10 手術後第五天 PEEP 已增加至 10 cm H 2 O, 而 V T 增加至 1000 ml 相關評估數據如下 : BP 130/60 mmhg ph 7.43 HR 120bpm PCO mmhg RR 10 breaths/min PO mmhg BT 38.3 C(101 F) HCO mmol/l
11 人工呼吸器的設定和 PEEP 醫療處置 PEEP 已增加至 10 cm H 2 O V T 增加至 1000 ml 使用範圍 臨床上常應用 Best PEEP 的作法, 由 5 cmh2o 的 PEEP 開始, 逐次增加 3~5 cmh 2 O, 達到 SaO2 90% FiO2 需求 < 氣道壓力及血壓均可接受的範圍 一般而言,ARDS 病患所需的 best PEEP 約為 7 ~20 cmh 2 O Tidal volume 早期 (680~1020ml) (10~15 ml/kg) 目前建議 (340~544ml) (5~8ml/kg)
16 病情進展 病人情況 氧合狀況已逐漸穩定並嘗試嘗試脫離呼吸器 尿量 治療原則 supplemental oxygen required to maintain the PaO 2 above 60 mm Hg or the SaO 2 above 90% should be used. Efforts should be made to decrease FIO 2 to less than 60% as soon as possible in order to avoid oxygen toxicity. Urine output : (1) minimal acceptable urine output for an adult is ml/kg/h (daily volume normally ml/d). (2) 依安先生體重最少約 816~1632 ml/d
17 問題 1.ARDS 的危險因子? 2. 氧合的指標? 3.PEEP 的使用 4. urine output 的指標與治療? 5. 呼吸器脫離的指標? 6. Other Strategies in Mechanical Ventilation?
38 氧合指標 Treatment of the hypoxemia seen in ARDS usually requires tracheal intubation and positive-pressure mechanical ventilation. The lowest levels of PEEP (used to recruit atelectatic alveoli) and supplemental oxygen required to maintain the PaO 2 above 60 mm Hg or the SaO 2 above 90% should be used. Efforts should be made to decrease FIO 2 to less than 60% as soon as possible in order to avoid oxygen toxicity. PEEP can be increased as needed as long as cardiac output and oxygen delivery do not decrease and airway pressures do not increase excessively. Prone positioning may transiently improve oxygenation in selected patients by helping recruit atelectatic alveoli; however, great care must be taken during the maneuver to avoid dislodging catheters and tubes.
39 PEEP 的使用 PEEP 之使用在 ALI/ARDS 病患非常重要 適當的 PEEP 可募集較多的肺泡參與換氣, 增加肺順應性, 減少死腔, 降低肺內分流, 而可提高 PaO2, 減少氧氣的使用 但是過高的 PEEP, 則會造成肺泡過度膨脹, 肺順從性降低, 氣道壓力上升, 並會降低心輸出量 因此, 臨床上常應用 Best PEEP 的作法, 由 5 cmh2o 的 PEEP 開始, 逐次增加 3 ~5 cmh 2 O, 達到 SaO2 90% FiO2 需求 < 氣道壓力及血壓均可接受的範圍 一般而言,ARDS 病患所需的 best PEEP 約為 7 20 cmh 2 O
40 MAINTENANCE OF URINE OUTPUT Maintain adequate urinary output (30 50 ml/h). Insert an indwelling urinary catheter to monitor urine output. If myoglobinuria is present, rehydrate the patient with isotonic saline, alkalinize the urine with intravenous administration of bicarbonate, and consider the use of mannitol, 0.25 g/kg intravenously, to promote diuresis. Maintain blood pressure and urine output with intravenous infusion of crystalloid solutions and inotropic agents as
41 necessary (monitoring of central venous pressure or pulmonary capillary wedge pressure may be required). - Adrenergic drugs -Adrenergic drugs are contraindicated because they produce vasoconstriction and decrease heat exchange. Dobutamine may be preferable to dopamine as an inotropic agent, because it does not have the -adrenergic renal effects associated with dopamine at rapid rates of infusion.
42 Criteria for Extubation from Mechanical Ventilation Parameter Value Pulmonary mechanics Vital capacity > ml/kg Resting minute ventilation > 10L/min (tidal volume x rate) Spontaneous respiratory rate < 33 breaths/min Lung compliance > 100 ml/cm water Negative Inspiratory force (NIF) > 25cm water Oxygenation A a gradient < 300 Hg Shunt fraction < 15% PO 2 (on 40% FIO 2 ) > 70mmHg PCO 2 < 45mmHg
43 Other Strategies in Mechanical Ventilation Several additional mechanical ventilation strategies that utilize specialized equipment have been tested in ARDS patients, most with mixed or disappointing results in adults. These include high-frequency ventilation (HFV), i.e., ventilating at extremely high respiratory rates (5 20 cycles per second) and low tidal volumes (1 2 ml/kg). Also, lung-replacement therapy with extracorporeal membrane oxygenation (ECMO), which provides a clear survival benefit in neonatal respiratory distress syndrome, has yet to have proven survival benefit in adults with ARDS.
44 Ongoing research on partial liquid ventilation (PLV) with perfluorocarbon, an inert, high-density liquid that easily solubilizes oxygen and carbon dioxide, has revealed promising preliminary data on pulmonary function in patients with ARDS, but also without survival benefit. Data in support of the efficacy of "adjunctive" ventilator therapies (e.g., high PEEP, inverse ratio ventilation, prone positioning, HFV, ECMO, and PLV) remain incomplete, so these modalities are not routinely used.
45 討論 Vancomycin 的使用與注意事項?
46 Vancomycin dose Clinical Syndrome Possible Etiologies Treatment Comments Sepsis without a Clear Focus Septic shock Pseudomonas spp., gram-negative enteric bacilli, Staphylococcus spp., Streptococcus spp. Vancomycin ( q12h) plus Adjust treatment when culture data become available. Drotrecogin alfa (activated) a or lowdose hydrocortisone and fludrocortisone may improve outcome in patients with septic shock.
47 Red man syndrome Vancomycin must be administered in a dilute solution slowly, over at least 60 minutes (maximum rate of 10 mg/minute for doses >500 mg).  This is due to the high incidence of pain and thrombophlebitis and to avoid an infusion reaction known as the red man syndrome or red neck syndrome. This syndrome, usually appearing within 4 10 minutes after the commencement or soon after the completion of an infusion, is characterized by flushing and/or an erythematous rash that affects the face, neck and upper torso. These findings are due to non-specific mast cell degranulation and are not an IgE mediated allergic reaction. Less frequently, hypotension and angioedema may also occur. Symptoms may be treated or prevented with antihistamines, including diphenhydramine, and are less likely to occur with slow infusion. :120-1
48 Vancomycin-resistant enterococcus Vancomycin-resistant enterococcus (VRE) is the name given to a group of bacterial species of the genus Enterococcus that is resistant to the antibiotic vancomycin. 
49 Enterococci are enteric and can be found in the digestive and urinary tracts of some humans. VRE was discovered in 1985  and is particularly dangerous to immunocompromised individuals. VRE species have an enhanced ability to pass resistant genes to other bacteria. While infection of healthy individuals is uncommon, it is possible that they could be colonized with newly-resistant bacteria.
50 There are six different types of vancomycin resistance shown by enterococcus : Van-A, Van-B, Van-C, Van-D, Van-E and Van-F. Of these, only Van-A, Van-B and Van-C have been seen in general clinical practice so far. The significance is that Van-A VRE is resistant to both vancomycin and teicoplanin, Van-B VRE is resistant to vancomycin but sensitive to teicoplanin, and Van-C is only partly resistant to vancomycin, and sensitive to teicoplanin. In the US, linezolid is commonly used to treat VRE, as teicoplanin is not available.
51 VRE can be carried by healthy people who have come into contact with the bacteria. The most likely place where such contact can occur is in a hospital (nosocomial infections), although it is thought that a significant percentage of intensively-farmed chicken also carries VRE. In 2005, Lactobacillus rhamnosus GG (LGG), a strain of L. rhamnosus, was used successfully for the first time to treat gastrointestinal carriage of VRE in renal patients.
52 參考文獻 余忠仁修訂日期 :96/03/30 急性呼吸窘迫症候群 取自 ttp://ntuh.sicu.org.tw/upload/nursing_protocol/s doc Mark S. Chesnutt, MD, Alex H. Gifford, MD, Thomas J. Prendergast, MD CURRENT Medical Dx & Tx Chapter 9. Pulmonary Disorders Vancomycin 取自 Vancomycin-resistant enterococcus 取自
53 Jason D. Christie, Paul N. Lanken Principles of Critical Care > Part IV. Pulmonary Disorders Chapter 38. Acute Lung Injury and the Acute Respiratory Distress Syndrome Authors John Hansen-Flaschen, MD Mark D Siegel, MD Section Editor Polly E Parsons, MD Deputy Editor Kevin C Wilson, MD Acute respiratory distress syndrome: Definition; epidemiology; diagnosis; and etiology
54 Clinician's Pocket Reference Chapter 6. Laboratory Diagnosis: Urine Studies Harrison's Online > Chapter 115. Approach to the Acutely Ill Infected Febrile Patient > The Acutely Ill Patient: Treatment Clinician's Pocket Reference > Chapter 20. Critical Care > Ventilator Management > Ventilator Weaning > Bruce D. Levy, Steven D. Shapiro Harrison's Online > Part Eleven: Critical Care Medicine > Section 1: Respiratory Critical Care > Chapter 262. Acute Respiratory Distress Syndrome
55 Rebecca C. Bowers, MD, & Timothy K. Anderson, MD CURRENT Diagnosis & Treatment: Emergency Medicine > Chapter 44. Disorders Due to Physical & Environmental Agents