Terapia intensiva a pacientului neuro-critic - prezentare generala-
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Transcript of Terapia intensiva a pacientului neuro-critic - prezentare generala-
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Antoniu Brinzeu
Program cofinantat din Fondul Social European prin Programul Operational Sectorial Dezvoltarea Resurselor
Umane 2007-2013
INVESTESTE IN OAMENI!
Continutul acestui material nu reprezinta in mod obligatoriu pozitia oficiala a Uniunii Europene sau a Guvernului Romaniei
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Accidente vasculare cerebrale ischemice Hemoragii cerebrale: subarahnoidiene ,
intracerebrale Traumatisme cranio – cerebrale,vertebro-
medulare Tumori cerebrale,medulare Neuroinfectii Status epilepticus Boli neuromusculare decompensate care
necesita suport functional ( ventilator)2
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Traumatism cranian – Hematom intracerebral Traumatism cranian – Hematom intracerebral – SCJUT– SCJUT
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TCC
•Edem cerebral
•Devierea liniei mediane
•Ventricol stang nevizualizat
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Ischemie cerebrala secundara Ischemie cerebrala secundara – colectia SCJUT– colectia SCJUT
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Abcese cerebrale multiple – Abcese cerebrale multiple – colectia SCJUTcolectia SCJUT
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Abcese cerebrale multiple – Abcese cerebrale multiple – colectia SCJUTcolectia SCJUT
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20102010
Bolnavi neurocritici Bolnavi neurocritici 578578 IOT 322IOT 322
Neurologie1Neurologie1Neurologie2Neurologie2
NeurochirurgiNeurochirurgiee
Urgente - UPUUrgente - UPU
Traumatisme cranio-cerebrale 109109Hemoragii subarahnoidiene anevrismale 5757 Hemoragii subarahnoidiene neanevrismale 77 Accidente vasculare cerebrale hemoragice 108108Accidente vasculare cerebrale ischemice 8484 Tumori 133133Hidrocefalii 8 8 Traumatisme vertebro- medulare 1414Infectii 1919
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Zile de spitalizare 5724
Complicatii
Costuri
DeceseDecese 259 259
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Tratamentul specific bolii de baza
Sustinerea functiilor vitale
Nursing, prevenirea complicatiilor
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AVC ischemic – repermeabilizare AVC hemoragic – evacuarea
sangelui/hemostaza Tumori cerebrale: ablatie ± chimioterapie
± radioterapie Leziuni traumatice: evacuare,
decompresiune, hemostaza Neuroinfectii : antibiotice ± corticoizi±
chirurgie
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1. Respiratia2. Circulatia3. Echilirul hidroelectrolitic si acidobazic4. Nutritia - metabolismul5. Homeostazia termica 6. Excretia 7. SNC
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Monitorizare
Optimizarea parametrilor…
tratament
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8. Analgosedarea9. Tratamentul /profilaxia convulsiilor10.Profilaxia ulcerului de stress11.Profilaxia tromboembolismului pulmonar12.Profilaxia escarelor13.Toaleta/igiena generala,orala,perineala14.Kinetoterapia
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Factorii sistemici favorizanti ai
leziunilor secundare
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1.Hipotensiunea2.Hipoxia3.Anemia4.Hipo/hiper glicemia 5.Hiper si hipocapnia
6.Alcaloza metabolica7.Acidoza metabolica 8.Hiperosmolaritatea9.Hiposmolaritatea11. Hipertermia
dupa N. Bruder,P.Ravussin, B. Bissonnette La reanimation neurochirurgicale, modificat
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Obiective
•Normocapnie•Normoxie
Monitorizare : SpO2, PaO2, PaCO2
Continut O2 – 200ml/l
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RealizareRealizare
•Oxigenoterapie
•Terapie respiratorie
•Ventilatie mecanica
1. Respiratia
SpO2 ≥ 95 %SpO2 ≥ 95 % ( 98%) ( 98%)PaO2 - 60-100 mmHgPaO2 - 60-100 mmHg
(90)(90)PaCO2- 36-40 mm HgPaCO2- 36-40 mm Hg
Marino – the ICU Book
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1. Respiratia
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1. Respiratia
DO2 = CaO2XCOCa O2 = Hb X SaO2X 1,34
Hb – vehicolul pt OHb – vehicolul pt O22
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Trigger hemoglobina:
conventional
≈ 10g/dl ( 1942)
Trigger Trigger fiziologic:fiziologic:
Hipoxie globala :Hipoxie globala :
Lactatemie ↑Lactatemie ↑SvOSvO22↓↓
Hipoxie regionalaHipoxie regionalaModificari EKGModificari EKG
Marino – the ICU Book
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1. Respiratia
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DO2 = CaO2XDCCa O2 = Hb X SaO2X 1,34
Trigger : Extractia oxigenului
SaOSaO22 - SvO - SvO22 >50%>50%
Marino – the ICU Book
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2. Circulatia
Obiectiv specificMentinerea presiunii de perfuzie cerebrala –
PPC ≥ 60 – 70 mm Hg PAM = 80 – 100 mmHg
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2.Circulatia
Normovolemie – evitarea hipervolemiei
Medicatie vasoactiva - Noradrenalina – i.v. continuu
Monitorizare :PA; PVC
Debit cardiac – monitorizare minim invaziva - VigileoDebit cardiac – monitorizare minim invaziva - Vigileo
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PPC = PAM - PICPPC = PAM - PIC PIC ≤ PIC ≤ 10mmHg10mmHg
Monitorizarea PIC/PPC in TI
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3. Echilibrul hidroelectrolitic
Necesarul estimat
Hidric Electrolitic:NaKCL
Bilantul Bilantul hidric,electrolihidric,electroli
tictic
24 de ore24 de ore12 ore12 ore4 ore4 ore
1 ora !!! 1 ora !!!
Echilibrul Echilibrul hidroelectrolitic hidroelectrolitic
→ →
VolemiaVolemiaDebitul cardiacDebitul cardiacPresiunea Presiunea arterialaarterialaOsmolaritateaOsmolaritatea
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INTRARI :INTRARI :ABORD VENOS CENTRAL, PERIFERICSONDE GASTRICE, ENTERALE
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intravenoaseintravenoase enteraleenterale productie productie endogena endogena (ex(ex..apa endogena)apa endogena)
3. Echilibrul hidroelectrolitic
A. Mogoseanu Elemente Practice de Reanimare
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IesiriIesiri::
• diurezadiureza• perspiratieperspiratie•
transpiratietranspiratie• aspirat aspirat
gastricgastric• scaun scaun • drenaje, drenaje, •
pansamentepansamente ( cantarire)( cantarire)
3. Echilibrul hidroelectrolitic
Bilantul = Intrari – iesiri = “sold “
A. Mogoseanu Elemente Practice de Reanimare
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Echilibrul hidroelectrolitic - normovolemia
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Riscurile hipovolemieiRiscurile hipovolemiei
In caz de HIC – scade viteza In caz de HIC – scade viteza de circulatie a hematiilorde circulatie a hematiilor
Oferta de oxigen ↓Oferta de oxigen ↓
Ischemie cerebralaIschemie cerebrala
Doppler Doppler transcranian transcranian
ACMACM
IP ↑Viteza de circulatie
diastolica ↓
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Riscurile hipervolemiei
TCCHSA – anevrisme rupteEdem cerebralEdem cerebralEdem pulmonarEdem pulmonar
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Lezarea barierei Lezarea barierei hematoencefalicehematoencefalice
Lezarea Lezarea capilarelor capilarelor pulmonare pulmonare
Insuficienta Insuficienta ventriculara stgventriculara stg
•SRIS – in HAS
•Contuzie – in TCCpulmonara, miocardicaN. Bruder,P.Ravussin, B. Bissonnette La reanimation
neurochirurgicale
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Monitorizarea volemiei : detectarea hiper sau hipovolemiei
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Parametrii staticiParametrii staticiPresiunile cardiace Presiunile cardiace de umplerede umplere•PVCPVC•PCWPPCWP Volumele cavitatilor Volumele cavitatilor cardiacecardiaceVolumul telediastolic al Volumul telediastolic al VDVDVolumul telediastolic al Volumul telediastolic al VSVSVolumul cardiac Volumul cardiac telediastolic globaltelediastolic global
Parametrii dinamiciParametrii dinamici
Variatiile respiratorii Variatiile respiratorii ale presiunii arteriale si ale presiunii arteriale si ale volumului bataieale volumului bataie
Scaderea inspiratorie a Scaderea inspiratorie a presiunii atrialepresiunii atriale
Test clinicTest clinic
Ridicarea pasiva a Ridicarea pasiva a membrelor inferioaremembrelor inferioare
Evalueaza raspunsul hemodinamic la terapia volemica
si implicit necesitatea de a “ umple “ patul vascular.
Yearbook of ICUand Emergency medicine 2007 - Passive leg raisingYearbook of ICUand Emergency medicine 2007 - Passive leg raising
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4. Nutritia si metabolismul
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Nutritia enterala : prima alegere
Atentie la complicatii Atentie la complicatii :
Hipoglicemia Hipoglicemia HiperglicemiaHiperglicemiaAcidozaAcidozaAlcalozaAlcaloza
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Glicemia : valori ideale – pericol de Glicemia : valori ideale – pericol de hipoglicemiehipoglicemie
Valori optime 100 – 150 mg/dlValori optime 100 – 150 mg/dl
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5. Echilibrul acidobazic
→
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Acidoza respiratorieAcidoza respiratorieAlcaloza respiratorieAlcaloza respiratorie
Sedare Sedare VentilatieVentilatie
PaCO2 = 40 ± 2 mm Hg PaCO2 = 40 ± 2 mm Hg Usoara hipocapnie 35 – 38 mm Usoara hipocapnie 35 – 38 mm
HgHg
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Alcaloza Alcaloza metabolicametabolicaAcidoza Acidoza metabolica metabolica
BE = ± 2 mEq/l
Alcalemie : pH ≥ 7,45Hb “ zgarcita”Hipoxie tisularaK ↓cauza si efectAritmiiSlabiciune musculara
Merck Manual 18 –th Ed. Acid - Base regulations and disorders
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Acidemie = pH≤ 7,35Acidemie = pH≤ 7,35DDisfunctii cardiace:isfunctii cardiace:
contractilitate ↓dilatatie arteriala, contractilitate ↓dilatatie arteriala, venoconstrictie,rezistenta vasculara venoconstrictie,rezistenta vasculara pulmonara ↑pulmonara ↑
35Merck Manual 18 –th Ed. Acid - Base regulations and disorders
Aritmii SocAlterarea metabolismului si volumului neuronal → obnubilare, coma
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6. Monitorizarea si controlul osmolaritatii sanguine/osmoterapia
Cotrell and Young - Neuroanesthesia 36
Osm /kg= 2X Na+ Glicemia mg/dl: 18+ ureea mg/dl:6
Valori medii : Plasma - 289 mOsm/kg
H2OLCR – 289 mOsm/kg H2O *
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7. Temperatura centrala7. Temperatura centrala
Temperatura cerebralaTemperatura cerebrala
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Normotermia – combaterea Normotermia – combaterea hipertermieihipertermiei.
Mijloacele medicamentoase sunt de Mijloacele medicamentoase sunt de preferat: paracetamol, preferat: paracetamol, antiinflamatoareantiinflamatoare
Locul de Locul de masurare:masurare:
TimpanTimpanEsofagEsofag
NasofarinxNasofarinxArtera Artera
pulmonarapulmonaraRectRect
Important Important factor de factor de agresiuneagresiune
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8. Tratamentul/profilaxia convulsiilor
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Profilaxia : nu exista punct de vedere unitar
Rezonabil : administrarea in starile cu risc crescut
Convulsiile : leziuni cerebrale secundare ( cresterea
metabolismului cerebral + favorizarea hipoxiei)
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Starea de rau epileptic - status epilepticus
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Definitie: activitate convulsivanta persistenta sau
care se repeta la intervale scurte, fara revenire intre crize
Durata > 30 min.
Practic
tratament:3 crize succesive > 10 min.
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Tratament in status epilepticus: status convulsivant sau nonconvulsivant ( EEG)
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Benzodiazepina i.v :
Diazepam 0,2 mg/kg
Clonazepam0,02mg/kg
Lorazepam 0,1mg/kg
.
Incarcare cu fenitoin i.v. – 18 mg/kg – 50
mg/minut
Intretinere : 100 – 200 mg/zi
Conc plasmatica 10 – 12 micrograme/ml
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Status epilepticus refractar :
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Anestezie generala
Propofol TiopenthalIOT, ventilatieMonitorizare + suport hemodinamic
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Tratamentul edemului cerebral:
* N. Bruder,P.Ravussin, B. Bissonnette La reanimation neurochirurgicale
Edemul citotoxic – celularEdemul vasogenicEdem citotoxic + vasogenic
Edemul citotoxic – celularEdemul vasogenicEdem citotoxic + vasogenic
Cauze *Edem difuz: Traumatism cranianHemoragie subarahnoidianaEncefalopatie hipertensivaMeningite bacterieneEncefalite viraleHepatita fulminantaEpurare extrarenalaEncefalopatie anoxicaIntoxicatie cu apa
Edem localizat:Accident vascular ischemicTumoriHematom intracerebral
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Edemul citotoxic sau celular :
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Alterarea permeabilitatii membranare:
acumulare intracelulara de apa, Na+, Ca++
Alterarea permeabilitatii membranare:
acumulare intracelulara de apa, Na+, Ca++
Deschiderea barierei hematoencefalice:
trecerea de apa, electroliti si proteine in spatiul interstitial
Deschiderea barierei hematoencefalice:
trecerea de apa, electroliti si proteine in spatiul interstitial
Edemul vasogenic
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Prevenirea trombozelorPrevenirea escarelorProfilaxia hemoragiilor digestive superioarePrevenirea atrofiilor musculare si a anchilozelor
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Terapie posturalaMobilizare pasiva Meloterapie ……
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