? s?ßa??
  p??a??t?ta a??pt???? s?ßa??? ep?p????? ap? t?
  ??s? ? t? ?e?ape?t??? a????
• ?? e?tat???????? ße?t?????? t?? p?????s? t??
  ßa???? pas???t??

4
What is an intensivist With apologies to
Rudyard Kipling!!! If

• If you can keep your head when all about you
• are losing theirs and needing help from you
• If you can treat a mans heart and lungs and
  kidneys,
• but remember to treat his family too
• If you can wean and not be tired by weaning,
• Or, ventilate without too many sighs,
• Or, intubate, whilst the oximeter is screaming,
• And yet don't look too good, nor talk too wise
• If you are not afraid to get your hands dirty
• But always remember to wash them clean again
• If you can meet with inflammation and infection
• And treat those two imposters just the same
• If you can force a heart and nerve and sinew
• To serve their turn long after they are gone,
• And yet still find the knowledge in you
• To recognise when you have pushed them for too
  long

• If you can talk with drug reps and keep your
  virtue,
• Or teach your staff- nor lose the common touch
• If neither surgeons nor physicians can hurt you
• If all men count on you, but none too much
• If you can fill when filling's indicated
• Yet diurese - when the fillings done
• Yours is the Unit and everything that's in it,
• And - which is more you re an Intensivist my
  son!
• Jeremy Cohen, Gold Coast Hospital

5
What is an intensivist With apologies to
Rudyard Kipling!!! If

• ?? µp??e?? ?a µ?? ???e?? t? µ?a?? s?? ?ta?
• ?? ????? ????? ??se? t? d??? t??? ?a? ??e?????ta?
• t?? ß???e?a s??.
• ?? µp??e?? ?a f???t??e?? t?? ?a?d??, t???
  p?e?µ??e?
• ?a? t??? ?ef???? t?? a???st??, ????? ?a ?e????
  ?a? t?? ???????e?a t?? .
• ?? µp??e?? ?a ap??a?a?t?se?? t?? ????st? ap? t??
  a?ap?e?st??a ?a? ?a µ?? e?a?t???e?? ap? t??
  ap??a?a?t?sµ?
• ? ?a t?? ae??se?? ????? p?????? a?aste?a?µ???
• ? ?a t?? d?as?????se??, ?ta? t? ???µet?? ?t?p?e?
  s??a?e?µ?
• ?a? de? t? pa??e?? ??a??? ??te s?f?? .
• ?? de? f?ß?sa? ?a ?e??se?? ta ????a s?? a???
  p??ta ??µ?sa? ?a ta p???e??
• ?? ta pa? ?a?? µe t?? f?e?µ??? ?a? t? ???µ??? ?a?
  t?? ?e?ape?e?? s?st?
• ?? µp??e?? ?a e?d??aµ?se?? µ?a ?a?d??, ??a ?e???,
  ??a µ?, ?ste ?a epa??????? st?? p??t??a ?at?stas?
  t??? ?a? e?a??????e?? a??µ? ?a ??e?? t?? s?f?a ?a
  µ?? t? pa?a???e??

• ?? µp??e?? ?a µ???? µe t??? fa?µa?e?t?????
  a?t?p??s?p??? ?a? ?a ??at?? t?? a???p??pe?a s??,
• ? ?a d?d?s?e?? t? p??s?p??? ????? ?a ???e?? t?
  s????? ???µ?.
• ?? de? µp????? ?a se p????s??? ?? ?e???????? ? ??
  pa???????
• ?? ???? p??t????? se s??a a??? ?a???a? t??? p??a
  p???
• ?? µp??e?? ?a ?eµ?se?? t? ?????f????? t??
  a???st?? ?ta? ??e???esa? ?a? a??µ? ?a d?????se??
  t?? ????st? ?ta? ? ?????f???a e??a? ?eµ?t?
• ???? s?? e??a? ? ??T ?a? ?t? ?p???e? se a?t?,
• ?a? t? s?µa?t???te?? e?sa? e?tat???????? pa?d?
  µ??!
• Jeremy Cohen, Gold Coast Hospital

6
An Intensivist knows and practises the 4 rules of
Intensive Care

• (with humblest apologies to Les Galler, Stephen
  Streat and the Department of Critical Care
  Medicine, Auckland Public Hospital)
• Oxygen is good
• (actually we can debate that one, but that's
  another story)
• Air goes in and out
• (things are definitely better when air does
  this)- we've recently jet ventilated a patient
  for about 130 days with massive air leaks and
  ARDS- and she is now back at college studying to
  be a travel consultant, but I digress
• Blood goes round and round
• (surgeons sometimes mix up this rule and we find
  blood going in and out....and in... and out)
• It doesn't matter how much mayonnaise you pile on
  to chicken shit it
• will NEVER taste like chicken salad.
• Most family discussions are about putting this
  rule to them in a nice way.

7
Loeb's laws

• 1. If you don't know what to do, do nothing
• 2. If what you're doing is working, carry on
  doing it
• 3. if what you're doing is not working, stop it
• 4. Above all else, keep the patient out of the
  hands of the surgeons!

8
1 Members of the Task Force L.G. Thijs
(Chairman), G. Baltpoulos (Greece), J.K. Bion
(UK) , J. Carlet (France) J. Eklund (Sweden),
P. Ferdinande (Belgium) ,A. Frutiger
(Switzerland) G. Iapichino (Italy) R.P.
Moreno(Portugal), J.M. Pimentel (Portugal), M.
Planas (Spain), G. Ramsay (Netherlands), K.
Rheinhart (Germany), D. Reis Miranda
(Netherlands) H. Steltzer (Austria) R.J.M.
Strack van Schijndel (Netherlands), J. Strøm
(Denmark), J. Takala (Finland)
9
S?st?se?? ??a t?? f???t?da ???t??a? st?? as?e??
t?? ??T 1

• ???????e?ste
• t?? pa???sa ?at?stas?
• t? ?st????? t?? pe???d?? ap? t?? p??????µe??
  a???????s?
• ta e???µata t?? a?t??e?µe????? e??tas??
• S?s?et?ste t?? a??a??? sta ??t??? s?µe?a µe t?
  ??????s? t?? fa?µ???? ?a??? ?a? ???e? a??a???,
  ???s?µ?p????ta? ??????????? d????aµµa ??s??e?a?
• ??as??pe?ste
• ta ??t??? s?µe?a ?at? t?? pe???d? ap? t??
  te?e?ta?a a?as??p?s?
• t? ?st????? ????? fa?µ????, s?µpe???aµßa??µe???
  ?a? t?? s??e??? e???se??
• ?????e?a ?a? d?s?
• ???a??? st? d?s? ? st? s????t?ta ???? µetaß????
  st? ?ef???? ?a? ?pat??? ?e?t?????a ? ???? ?????
  fa?µa??????t???? ?????
• ???a??? st?? ?d? t?? ??????s??
• ???a??? fa?µa?e?t???? a????ep?d??se??

10
S?st?se?? ??a t?? f???t?da ???t??a? st?? as?e??
t?? ??T 2

• ??as??pe?ste, a? e?de????ta?
• ?? d????aµµa t?? a?ap?e?st???? f?s????e?ape?a?
• ?a d?a???µµata t?? a?µ?d??aµ???? ?ata??af??
• ?a d?a???µµata µe ta ap?te??sµata t??
  e??ast???a??? e?et?se??
• ?a d?a???µµata ????? ?ata??af?? pa?a???????s??
• ??a ta p??ß??µata, p??s??t??ta?, e??µe?????ta?,
  s?s?et????ta? ? afa????ta? p??ß??µata a?????a µe
  t?? e?de??e??.
• t?? ?p?st????t??? f???t?da
• ??d?f??ß?a ????
• T?ept??? ?at?stas? ?a? ?p?st?????
• ???f??a?t??? ?e?ape?a ?a? ?p?st?????
• ?????e?a pa?aµ???? t?? ?a?et???? ?a? ?????
  epeµßat???? s?s?e??? st?? ??s? t???
• S???e?t??ste t?? pa?at???se??
• t?? ??s??e?t??, t?? f?s???e?ape?t?? t??
  a?ap?e?st????, t?? as?e??, t?? ???????e?a? ?.a
• ??as??pe?ste ?a? ????ste t??? ???d?????
  s?????t??? µe ta ?f???, t?? e?tat???? ?e?ape?a?.

11
?a???s?as? a???st?? 1

• ???µatep???µ? ?????a
  ??t?a e?s?d???ep???aµµat???
• ????p?????ta ??s?µata
  ?µ??a ??s??e?a?
• ?????S? ???? S?S?????? ?ST??O? S??? ?.?.T
• ?????eta? t? s?st?µa p?? p?s?e? pe??ss?te??.
  ???t?µ?ta? ? pa???s?as? a?t?? p?? ? ????st??
  ??e? ?a? ??? a?t?? p?? de? ??e?, e?t?? e?d????
  pe??pt?se?? p.?. de? ??e? e?te?????? ????? ?a?
  de? pa???e? ?p????a, de? ep???????e? ?a? de?
  pa???e? ?atast???.
• ?e?t???? ?e??fe???? ?e????? S?st?µa
• ?aµß??e? ?atast???? ?p?ped? s??e?d?s??, ???e?
  (µ??e???, a?t?d?as?), GCS, ???aµ?d??? S??d??µ??
  ?a??se?? pe??fe????? ?e????.
• ?a?d?a??e?a?? S?st?µa
• ??t???a?? ??es?, Sf??e??, ?a?d?a?? ?a????
  (?e?µ???as?a ?????, ??d?µata, d?????s?,
  pe??fe????? sf??e??), ?F?, ?e?t????? G?aµµ??
  (?µ??a).
• ??ap?e?st??? S?st?µa
• ??p?? ??ap???? (???, ??a?e??st?µ?a, ??t?µat?
  a?ap???) ??ta??a?? ae???? a?µat?? (µ??µa
  e?sp?e?µe??? ???????? FiO2, PaO2), CXR
  (??t???µ??f?????a), ?e?????a ?????se?? (p?s?t?ta
  p???t?ta), S????e? pa????te?s??,
  F?s????e?ape?a.
• Gast?e?te???? S?st?µa
• ???te?? ?????ast????? s????a? (s?t?s? ?
  pa????te?s?),
• ?at?te?? e?te????? ???? (s????t?ta, p???t?ta),
  ?e??se?? (a???µ??, e?d??, p???t?ta), S????e?
  pa????te?s??.
• ?ef???
• ?s?????? ????? 24????, ??s?t?ta ????? 24????,
  ??e?ßas??? ?s????p?a, ?ef???? ??ep???e?a?
• ??d???????? S?st?µa
• S???a?? (S?), ?a (?p???? ??aß?t??), T??e?e?d??,
  ?p??ef??d?a.

• G. ?pa?t?p????? - ?. ????a??e?? , ?a?ep?st?µ?a??
  ?.?.T, ??s???µe?? ???

12
?a???s?as? a???st?? 2

• ???s?e?et??? S?st?µa - T????
• ?a??se?? ?st?? a????se?? µ???, ?at??µata,
  ?ste?se??, ??????se??, ????s???e?ape?a.
• ???µa
• ??d????, ????, ?ata???se??, ?e?µat?t?de?,
  ??a???µata.
• ??et?se?? ??µat??
• Ge???? a?µat??, Ge???? ?????, ????, ?pat???
  ???????a, ?ef???? ?e?t?????a, ??e?t????te?,
  ??d???? ??et?se??.
• ?a??????e?e?
• ??µat??, ????????? ?????se??, ?????, ???, ????,
  ????? ß????????? ?????.
• ?pe?????st???? ??et?se??
• ??????? t?µ???af?a, ?a???t??? t?µ???af?a,
  ???e????af?a, ?p??????, ???e?.
• F??µa?a
• ?atast???, ??a???s?a, Gast??p??stas?a,
  ??t?p??t??? (????), ??t?ß??t???, ???t??pa
  ??e??s?spast???, ??????d?asta?t???, ???a.
• ??s??e?t??? f???t?da t?a?e??s????a, st?µat??,
  d??µat??, ?f?a?µ??, ?e?t????? ??aµµ??,
  pa???ete?se??, t?a?µ?t?? ?.?.p.
• S?µpe??sµata
• ??????s? - ?a??t?ta ??s??
• ???ß??µata ???te???µe?e? ??se??
• S?µß????? ?at???
• ???µ???s? ???????e?a?

• G. ?pa?t?p????? - ?. ????a??e?? , ?a?ep?st?µ?a??
  ?.?.T, ??s???µe?? ???

13
G????? F??????? S??? ??T 1

• ????µata p?? p??pe? ?a s?eft?µaste
• ???µ??e??, ???e?t??? ste????
• Gast??t?da ap? st?e?
• ?? t? ß??e? f?eß??? ???µß?s? ?a? p?e?µ?????
  eµß???
• ?p?de???s? t?? ?a??? d?at??f??
• ?t??a ????
• S?st? t?p???t?s? t?? ?a?et???? ?a? t?? s??????
• ?p?p????? d?a???st???? test
• ?????????????? a????e? ?a? p??sa?µ????

• ?pe???µ?se??
• ???a?? µ???sµ???? ??aµµ??
• ?2-a?ast??e??, a?t?????a ? s????a?f?t?
• ???f??a?? ??a e? t? ß??e? f?eß??? ???µß?s?
• ??te???? ? pa?e?te???? d?at??f?
• ???a?? st?? a?t?ß??s?
• ??t?????af?a ???a??? µet? t?? t?p???t?s? ??aµµ??
• ??as??pe?ste t?? ???st?? a??e???e? ap? ta f??µa?a
  

14
G????? F??????? S??? ??T 2

• ????µata p?? p??pe? ?a s?eft?µaste
• ??????t?ta fa?µ????
• ?????? ??a ß?taµ??e?
• F?µat??s?, pe???a?d?a?? ??s?, ep??ef??d?a??
  a?ep???e?a, µ???t?as??? s???
• ?p???e?ste t? µ???a?d?a?? ?µf?a?µa, t??
  p?e?µ????a?a, t?? ?pe????a?µ?a ? t?? ?p???a?µ?a,
  t?? µe??µ??? ?ef???? ?e?t?????a µe f?s????????
  ??eat????? ????, ta sf??µata st? ??????s? t??
  fa?µ???? ? st? ?ata??af? t???, t?? p?e?µ?????
  a??e?a?? ??s?, ?a? t?? ??s??? p?? s?et????ta? µe
  t?? HIV.

• ?pe???µ?se??
• ?????te ??a p??sa?µ???? st? d?s? t?? fa?µ????
• ?a?s?p??? a???? ?a? ?atast???
• ????ste t?? as?e??
• ??????ste ta f??µa?a ap? t? st?µa, a? e??a?
  d??at?
• ????µat? ??e???eta? t?? a?t???a?? ?a?et??a ?
  as?e???
• ??ste t? ?e?aµ??? ?????

15
??????F? 1

• ????µata p?? p??pe? ?a s?eft?µaste
• T?ste st????? ??a ?at?????? ??ept??? ?p?st?????
• ?p?f??ete ? e?a??st?p???ste t?? ?ataß?????
  ?at?stas?
• ?p??t?t? a?ep???e?a ß?taµ???? ? ?at? t?? pa?aµ???
  st?? ??T
• ?p?f??? ?pe?ß?????? p??s????? ?????
• ???????a (d?sa?e??a st? ?a?t???, ?aµ??? p??te???,
  ?pe??sµ?t???t?ta, fa?µa??epa??µe??, ???µ?d??)

• ?pe???µ?se??
• ?p?????ste t?? ?e?µ?d???? ?a? p??te??????
  a????e?. ?????? p?s?t?ta 30 kcal/kg ?a? 1,5g
  p??te????/kg
• ?a?????? fa??t?gt e?te???? d?at??f?
• ??te???? d?at??f? gt pa?e?te???? d?at??f? st???
  pe??ss?te???? as?e?e??.
• ????µ??e? ?e?µ?d???? ?a? p??te?????? apa?t?se??
  se p??et?, ???µ???, e??e???sµ?, ?p??ad?p?te
  s??e??µe?? f?e?µ???d? d?ad??as?a, ???sµ??a
  f??µa?a.
• ???sa?µ?ste t? ???? p??te???? st? ?ef???? ?
  ?pat??? a?ep???e?a

16
??????F? 2

• ????µata p?? p??pe? ?a s?eft?µaste
• ??a??st?p???ste ?a? p????ßete t?? ?pe?????a?µ?a
• ???sa?µ??? t?? ?p?st?????? ? t?? e?d??? t??
  d?at??f?? se as?e?e?? µe ?ef???? ? ?pat???
  a?ep???e?a
• ????µe? ep?p????? epa?as?t?s??
• ??e?a a?ep???e?a ß?taµ????

• ?pe???µ?se??
• ??ß??µ??? ???? ßas???? de??t?? t?? ??ept????
  ?at?stas??.
• ??ste ß?taµ??? ?
• S?efte?te t?? p??a??t?ta ???s?µ?p???s?? f??µ???a?
  ??a t? µe??s? t?? ????? (t?s? e?te????? ?s? ?a?
  pa?e?te?????).
• ??ste f?sf??? ????? ?at? t? d????e?a t??
  epa?as?t?s??.
• S?ed??ste t? ??????s? ??s??????? se ?????
  ?a?e?te???? ??at??f?. ?????te t?? ?pe?????a?µ?a
  (??????? lt110-120 mg/dL).

17
????? ??F???? ??????????"The dumbest kidney is
smarter than the smartest physician"

• ????µata p?? p??pe? ?a s?eft?µaste
• ???e?µµa ?????, ?p???de?s?, ?aµ??? ?a?d?a??
  pa????, ?atap????a.
• ?ef??t????? f??µa?a
• ?p?f?a?? t?? e??d?? t?? ?????
• ???µes? ?ef??t?da
• ??d???s? s?µpt?µ?t?? s?st?µat???? ??s??,
  p??????a???? a?ep???e?a
• ?a?µ?? p???p?????sa? ?????a? ?ef????? a?ep???e?a?

• ?pe???µ?se??
• ?et??ste?a, Cl- ?????,??eat????? ?a?
  ?sµ?t???t?ta
• ??????ste t?? ????- ??a???te ta ?ef??t?????
  f??µa?a -???sa?µ?ste t? d?s? t???
• S?µß???e?te?te ?ef?????? ??a a?µ?d????s? ? ????
  ?e?ape?a- p??sa?µ?ste t? d?s? t?? fa?µ????
• ?pe???????f?µa ?ef??? a? e?de????ta?
• ?????te t?? ?a?et??a ?a? a?t??atast?ste t?? a?
  ?p???e? ??de???
• Staµat?ste t? s?µp????µat??? ??????s? ?a???? a?
  e?de????ta?- ???sa?µ?ste t? d?a?ta (Na,
  p??te???, ?t?.)
• ????ste t?? as?e?? se ?a??µe???? ß?s?.

18
????? ???????S???? ??????????, ???

• ????µata p?? p??pe? ?a s?efte?te
• ?p???e?a ???????s??
• ?p?de???s? ???? ???µ????, ?p?s?t?sµ??,
  s?µf???t???? ?a?d?a??? a?ep???e?a?
• ?????se?? st??? ae?a??????
• ???a ?at???? p??ß??µata (s???p?????sa ?a?d?a??
  a?ep???e?a)
• ?p?tas? ?a? ?aµ??? ?a?d?a?? pa???? ?? ap??t?s? se
  ae??sµ? µe ?et??? p?es?
• ?p??at??a?µ?a, SIADH
• S?ßa?? p?e?µ????? ?p??tas?
• St???s? ?p???
• S???p?????sa µetaß????? a?????s?

• ?pe???µ?se??
• ???pe? ? as?e??? ?a e??a? d?as?????µ???? ? se
  µ??a???? ae??sµ? ??-epeµßat??? µ??a???? ae??sµ?
• ??????d?asta?t??? ???t???ste??e?d?, ?p?at??p??
• ?pa???? s?µp????µat??? ???????
• ??e?µ???a ??e?a ß?????t?da -??t?ß??t??? ??????
• ????µ? ??ept??? ??????
• ?p?ped? ?e?f???????, a? e?de????ta?
• ?e???sµ?? a?ap?e?st??a ?aµ???? e?sp?e?µe???
  ?????, µa???? e?p?e?st???? ??????, ?????
  e?sp?e?st??? ???, pa?a??????e?ste ??a
  a?t?µat?-PEEP.
• S?efte?ta? t?? p???µ? ap?s??des? ap? t??
  a?ap?e?st??a

19
????? ???????S???? ??????????, ARDS

• ????µata p?? p??pe? ?a s?efte?te
• ??t?a S??? -p?e?µ????? ? µ?-p?e?µ????? est?a
• ??s??f?s? ?ast????? pe??e??µ????
• ?pe?f??t?s? µe ????- s?µf???t??? ?a?d?a??
  a?ep???e?a
• ???????e?ste t??? ???d????? ??a t?????t?ta ap?
  ???????? se a?t?pa???es? µe t?? ep?p????? t??
  PEEP.
• S?efte?te s?st?? ???µ?se?? ?????-p?es?? st??
  µ??a???? ae??sµ?
• ?aµ??? a?ß??µ??? s?µß???e? st? p?e?µ????? ??d?µa
  

• ?pe???µ?se??
• Te?ape?t???? st???? FiO2 lt0,50, ? ?aµ???te??
  PEEP (lt5-10 cm H2O), p?? d?d??? ap?de?t? PaO2
• ?ate?????µe?? ? a?t?ß??s? e????? f?sµat??
• Est?a ???µ???? st??? µa?a???? ?st??? ?
  e?d??????a??
• ??????t???,a? e??a? apa?a?t?t?. ?ata??af?
  p??s?????/ ap?????s?? ?e??? ?a??µe???? ??????
  p??s????? ????? ??a a???s? t?? D?2
• ??e???eta? ?a?et??a? Swan-Ganz
• ?e?????ste ? µe??ste t?? p?es? st??? ae?a??????
  (pressure controlled ventilation-)
• ?a?a??????e?ste t? ?ef???? ?e?t?????a, t???
  ??e?t????te?, t?? ?pat??? ?e?t?????a, t? ???t???
  ?at?stas?? ??a MODS

20
?ST??

• ????µata p?? p??pe? ?a s?efte?te
• ? f?e?µ??? t?? ae?a????? e??a? ? p??t?pa??? a?t?a
  t?? status asthmaticus.
• ? a?t?µat?-PEEP ? ? ?pe?ae??sµ?? ????a??e? st??
  a?ta??a?? ae???? ?ta? ???s?µ?p??e?ta? ? µ??a?????
  ae??sµ??
• ???a??? a???µ???? de??t?? ep?p????? ap? t??
  µ??a???? ae??sµ?

• ?pe???µ?se??
• ???t???ste??e?d? se ?????? d?se?? -?p??et???
  a???? µe e?sp?e?µe???? ß2-a????st?? (???a?a, a?
  ??e???eta?)
• ? ?e?f?????? ep?peda
• ????µ? d?as?????s?
• ?pa???? ???????s?
• Se µ??a???? ae??sµ? ?aµ???? a?ap?e?µe???
  ?????, ????? e?sp?e?st??? ??? ?a? ?aµ???
  a?ap?e?st??? s????t?ta? ap?f??? ßa??t?a?µat??/
  PEEPin
• ?p??e? ?a ??e?aste? ?a ?ataste??ete ? ?a
  pa?a??sete t?? as?e?? ??a ?a µe??sete t??
  ?pe?ae??sµ?
• Od???? pa?a???????s?? ap??t?s?? st? ?e?ape?a ?
  ?et??ste t?? µ???st? ??? ? t?? FEV

21
????????? ??????OS?

• ????µata p?? p??pe? ?a s?efte?te
• ??t?µ?ste t?? ßa?µ? t?? µe??s?? t?? ?????.
  ?pe??sµ?t??? st???e??
• ?p?f??ete t?? ?pe?ß????? a?t??at?stas? µe ????
• ???te t?? pa?????ta p???d?t?s?? t?? d?aß?t????
  ?et????s??
• ?p?f??ete t?? ?p?????a?µ?a ?at? t? d????e?a t??
  d?????s??
• ??a?????ste ta ?a?a?t???st??? t?? ep?p????? ap?
  t?? ?pe??sµ?t???t?ta
• ?p?????ste ta e??e?µµata se ?e?? ?a? ????
• ??t?µ?ste t?? pa???s?a t?? s???pa????s??
  d?ata?a??? st?? ??e?t????t??? ?s????p?a
  (?a?a?t??? ????s?, µetaß????? a?????s?)
• ?p?f??ete t?? ?p??a??a?µ?a ?at? t? d????e?a t??
  d?????s??

• ?pe???µ?se??
• ??ste ??s??????. ???s?µ?p??e?ste s??e?? ????s?
• ?p?????ste ??????ste t? ???e?µµa ?e???
• S????? ??e???? ????????/ ??e?t????t??
• ??a??p? ????s?? ??s??????? ?ta? ? ??????? 250
  mg/dL ?a? t? HCO3- e??a? gt18meq/L.
• ?p?f??ete t?? ?p?????a?µ?a- ?a?a??????e?ste t?
  ????? ?a? t?? f?sf??? ????
• Osµ?t???t?ta ?????, ??????? ?????, ?t?.
• ?????te t??? pa?a???????? ???p???, t? µ?t?, t?
  st?µa, t??? µa?a???? ?st???, t? ????p???t??? ?a?
  , t?? ?????? ??a ???µ???, ?a? µe a?t?????af?a
  ???a??? ??a ???µ??? st? a?ap?e?st???.

22
?????????????

• ?pe???µ?se??
• ?et??ste t? Na, Cl-, t?? ??eat????? ?a? t??
  ?sµ?t???t?ta ?????
• ?p????e?ste ? µet?e?ste t?? ?sµ?t???t?ta t?? ????
• ?e??s? t?? ????? ??sate ?s? µe ????
• ??t?ste a? ? as?e??? d???e? (µp??e? ?a e??a?
  µe??µ???? ? ????? a?µat??)
• ??as??pe?ste t? ??sta t?? fa?µa?e?t???? a?????
• ? ßas??? ?e?ape?a µp??e? ?a e??a? ? pe?????sµ??
  t?? ?dat??
• S?efte?te t?? a????? ??a ??????s? ?p??t????
  d?a??µat?? ?????????? ?at???? (?p?????ste µe
  p??s??? t?? p?s?t?ta) ?a? f????seµ?d??
• ???? ?e?ape?a (deµe??????????).

• ????µata p?? p??pe? ?a s?efte?te
• S?efte?te t?? µe??s? t?? ????? (µ?-?sµ?t???
  e????sµa ??a t?? ?????s? t?? ADH).
• S?efte?te t?? ??d?µat??? ?at?stas? µe
  ?p??at??a?µ?a (?????s?, ?ef??s??? s??d??µ?,
  s?µf???t??? ?a?d?a?? a?ep???e?a)
• S??d??µ? ap??sf???? ?????s?? ADH µe µ?-?atast???
  t?? ADH.
• F??µa?a (d?????t??? t?? t?p?? t?? ?e?a??d??)
• ?p??ef??de?a?? a?ep???e?a, ?p????e?e?d?sµ?

23
??????????????

• ????µata p?? p??pe? ?a s?efte?te
• ?a??????ta d?aß?t?
• Sa??a??d? d?aß?t?
• ???a? µe??µ???? ? ????? a?µat?? t?? as?e?? ??a
  p??? ?a???
• S??a??????? µe??s? t?? ?????
• ?a ???a s??e?????? ?a e??a? a?a??

• ?pe???µ?se??
• ?p?????ste t? ???e?µµa ?dat?? ?a? t??
  s??e????µe?? ap??e?a ?dat??
• ??t??atast?sete µe ?p?t????? ???? (0,45 NaCl,
  D5W) st?? ?p?????s???ta ???µ?
• ??t??ataste?ste t? ???e?µµa t?? ?????, a?
  ?p???e?, µe f?s???????? ???
• ?et?e?ste t?? ?sµ?t???t?ta ?????, t? Na, t? Cl-
  ?a? t?? ??eat?????
• ??e???eta? ? as?e??? ??e??? desµ?p?ess???

24
?????S?

• ?pe???µ?se??
• ??????s? t?? ?????. ?p?fas?ste p?? ?a? t? ?a
  d?sete ?a? p?? ?a pa?a???????sete t?? ?at?stas?
• ?? ?p???e? µe??s? t?? ?????, d?????ste t?? a?t?a
• S?e??? t? s??? µe Gram ?et????? ???a??sµ??? (?
  candida)
• ??ste ?a?????? a? ?p???e? ??????? ??de???
• ?? ?pe?????a?d?????f?µa µp??e? ?a ß????se?
• ??e???eta? ? as?e??? ?a?et??a Swan-Ganz
• ?est d???e?s?? µe ??s??t??p??? ? eµpe?????
  ?e?ape?a µe ???t???ste??e?d?

• ????µata p?? p??pe? ?a s?efte?te
• ?p??e?a ?????
• S???. (S?efte?te t?? p??a??? p????. ?p??e? ?a
  ??e?as?e? ?a efa?µ?sete eµpe????? ?e?ape?a)
• ?a?d???e???. (?p???e? ??p??a ?p???a)
• F??µa?a ? t?? ?p????p? a???? (???????µe?? ap?
  ??at?? ? ???)
• ?p??ef??d?a?? a?ep???e?a
• ??e?µ????a?a, pe???a?d?a?? s?????? ?
  ep?p?µat?sµ?, µ???t?as??? s???, ?pe?ß????? d?s?
  t??????????, aµ???e?d?s?).

25
??T?????S SWAN-GANZ

• ?pe???µ?se??
• ?????te ??a a?te?de??e??
• G???te ??a s?µe??µa ??a t? d?ad??as?a
• ???te µet??se?? ?a? ?ata????te aµ?s?? µet? t??
  t?p???t?s?
• ????te µ?a a?t?????af?a ???a??? µet?
• F??te t?? µetat??p?a ?a? t?? as?e?? st? ?d??
  ep?ped? p??? ???ete t?? µet??se??.
• ????te t?? f?sa??de? a??a st?? ??aµµ?? ? st??
  µetat??p?a.
• ?fa???ste t?? ?a?et??a ?s? p?? s??t?µa ???eta?
• ?p?ßeßa??ste t?? ?a?d?a?? pa???? µe t? µ???d?
  Fick
• ?et??sete ???esµ? µe ?2 st? µe??t? f?eß??? a?µa

• ????µata p?? p??pe? ?a s?efte?te
• T?s? t?p???t?s?? (asf??e?a, ???d????, eµpe???a
  t?? ??at???)
• ?????? p????, a???µ?? a?µ?peta????, ?????? ????,
  ????? ???d???? ??a a?µ???a??a
• ?ata??af? st?? ?at???? f??e??
• ??t?µe?ste t?? a????? ??a pa?a???????s? t??
  ?e?ape?a?
• ???ß???te a? ? e?µ??e?a t?? ded?µ???? ?a e??a?
  d?s???? (µ??a????? ae??sµ??, a??e?a?? a?ep???e?a,
  p?e?µ????? ?p??tas?)

26
???????G?? ??? ?? ??O???? G?S?????????? S?S????

• ????µata p?? p??pe? ?a s?efte?te
• ?a?e?a d?????s? a?µ?sfa?????? ?a? a?µ?d??aµ????
  ?at?stas??
• ?st?a a?µ???a??a?
• ??e? ? as?e??? a?µ???a???? est?a se ???? s?µe??
  e?t?? ap? t? a??te?? ?ast?e?te????
• S?efte?te t?? a????? ??a p???µ? ep?µßas?
• ??as??pe?ste p??a?? p??ß??µata a?µ???a??a?, p????
• ??t?p?ste p?te d????ta? ?pe?ß?????? p?s?t?te?
  p?????t?? a?µat??
• ?a????? ta a?t?????a, ?? ?2-a?ast??e?? ?a? ??
  a?ast??e?? t?? a?t??a? ??p??? ????
• ??ast????µe? a?t?e? ? s?µß?????se? a?t?e?

• ?pe???µ?se??
• ?a?a??????e?ste s????
• ta ??t??? s?µe?a
• t?? a?µat????t?
• ?p????te t?? t?µ? t?? a?µat????t? p?? p??pe? ?a
  d?at???sete
• S?efte?te t?? a????? ?a? t?? ????? ??a t?
  d?e????e?a e?d?s??p?s??
• S?µß???e?te?te ??a? ?e???????
• ?? as?e?e?? µe pa???????? pa?atetaµ??? ?????
  p?????µß???? µp??e? ?a ?fe?????? ap? f??s??
  ?ate???µ??? p??sµa
• ??e?????ta? µeta???se?? a?µ?peta???? ??e???
  desµ?p?ess??? (?ef???? a?ep???e?a)

27
??????S, ??????????O? ? ???????S

• ????µata p?? p??pe? ?a s?efte?te
• ??a est?a ???µ????
• ???e??? ap??t?s?? ap? t?? a?a?????sµ??? ? t??
  ?p?t???µe?? est?a ???µ????
• ???a???a??? ???a??sµ??
• Fa?µa?e?t???? p??et??
• S?st?µat??? µ?-???µ?d?? ??s??
• ????? st?? eµpe????? a?t?ß??s?
• ???? ??s? t?? p??et?? (ßa??? e?t?p?sµ??? ???µ???
  e?d??a?d?t?da, ?ste?µ?e??t?da)
• ????sµ???? ?a?et??a? ? ???? s?µa
• S?efte?te t?? ???µ??e?? t?? pa?a??????? ???p??,
  ??S, ?t??a ????, s?pt??? a????t?da.

• ?pe???µ?se??
• ??et?ste t?? ??se?? t?? ?a?et????, t??
  ?e?????????? ?????, t??? pa?a???????? ???p???,
  t?? ???? ?a? t??? ????t???, t?? µe???e?
  a????se??, ta ???a?a t?? p?????, t??? ?a?et??e?
  ?a? t??? s????e?, ta de?µat??? e?a???µata, ta
  ????a ?a? ta p?d?a.
• S?efte?te t??? ?pe????t?????, pe???a?d?a???? ?a?
  ?p?d?af?a?µat????? ??????, pe???ef???? ???µ???,
  ap?st?µa st? sp???a, p??st?t? ? e?d??????a??,
  ?µf?a?t? st? ??te?? ? ?????s? t?? e?t????.
• ?p?st?µa st?? pe????? ???st?? ???µ????.
• ??as??pe?ste ta p??????µe?a ap?te??sµata t??
  ?a???e??e??? ?a? t? ???s? a?t?ß??t????
• S?efte?te t?? a??a?? st?? eµpe????? a?t?ß??s?
• ???te ?a??????e?a ap? t?? s?????sµ??e? est?e? s??
  ?p??esd?p?te s???e???µµ??e? pe??????
• ??a???te ? a????te t??? ?a?et??e?
• S?efte?te t?? µ????s? t?? a?µat?? µe ???t??ta ?
  t?? d????t? ?a?t??t?as?
• ??a???te t?? a?t?ß??s?
• ?a???????? ?pe???????f?µa, a?????? t?µ???af?a,
  ??????, sp????????af?µata ?e?????tt????

28
??????????????? (???? ??? ??????T???????)

• ????µata p?? p??pe? ?a s?efte?te
• ???et?, ?p?t???µe?? ???µ???, ap??t?s? sta
  a?t?µ????ß?a??
• T??µß???tt?pe??a ?a? a?t?µat? a?µ???a??a
• Fa?µa?e?t??? p??et?
• ??t?d??se?? st?? µet????s?
• Staf????????, ???t??ta, ???e? e??a???a???
  ???µ??e??
• ?st?e? ???µ???? se as?e?? ????? ??dete??f??a
  µp??e? ?a ????? s?????a ?a? e????µa, ?????
  ???dasµ?
• ??e?µ?????? d????se?? ?a? e??a???a?? ???µ???

• ?pe???µ?se??
• ??e?e???s? p??et??. ?e?te pa?ap???
• ??d???? est?e? µa?a??? ?st??, pe??ed????
  ap?st?µa, ?a??????e?e? ????? ??a µ???te?,
  p?e?µ??e?
• ??????s??p?s? µe ß????????e??d??? ??p??s?
• ?µpe????? a?t?ß??s?.S??e??ste µ???? t?? ?p?????s?
  t?? p??et??, µ???? ? ????st?? ?a ta p?e? ?a??,
  ??dete??f??a gt1000 /µL.
• ?µpe????? ? ?ate?????µe?? ??????s? ßa???µ??????,
  aµf?te??????? ?, a?t?????? f??µa???,
  a?t?f?µat???? f??µa???
• ?????te t??? e?da??e?a???? ?a?et??e?, ?a?et??e?
  ??st??.
• ?eta???se?? a?µ?peta????, p??f??a?? ??a a?t?µat?
  a?µ???a??a (? a? ?d? a?µ???a?e?)

29
??T????G?? ?? ??? ??????? ??S G??S?O??S
30
??a?e???µ??? ?a?µ?????s? t?? ??a?µat?? (Revised
Trauma Score-RTS-)1
RTS0.9368 GCSc0.7326SBPc0.2908RRc
31
?a?µ?????s? t?? ??a?µat?? (Trauma Score)
32
? ???µa?a CRAMS
1?a?µ?????a 8 de???e? s?µa?t???
t?a?µa.?a?µ?????a 9 de???e? µ???? t?a?µa
33

• Fink's primary rule is
• "Never put off for tomorrow what you can do
  tonight, because you never know what is going to
  come in tomorrow."
• The secondary rule is
• "Never go to bed on a subdural hematoma until you
  have either ruled it out or taken it out."

34
?T??? ??? ?????? T?????

• ??a??e???a (Beneficence)
• ?? ß??ß? (nonmaleficence), (primum non nocere)
• ??t???µ?a (autonomy)
• ???a??s??? (justice)

35

• AMA Task Force Quality Care at the End of Life
• chaired by Dr Thomas Reardon

Doctors must learn to sit down and say ''There
is nothing more I can do, but I'll be here to
help you through''

• "When people die after prolonged suffering, the
  doctors say, "We did everything we could" They
  don't say,
• "We put this person through hell before he died"
  William Knaus Newsweek 4 December 1995

36
?????? ap?f?se??
37
S??????s? t?? ?????? a????

• ????s? ?f???µ?? ?e?ape?a? ? a?t???µ?a gt ?fe??e??)
• ????s? a?at??????? ?e?ape?a? ??? ß??pte?? gt
  a?t???µ?a)
• ?a ?????? ta p??ta? a?t???µ?a gt ?????????
  d??a??s???/a?t???µ?a

38
?a?ade??µata µ?ta?a? ?e?ape?a?

• ?????a f?t??? ?at?stas? (Helga Wanglie)
• ?????
• ????? te???????a
• ?e???? ?????a
• ??s?? te????? stad???

39
?at?????? d??a??µ?t?? t?? as?e??

• ?a ??e? s??et? ?a? seßast? f???t?da
• ?a e??µe???eta? ??a t? d?????s?, ?e?ape?a ?a?
  p?????s?
• ?a ?aµß??e? ap?f?se?? ??a t? ?e?ape?a
• ?a d??e? µe????t???? ?d???e?
• ?a ?p???e? seßasµ?? t?? ?d??t???? ????
• ?a ?p???e? eµp?ste?t???t?ta
• ?a ??e? p??sßas? st?? ?at???? f??e??
• ?a ??e? p??sßas? st?? ?at???? ?p??es?e?
• ?a ??e? e??µ???s? ??a t?? p?a?t???? t?? ?p??es???
  ??e?a?
• ?a s?µf??e? ? d?af??e? ??a t? s?µµet??? t?? st??
  ??e??a
• ?a a?aµ??e? ?????? s?????s? t?? ?e?ape?a?
• ?a e??a? e??µe??µ???? ??a t?? p???t??? t??
  ??s???µe??? se ??µata f???t?da? t?? as?e??? ?a?
  t?? d??at?t?te? ep???s?? t?? p??ß??µ?t??

40
S?G????S??S ?????? ?O? ?T??O? ???O?

• ?at???? ?ata??t?ta
• ???? ?T??O? ???F?S?O?
• ??t?µ?s? ??a??t?ta? ????? ?p?f?se??
• O? ??a??t?ta ????eta? ?e???? ? d??at?t?ta t??
  as?e?? ?a 1) d??eta? ?a? ?ata??e? µ?a a?a??t???
  e??µ???s?, 2) a?t?d?? st?? e??µ???s? µe ?at??????
  t??p?, ?a? 3) µetaf??e? t?? ap?fas? ?a? t??
  ep???µ?e? t?? st?? ?e??p??ta ??at??.
• ?pe?????? ????? ?p?f?se??
• ?p? ?????? ???? ?p?fas??

41
Withholding ?a? Withdrawing

• S?G?????S? ??? ???S??S? ??S ???S??????S ??S ?O?S
• ?d???e? ??a µ? a?a???????s? (Do Not Resuscitate
  DNR)
• S?????t?s? ? ap?s??s? t?? ?e?ape?a?
• ?. Stad?a?? ???s????s?
• ?. S?ed?asµ?? ?e?ape?a?
• G. ?p?s??s? ??t??? ?p?st??????

42
??s???µe?a??? p???t???? p?? ß?????? st?? p??????
? ep???s? t?? ?????? s??????se?? st? ??T.

• ???t???a e?s?d?? ?a? e??d?? ap? t? ??T
• ???p?? ep???s?? t?? ?????? s??????se??
• ??t??? DNR
• ?d???e? ??a s?????t?s? ? ap?s??s? t?? µ?t???
  ?p?st??????
• F???t?da t?? as?e?? p?? pe?a??e?
• ???sµ?? t?? d?ad??as?a? d?????s?? t?? e??efa?????
  ?a??t??
• ??t?se?? ??a d??e? ??????? ? ?st??
• ???a??t??? ????? ??µata

43
?????????? ??????????

• ????de? ??tat???? Te?ape?a? ??tat???? ????de?
  ???µ??
• ??????????
• ??S??? S??????? G?? ?? ???G?OS?
• ??µa???µe?? ep?ped? s??e?d?s??.
• ?p?d????a??µ??? s????.
• ??ata?a??? t?? a?t??????, ?p?? ?pt????
  ?e?da?s??se??.
• ?p?p??sa?at???sµ??.

44
S????? a?t?a pa?a????µat?? st? ??T.

• St???s? ?a???t???? ? a????? ? t?????t?ta
• ?p?d??se?? fa?µ????(p.?. ???t???ste??e?d?,
  s?µet?d???, ??d??a???)
• ?p???a
• ?p???de?s?
• ???µ??e?? (p.?. s?st?µat???? ? ?e?t????? ?e??????
  s?st?µat??, HIV)
• ??µ???? ß??ße? (p.?. ?p?s?????d?? a?µ?t?µa)
• ?etaß?????? d?ata?a??? (p.?. ??e?t????t????
  d?ata?a???, ?pe?asßest?a?µ?a, ?pe?????a?µ?a)
• ?p???pt???? ? µetep???pt???? ?atast?se??
• ?ete??e???t???? ?atast?se??
• ?µß??? ap? ??p??
• ?f?d?t?s?
• St???s? ?p???
• ?e??ßa????t??? st?e?
• ??e?µ????? eµß???

45
F??µa?a p?? µp??e? ?a p???a??s??? pa?a????µa st?
??T1

• ??????ß??? F????????????e?
• ?µ??da???? Ga?s????ß???
• ?µfetaµ??e? ??ast??e?? ?2
  ?staµ????
• ?µf?te?????? ? ??te?fe???? ??fa
• ??t?ep???pt??? ?s???a??d?
• ??t??ata???pt??? ?etaµ???
• ??t??staµ????? ?et????a????
• ?t??p??? ?a? ???a ?eß?d?pa
• a?t??????e????? ??d??a???
• ?a?ß?t?????? ?e???fa???d?t?
• ?e???d?a?ep??e? ?et????p?aµ?d?
• ??ta-ad?e?e?????? ?et????da????
• ap???e?st?? ?? ste??e?d?
  a?t?f?e?µ???d?
• S?µet?d??? ?p??e?d?
• ???t???ste???e?d? ?a?????a p???a??aµ?d??
• ?????se???? ???pafa?????
• ?????sp????? ????d???
• ?a?d?a??? ?????s?de? ???µe??p??µ?-S???f?µe???
  a????
• ?p?et??? ??fa (e?????p???t???)

46
????T????

• ??S??? S??????? G?? ?? ???G?OS?
• ?ata???pt??? d???es?.
• ??s??µa a?a???t?ta? ?a? ad??a??????t?? e?????.
• ????t???? s???e??.
• ?pa?a?aµßa??µe?e? s???e?? ? e???? ?a??t?? ?
  a?t??t???a?.

47
???S???? ??? F???S

• ??S??? S??????? G?? ?? ???G?OS?
• Fa?e??? t??µ?? ? pa?????.
• ????µ??? epa???p??s?.
• F?ß?? ?a µ??e? µ????.
• ??t???µ? af?p??s?.

48
?a????????? ?atast?se?? p?? s???? s?et????ta? µe
a??s???a

• ??e?µ?????? d?ata?a???
  ?e?????????? d?ata?a???
• ???
  S??????s?
  ?at? p???a?
• ??e?µ????? eµß???
  ??a??s?a
• ?s?µa
  ?p?????a
  ???taf???? ??ß??
• ?p???a
• F??µa?a
• ?at?stas? st???s??
• ??????t?ta ap? f??µa?a (p.?. aµfetaµ??e?,
  ???a???)
• ???µ??e??
• F?µat??s?
• ?????????s?
• ?a?d?a??? d?ata?a???
• ???pt?s? µ?t??e?d??? ßa?ß?da?
• ?a????sµ??? ???p??? ta???a?d?a
• ?p??e?a ???µ?d?? e?d??a?d?t?da
• St??????
• ??d????????? ?a? µetaß?????? d?ata?a???
• ??s??????µata
• ?a?????e?de?? ?????

49
???????? ???SO??????? p??s?p??? t?? ??T

• ??a ???s?µ? e??s?s? ??a ?a a?t???f?e? ?a?e?? t??
  a?t?e?t?µ?s? t?? p??s?p???? e??a? ? a???????
• ??t?e?t?µ?s??ea??st??? ep?te??µa
• ???sd???e?

50
?a?µ?????a ßa??t?ta? a?????a µe ta a?epa?????ta
???a?a
G?a ???e pa??µet?? ep????te t?? ?e???te?? t?µ?
t?? 24????. ?? ??p??a de? t?? µet??sate,
ßa?µ????e?ste t? µe 0. ?? ?????sµa t?? 6 t?µ??
d??e? t?? te???? ßa?µ?????a,. ??a ßa?µ?????a
µp??e? ?a ???eta? ???e 24 ??e?. Crit Care Med.
1995231638-1652
51
????da ??tat???? Te?ape?a??.?.T
????st??

• ????da ??tat???? Te?ape?a?
• ????da ?p??e?µ???? Ta??t??

G?at???
??s??e?t??
52
??tat??? Te?ape?a (?.T.) ???sµ??

• ??tat??? ?e?ape?a (??tat???????a) e??a?
• ? p??? ?????? ep?p?d?? s??e??? ??s??e?t???
  f???t?da ?a? ?e?ape?a a???st??, p?? ? ??? t???
  ape??e?ta? ?µesa ap? ??p??a a?ast????µ?
  a?ep???e?a e??? ? pe??ss?te??? ??????? ?
  s?st?µ?t??

53
????da ??tat???? Te?ape?a? (?.?.T.) ???sµ??

• ????da ??tat???? Te?ape?a? e??a?
• ? e?d???? ????? st?? ?p??? s???e?t?????ta? p???
  ßa??? ????st??, µe d???t??? a?ast????µe? ß??ße?
  t?? ??e?a? t???, ?? ?p??? pa?a?????????ta? se
  24??? ß?s? ?a? ?e?ape???ta? ad???e?pta ap?
• ??at????
• ??s??e?t?? ?a? e?d??? e?pa?de?µ?????
  f?s????epa?ape?t??
• µe ?????? te???????a? µ??a??µata ?a? e?a??et???
  p???p???e? te??????.

54
??T-Ge????

• ? ??T ?e?t????e? a?e???t?ta ap? ta ?p????pa
  tµ?µata t?? ??s???µe???
• ? ?atas?e?? t?? p??pe? ?a ???eta? µe t??
  ?p?????sa ???s? ?a? eµpe???a
• ?a µ??a??µata t?? p??pe? ?a e??a? t?t??a ?a? t?sa
  p?? ?a µp????? ?a p??sf????? t?? te?e?ta?a ????
  st?? ?e?ape?a ????? pe?????sµ??? ?? p??? t?
  ep?ped? ? t?? d????e?a t??

ESICM Guidelines 1998
55
???????? ?O? ??Tt? ?a?a?t???st??? t?? 10et?a?
70-80

• ?? ?????
• ????d?? ?at????? µe??d?? ?a? epeµßat???? te??????
  
• Ste?? pa?a???????s? s??e?? ??s??e?t???
  f???t?da as?e???
• G?????? d??s? se pe??pt?se?? ???se??
• S?????t??s? as?e??? se e?d??? ????

56
????G?????????? T?????? ???????S

• 1890-1910
• pa?a???????s? ??t???? s?µe???
• ???d???? a?µ???a??a?, shock, ap?f?a??? ae?a?????
  
• e?pa?de?µ???? ??s??e?t??
• ?e???????? a?a?s??s???????
• 1920 John Hopkins, ???
• 1930 Tuerbingen,Ge?µa??a

57
???????S????S ??T

• 1920-1950 ep?d?µ?a p????µ?e??t?da?
• 1929 ??st??? s?d????? p?e?µ??
• 1932 ??st??? 1? pa?d?at???? ??T
• 1950 ?a??f????a a?ap?e?st??e? ?et???? p?es??
• 1950-52 S?a?d??aß???? ???e?
• 1958 ?a?t?µ???, ?????t?,??f??d?

58
???S?????? ???????S 1950-1960

• ??d?t?a?e?a?? d?as?????s?
• ?e??sµ?? µe as??
• ??????a?a???f?se??
• ??a?e??st?µ?a
• ???a????? ae??sµ??
• ?e??s? ???t?t?ta? ap? 80 se 25

• ????a a?µat??
• ??????t?ta ?2
• ??d?t?a?e?a??? s????e? µe ae?????aµ? ?aµ????
  p?es??

59
??T

• 1960 Los Angeles 1? ??T shock ?a? t?a?µat??
• ??µat???? ??e???? ?a?d?a??e?a??? s?st?µat??
• ?a?et???asµ?? a?t????? f?eß??
• ?a?d?a?? pa????
• ??e???µe?? ??????s? ????? fa?µ????

• 1962 Stefa??a?e?, Kansas, Toronto,Philadelphia
  
• ??e? s?s?e??? te?????? (ap???d?st??,
  ß?µat?d?t??, a?t?p??t???)
• S??e??? ??G?af??? pa?a???????s?
• ?µes? a?t?µet?p?s? a????µ???
• 1976 ??T
• 100 ??s???µe??? µe gt300 ????e?
• 57 µe 200-300
• 29 µe 100-200
• 18 µe lt100

60
??????????S ??T

• 1958-61 Baltimore, Massachusetts GH, Pittsburgh
  ? 24??? s??e??? f???t?da
• 1967 University of Southern California
• ??a?????s? t?? ????? t?? e?tat????????
• ?at???? ??s??e?t??? p??s?p??? p??????
  apas????s??
• ??t?d??se?? ap? ?e?????????

61
?? ??T st?? ????da

• 1955-80 ????de? µete??e???t???? a??????? 1958
  ?p?d?µ?a p????µ?e??t?da?
• 1961???? st? ??T?
• 1960-70 ?e?????????? ????de? (????S,???????
  Sta????, Tessa??????)
• 19791? ????d??aµ? ??T st? ?a???
• 1980-90????d??aµe? ??T (?S?)

62
??T ???t???a d?µ?? ste????s?? ?

• ???? ??s???µe?? p??pe? ?a ??e? ??T
• ?a ??s???µe?a p?? ????? t?? d??at?t?ta ?a
  st??????? t?? ?e?t?????a µ?a? ??T
• ??e? ?? ??T de? ????? t?? ?d?e? d??at?t?te?
• ???? t? µ??e??? t?? ??T
• 5-10 t?? ?????? t?? ??s???µe???
• ??T µe ????te?a ap? 6 ??eß?t?a e??a? as?µf??e?
• ??T µe pe??ss?te?a ap? 6 ??eß?t?a µp??e? ?a
  ?e?t??????? µe t? s?st?µa t?? chairmanship
• ???e ??T p??pe? ?a ??e? ?a? µ?a ??F

ESICM Guidelines 1998 8? ???µ??e?a t??
ÊÅÓÕ1983
63
??T ???t???a d?µ?? ste????s?? ???

• ??s??e?t??? p??s?p???
• ????st?µe??/??
• ?pe????? t?? ?e?t?????a? t?? ??s??e?t???? ?µ?da?
  ?a? t?? ??s??e?t???? p???t?ta? p?? ??e? µ?a
  a?t??a??st?sa
• e??a? ?pe????? t?? ??s??e?t???? e?pa?de?s??
• ? p???staµ??? ?a? ? a?t??a??st?sa, f?s????????
  de?, µet????? st?? ?a??µe????? ??s??e?t????
  d?ast????t?te?
• ??e?d??e?µ??e? ??s??e?t??e? se ??T ?a? epe????ta
  
• ? a???µ?? t??? a?? ????? e?a?t?ta? ap? t? ep?ped?
  ßa??t?ta?/ ??s??e?t???? e???t?s?? t?? as?e??? t??
  ??T
• ??pa?de??µe?e? ??s??e?t??e?/t??

ESICM Guidelines 1998
64
??T ???t???a d?µ?? ste????s?? ?V

• ???e ??s??e?t?? /t??a f???e? se p??a? 40-50
  p??t??? ??SS
• ? s??????? a?a????a ??s??e?t?? a?? ?e?t??????sa
  ????? ??s???µe??? e??a? 1.3/1 (??a p???? ??????)

ESICM Guidelines 1998
65
??T ???t???a d?µ?? ste????s?? V ?p?ped?
??s??e?t???? e???t?s?? se µ?a ??T
ESICM Guidelines 1998
66
??T ???t???a d?µ?? ste????s?? V?

• F?s????e?ape?t??
• 1/12 ??eß?t?a ??a 7 ?µ??e? t?? eßd?µ?da
• ?e??????
• ??a??s?µ?? ??? t? 24??? µe p??te?a??t?ta st? ??T
  
• ?e????????
• ?e???????? t?? a?t?????????? ?a? t?? e??ast?????
  se 24??? ß?s?
• ??a?t??????
• ???? t?? e???s?µe? ??e?
• ???s?p??? ?a?a???t?t??
• ?e e?d??? e?pa?de?s? ??? t? 24???

ESICM Guidelines 1998
67
??T-???t???a ?e?t?????a? ??? as?e?e?? p??
??s??e?e? ? ??T

• ?????? ??s??e?e? ? ??T
• ?s?e?e?? p?? ????? a????? pa?a???????s?? ?a?
  ?e?ape?a? e??? ? pe??ss?t???? ??t???? ?e?t???????
  p?? µp??e? ?a d?ata?a????? ap? ??p??a ??e?a ??s?
  ? ap? ??p??a ?e????????? ? ???? ?e?ape?a
• ?s?e?e?? p?? ????? ?d? µ?a a?ep???e?a ??p??a?
  ??t???? ?e?t?????a? p?? ep?ßa??????e
• ?????? de? ??s??e?e? ? ??T
• ?s?e?e?? µe te???? st?d?? a?e??pe?t?? ??s??

ESICM Guidelines 1998
68
??T ???t???a e?s?d??

• ???t? p??te?a??t?ta
• ?????? ??a ?e?ape?a
• ?e?te?? p??te?a??t?ta
• ?????? pa?a???????s??
• ???t? p??te?a??t?ta
• ßa??? p???p?????sa ??s?? ?a? ??e?a ??s?? ? ?
  s??d?asµ?? t???, µe ???st? pt??? p?????s?
• Se ??e? t?? pe??pt?se?? ?a?? e??a? ?a µet???ta? ?
  ßa??t?ta ?a? ?a e?t?µ?ta? ? p?????s?

ASCCM 1998
69
??T ??d??? ???t???a e?s?d??

• ???efa????? ???at??
• ?ta? ? as?e??? e??a? d?t?? ??????? ?a? µ???? t??
  afa??es? t???
• ?s?e?e?? se µ???µ? f?t??? ?at?stas?
• ?s?e?e?? p?? a?????ta? t? ep??et??? ?e?ape?a
  t???, a??? ?????? ta ?a?? t?? ??T
• ?s?e?e?? p?? s???e?t?????? ta ???t???a e?s?d?? se
  ??F
• ??aß?t??? ?et????s? ????? ep?p?????,sta?e???
  ?a?d??- ???a??- ?e?????????? as?e?e??
  µete??e???t???, ?p?a s?µf???t??? ?a?d?a??
  a?ep???e?a ??p

ASCCM 1998
70
??T???t???a e??d??

• ???t? p??te?a??t?ta
• ??? a????? ??a ?e?ape?a, ap?t???a ?e?ape?a? ?a?
  pt??? ß?a??p???esµ? p?????s? p.?. t??a
  a?epa?????ta ???a?a ?a? ap?t???a t?? ?e?ape?a?
• ?e?te?? p??te?a??t?ta
• ap??s?a a?????? pa?a???????s??
• ???t? p??te?a??t?ta
• ßa??? p???p?????sa ??s?? ?a? ??e?a ??s?? ? ?
  s??d?asµ?? t???, µe ???st? pt??? p?????s?, p??
  de? a?tap???????a? st?? ?e?ape?a

ASCCM 1998
71
??T ???t???a ?e?t?????a? ??p?sa ??eß?t?a p??pe?
?a ??e? ? ??T

• ?sa ??e???eta?!
• ?ata??af? a?a???? ?a? efa?µ??? t?? ?ata??µ??
  Poison
• ????µ?? ??eßat??? p?? ??e?a??µaste
• xz.x0.5, ?p?? x ? µ?s? ?ata?e??aµµ??? a?????
  se ??eß?t?a ??T ?a? z 2.33,1.65, 1.28, 1.04,,
  0.80 ??a p??a??t?te? a?e??es?? ??eßat??? se p??t?
  ??t?s? 99, 95, 90, 85 ?a? 80, a?t?st???a
• ???????? p?a?µat???t?ta ? 6, 126, 30

ESICM Guidelines 1998
72
??T-???t???a ?e?t?????a? ???p???t?ta
p??sfe??µe??? ?p??es??? ??T

• St???e?a p?? f???ss??ta? ??a ???e as?e??
  et?s??? ap?????sµ??
• ??s??e?t???? f??t?? (?ISS, Omega, ODIN) ,
  ßa??t?ta ??s??e??µe??? as?e??? (APACHE II, SAPS
  II, MSOF,MODS ??p)
• ?p?p?????/p??ß??µata ?at? t?? ??s??e?a /
  epa?e?sa???? t? p??t? 24???
• ??d?? epeµß?se??/pa?eµß?se?? ?at? t?? ??s??e?a

ESICM Guidelines 1998
73
??T?d???e? s?ed?asµ?? ?

• ?µ?da s?ed?asµ??
• ? µe????t???? d?e????t?? ?? ??at??? t??, ?
  d?e??????sa/p???staµ??? ??T, 1 a???t??t??a?, 1
  d?????t????, 1 µ??a?????
• ep???????? p??pe? ?a ??t??e? ? ???µ? e???
  ???µ?????????, t?? p???sßest???? ?a? t?? p??a???
  ???st?? t?? ?at???
• ?p????????e? µe
• ?pe????ta, ?e??????e?a, e??ast????, e??atast?se??
  ?e?t???????? ??e????, a?t????????? e??ast????
  ?at?ep?ped? ? µe e?e???µe?? a?e???st??a
• ?µes? ?a? e????? ep????????a µe fa?µa?e??,
  a?µ?d?s?a, ?e?t???? e??ast???a, te????? ?p??es?a
  
• ??eµp?d?st? ?a? e??e??? t??ef????? ep????????a
  ??? t? 24???

ESICM Guidelines 1998
74
??T?d???e? s?ed?asµ?? ?? ?????/e??atast?se??/?e?
t?????e?

• ?pa???? ?e?t???????? ????? a?? ????? (20-25 tµ)
• ?p?µ???se?? as?e??? (1-2/10 ????e?)
• ?a?a?????e? ?e?t?????e?
• ep????????e? (t???f???,s?st?µa s??a?e?µ??,?????
  t????? ?a? ?µe???????)
• ??f?a ?a? s??t???a ??a ta ????afa ?a? ta
  a?a??s?µa t?? as?e?? (µe t?? ?d?a d??ta?? pa?t??)
  
• ?at?????? µ???d?? p??sa????? ?a?a??? ?a? apa?????
  a???a?t??, s?st?µa pa?a???????s?? (monitoring)

ESICM Guidelines 1998
75
??T?d???e? s?ed?asµ?? ??? ?????/e??atast?se??/?e
?t?????e?

• ?a?a?????e? e??atast?se?? (ap? t?? t???? ? t??
  ???f?)
• ?e?µa(220V)16-20 pa????? /??eß?t?-1 UPS 1 x-ray
• ?e?? (-500mmHg µe ??? 40l/min) ?a? ?at????? a??a?
  (5 Bar µe ??? 20l/min) 3 pa????? /?????
• ??????? (5 Bar µe ??? 20l/min) 4 pa????? µe ta
  ???µet?a t???/????? (2 e?at????e?)
• ??a?s??s???????? a???a
• ???s? (?est?-????) 1 /µ???s? ? 1 /5 ??eß?t?a
• ?ad??f???-t??e??as? 1 /µ???s? ? 1 a?? ??T !!

ESICM Guidelines 1998
76
??T?d???e? s?ed?asµ?? ?V ?????/e??atast?se??/?e?
t?????e?

• ?a?a?????e? ?e?t?????e?pa?a???????s?-?/?
  pa?a?????a
• ??at?µ??e?µ??? s?st?µa pa?a???????s?? µe
  ß?sµat??µe?e? µ???de?
• ??G,??,?F?, a?µat??? p?es? x 2, ?e?µ???as?a,
  pa?µ??? ???µet??a, ?ata??af? s??a?e?µ?? ?a?
  e?t?p?s? µetaß??t??.
• Fi?2, PFTs, mixed venous ?2sat, ST-T a????s?,
  a????s? a????µ???, µ?t??s? ß?????, ?µµes?
  ?e?µ?d?µet??a
• ?/? pa?a?????a
• ??e?t??????? f??e???,ep????????e?, f??µa?a,
  ?p?????sµ?? ??e?se??
• ?e?t????? sta?µ??

ESICM Guidelines 1998
77
??T?d???e? s?ed?asµ?? V ?????/e??atast?se??/?e?t
?????e?

• ?a?a?????e? ?e?t?????e?-?e?t????? ??s??e?t????
  sta?µ??
• ??f?a ??a ??t?pa ?a? ß?ß??a, ?/?, e?d?- e??-
  ep????????a
• Fa?µa?e??- ????? pa?as?e??? fa?µ????
• ?e?t????? sta?µ?? pa?a???????s?? ?a? ?ata??af??

ESICM Guidelines 1998
78
??T?d???e? s?ed?asµ?? V? ?????/e??atast?se??/?e?
t?????e?

• ?p????? 30 µ?t?a µ???st? ap?stas? ap? ??T
• ??a??s?µa 5 m2/??eß?t?
• S?s?e??? 5 m2/ ??eß?t?
• S?s?e??? d?a??µ?d?? 5 m2
• ????? ap????e?s?? a?a???t?? (25 m2) /?a?a??? (15
  m2)
• G?afe?? p???staµ???? 15 m2
• G?afe?? ?at???20 m2/ ?at?? p?????? apas????s??

ESICM Guidelines 1998
79
??T?d???e? s?ed?asµ?? V?? ?????/e??atast?se??/?e?
t?????e?

• G?afe?? ??aµµat??? 20m2/8 ????e? ??T
• ????? a??pa?s?? p??s?p???? 30m2/8 ????e? ??T
• ?p??d?µ?t?? ef?µe?e???t?? 15m2
• ???ast???? 15 m2
• ???ast???? s??t???s?? s?s?e??? 28m2
• ??????a 25m2
• ????? ?p?d????/a?aµ???? s???e??? 10m2

ESICM Guidelines 1998
80
??T?d???e? s?ed?asµ?? V??? ?????/e??atast?se??/?
e?t?????e?

• ????? ?pe?????? ?p?d???? as?e???10m2
• ????? e?d???? epeµß?se??/?e?ape??? 35m2
• ?????sa µa??µ?t?? 40m2
• ?????sa ?/? 20m2
• ????? ?a?a??st??a? 3-4m2
• ????? s????t?s?? µe t??? s???e?e?? 15m2
• ???e?? d??d??µ??, e?d??? d?peda, d?a??sµ?s? t?????

ESICM Guidelines 1998
81
??T?d???e? s?ed?asµ?? ?? ?????/e??atast?se??/?
e?t?????e?

• ???asf??e?a
• S?ed????aµµa se eµfa??? µ???? ßas???? ?e?t???????
  t?? ??T ?d?? d?af????
• ?p?f??? ?????s?? ?ap??? ?a? t?????? ae????
• ?d?? d?af???? e??a??µ???? ?a? as?e???
• ???a (p.?.a?t?µata a?????µe?e? p??te?)

ESICM Guidelines 1998
82
??T?d???e? s?ed?asµ?? ? ?????/e??atast?se??/?e
?t?????e?

• ?e??sµ??-???µat?sµ??
• 99 f??t?a??sµ???? a??a? ??a s?µat?d?a µ???? 5 µ
  a?a??????µe??? 10 f???? t? ??a, s?et??? ???as?a
  30-60, ?e?µ???as?a 16-27 oC(ta ???? se 16-21
  oC).
• F?t?sµ??
• F?? ?µ??a? ? 150 Ft-candle
• 20-100 Ft-candle f?t?sµ?? ???ta?
• F?t?sµ?? ??a epeµß?se?? a?????s?
• ?d?e?s?-ap???te?s?
• ?p????µ-e?d??? ap????sµ??? ?e??-ßa???? ?????e?

ESICM Guidelines 1998
83
??T?d???e? s?ed?asµ?? ?? ?????/e??atast?se??/?
e?t?????e?

• ?p????????e?
• (e?d?- e??-),s??a?e?µ??, t??e-e?d?p???s?,
  d??t?a
• ??a?e???s? s?s?e???
• ??a??s?µa-s????? pa?a??e??e?
• ??d??? ???t???a ep?????? s?s?e??? e?d????
  p??d?a??af??
• ?p????e?s? s??t???s?-ap?ste???s?, a?a???s?

ESICM Guidelines 1998
84
? ???????? T??????? S??? ??????

• ??s???s? st?? 8? ???µ??e?a t?? ??S? ??a t??
  ?pe????sa ?a? ??tat??? ?at????, 1983.
• ?? ?2ß/ 5094/ 17-3-88??s???s? ??a a?a?????s? t??
  e?tat???????a? ?? e?e?d??e?s??
• ?? 517 202?/ 24-12-91 ??????s? ?e?t?????a ??T
  st?? ?d??t??? t?µ?a
• ??µ?? 2071/ 5,2?/1992?a?????s? e?e?d??e?s?? st??
  ??tat??? Te?ape?a
• ??S? 10/97/ 28-12-92 ?a???? e?e?d??e?s?? se
  ???????? ??s???µe?a
• 2519/1997 ???µ?s? ?eµ?t?? ??T
• ?? 235 ?a???t?µa 3.5.1. 3.5.4. /F??
  199-14/9/2000??????s? ?e?t?????a ??T st??
  ?d??t??? t?µ?a

85
ISO t?? ?a? ??T
86
S??????S???? G?? ??T

• ? ??T e??a? p??? ????
• ?t??eta?
• e?e? p?? ??e???eta?
• ?ta? ??e???eta?
• ?s? µe???? ??e???eta?
• ?p?? p??pe?
• ap? a?t??? p?? p??pe?
• ?e?t????e? µ??? µe
• t?? a?a??a?e? d?µ??
• t??? apa?a?t?t??? e??p??sµ???
• t? apa?a?t?t? p??s?p???
• a?t??? p?? ?????? ??T

• St?? ??T
• 8 st??? 10 ????!!! (???t?t?ta 21)
• de? ??s??e???ta? et??µ????at??
• de? ?p???e? p?t? ?e?? ??eß?t?
• ??s??e???ta? 30 ????st?? a?? ????? t? ?????
• ?µe??s?? ??st?? a?? ????? 1500 e???
• ? ???a ??e? a????? pe??ss?te??? ??eßat??? ??T

87
(No Transcript)