tata S 14'0016'00

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tata S 14'0016'00

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And yet don't look too good, nor talk too wise; If you are not afraid to get your hands dirty; ... If you can talk with drug reps and keep your virtue, ... – PowerPoint PPT presentation

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Title: 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)

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