指南针：ACOG产科ICU(上)-基本概念

背景

答

除了在非常大的生育中心能够掌握核心的重症操作技能外，其他医护人员很少有机会进一步熟练或保持这些技能，虽然也有替代培训方法可行。有些技能可以在相应场合下监督培训（例如，气道处理技术可以在手术室内由麻醉医生监督操作），其他技能可以通过电子资源或网络进行训练（心电图的判读），还有一些则通过医学模拟培训来进行。

答

在开放的ICU病房，任何医生都可以开医嘱或进行诊疗操作，病人的管理或者会诊不必由专科重症医疗医生来完成。而在封闭的ICU病房，只有重症医疗主治医生才能开医嘱及管理病人。在混合或过渡模式的ICU病房，允许所有的医生开医嘱，但要求有一个现任重症医疗医生会诊、查房。

答

重症医疗也可按医生配备将ICU分为高强度（Closed ICU／High-intensity ICU，必须配备重症医疗医生咨询）或低强度（Open ICU／Low-intensity ICU，重症医疗医生可有可无）两种【13】。

与低强度的ICU医生人员配备相比，高强度的ICU医生人员配备使ICU病房和医院死亡率降低，使病人在ICU和医院的住院时间减少。虽然针对产科重症监护病人的数据有限，但是，这些研究结果也可能同样适用于这一人群【14, 15】。

答

重症治疗需要多学科合作来达到最好结局【16】。通常ICU团队包括医生、护士、药剂师和呼吸治疗师。在产科的ICU团队，还需要包括产科医生、母胎医学专科医生、产科护士、新生儿医生。

答

产科医生将病人转送到ICU时，需要熟悉医院ICU的类型，比如普通内科／外科ICU，或者心胸或神经内科或神经外科专科ICU，也需要知道产科医生在ICU的作用【17】。

答

美国重症医学会( American College of Critical Care Medicine)描述了三级成人重症医疗，第一级给予最高级别治疗。替代传统ICU的是高医疗依赖性病房，如次重症监护病房、心脏病人遥控监护病房以及长期使用呼吸机患者的专用病房 【10, 11, 18】。

答

因为ICU病床有限，所以应该保留给那些入住ICU能够获益的病人。大多数产科患者入住ICU 是根据分诊时的客观参数，符合特定标准的便可入住ICU，而不是取决于疾病的诊断。这些住院指标是由专家共识来制定，并经过美国联合委员会（正式全称为医疗保健组织审查联合委员会)审核，是公认的必行标准。

这些指标包括病人生命体征、实验室、影像和体检的特异性异常结果。这些标准都列于下面的图表“非孕期病人ICU入住客观参数”中。怀孕病人化验值的主要正常变量列于另一表格“孕期变化的主要生理和化验数值”中。

答

孕产妇ICU入住标准需要参考女性非孕期入住指标，结合孕产妇的一些主要生理和化验标准值而确定。见下表：

1

Panchal S, Arria AM, Labhsetwar SA. Maternal mortality during hospital admission for delivery: a retrospective analysis using a state-maintained database. AnesthAnalg 2001;93:134–41. (Level II-2) 

2

Keizer JL, Zwart JJ, Meerman RH, Harinck BI, Feuth HD, van Roosmalen J. Obstetric intensive care admissions: a 12-year review in a tertiary care centre. Eur J ObstetGynecolReprodBiol 2006;128:152–6. (Level III)

3

Umo-Etuk J, Lumley J, Holdcroft A. Critically ill parturient women and admission to intensive care: a 5-year review. Int J ObstetAnesth 1996;5:79–84. (Level III)

4

Hazelgrove JF, Price C, Pappachan VJ, Smith GB.Multicenter study of obstetric admissions to 14 intensive care units in southern England. Crit Care Med 2001;29:770–5. (Level II-3) 

5

Lapinsky SE, Kruczynski K, Seaward GR, FarineD,Grossman RF. Critical care management of the obstetric patient. Can J Anaesth 1997;44:325–9. (Level III)

6

Selo-Ojeme DO, Omosaiye M, Battacharjee P, Kadir RA Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study. Arch GynecolObstet 2005;272:207–10. (Level II-2) 

7

Munnur U, Karnad DR, Bandi VD, Lapsia V, Suresh MS, Ramshesh P, et al. Critically ill obstetric patients in an American and an Indian public hospital: comparison of case-mix, organ dysfunction, intensive care requirements, and outcomes. Intensive Care Med 2005;31:1087–94.(Level II-3)

8

Brace V, Penney G, Hall M. Quantifying severe maternal morbidity: a Scottish population study. BJOG 2004;111:481–4. (Level II-2)

9

Heinonen S, Tyrvainen E, Saarikoski S, Ruokonen E. Need for maternal critical care in obstetrics: a population-based analysis. Int J ObstetAnesth 2002;11:260–4. (Level III)

10

Ryan M, Hamilton V, Bowen M, McKenna P. The role of a high-dependency unit in a regional obstetric hospital. Anaesthesia 2000;55:1155–8. (Level III)

11

Zeeman GG,Wendel GD Jr, Cunningham FG. A blueprint for obstetric critical care. Am J ObstetGynecol 2003;188:532–6. (Level III)

12

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. Births: final data for 2005. Natl Vital Stat Rep 2007;56:1–103. (Level II-3)

13

Pronovost PJ, Angus DC, Dorman T, Robinson KA, DremsizovTT,Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151–62. (Level III)

14

Jenkins TM, Troiano NH, Graves CR, Baird SM, Boehm FH. Mechanical ventilation in an obstetric population: characteristics and delivery rates. Am J ObstetGynecol 2003;188:549–52. (Level III) 

15

Plante LA. Mechanical ventilation in an obstetric population. Am J ObstetGynecol 2003;189:1516. (Level III)

16

Brilli RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. American College of Critical Care Medicine Task Force on Models of Critical Care Delivery. The American College of Critical Care Medicine Guidelines for the Definition of an Intensivist and the Practice of Critical Care Medicine. Crit Care Med 2001;29:2007–19. (Level III) 

17

Chang SY, Multz AS, Hall JB. Critical care organization.Crit Care Clin 2005;21:43–53, viii. (Level III)

18

Nasraway SA, Cohen IL, Dennis RC, Howenstein MA, Nikas DK, Warren J, et al. Guidelines on admission and discharge for adult intermediate care units. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1998;26:607–10. (Level III)