|A Guide to Intensive Care Unit||ICU指南|
|This introductory guide to the critical care environment describes the ICU and the caregivers who staff it; the patients and how they are admitted, monitored, and treated; and some of the common life-support equipment. It includes a strategy for presenting your patient to your team and prepares you for the ethical issues that might confront you in the ICU. The guide also describes some of the career paths that culminate in leadership positions in critical care medicine.||危重病护理环境指南介绍了重症监护室及室内护理人员，病人与病人入院、监护和治疗方式，及一些常用的生命支持设备等内容。指南还包括如何向ICU小组介绍病人和如何作好应对ICU可能遇到的职业道德问题的心理准备，并对危重病人护理医学中提升领导职位的职业发展途径进行了描述。|
|The hospital you are in today is different from the hospital your attending physician claimed as his or her environment. Lengths of stay are down, patient acuity is rising, and critical care units are proliferating. Although the health care system is changing, hospitals will always need an area to care for their sickest patients--a critical care center. The need for these units is growing as patients at all extremes of life—the most premature infants, adults with cardiovascular disease, the severely injured—are growing, both in absolute numbers and in proportion to the general population. Citizens of developed nations around the world are living--and staying active--into the ninth and tenth decades of life. When they become ill, they often require aggressive intervention to stabilize their delicate physiologic balance so they can heal.||你今天所在的医院与你主治医生所说的那种环境已大不相同。病人住院时间缩短、病人要求提高、危重护理病房不断增多。虽然健康护理系统正在不断发生变化，但医院将始终需要有一个护理最病重的病人的区域 – 一个危重病护理中心。由于处于生命极端状态病人的增多，如早产儿、成人心血管疾病患者和重伤病人等，无论是按绝对数字还是按总人口比率计算，对这些病房的需求也在增长。发达国家人口正进入到人生的90和100岁。一旦生病，他们就常常需要采取入侵性措施使他们那脆弱的生理平衡得以稳定，使疾病得以治愈。|
|The interventions required to manage life-threatening illnesses generally include both core supports--intensive nursing care and cardiopulmonary monitoring--as well as supports focused on the patient's particular illness. While nearly all ICUs are capable of providing a spectrum of care, many have developed a focused area of excellence: care of critically ill and injured children in the pediatric ICU （PICU）; adult cardiac diseases in the coronary care unit （CCU）; perioperative care, trauma care, and care of multiple organ dysfunction in the surgical ICU （SICU）; care of neurological and neurosurgical patients in the neuroscience ICU; and so on. Many teaching hospitals also have graded critical care centers such as intermediate care units and telemetry units where patients who require more than ward care can benefit from specific monitoring and intervention.||威胁生命的疾病的处理措施包括核心支持—重症护理和心肺监护—及以病人特定疾病为重点的支持措施。尽管几乎所有的ICU都能够提供整套的护理，但很多ICU都有自己 重点关注的强项：儿科ICU（PICU）危重病及受伤儿童的护理；冠心病监护室的成人心脏病护理；外科ICU（SICU）的围手术期护理、外伤护理和多种器官功能障碍的护理等；神经科ICU的神经和神经外科病人护理；等等。很多教学医院也有不同等级的危重病护理中心，如过渡监护治疗病房和远程治疗病房等。需要病房外护理的病人可以从远程治疗特殊的监护和介入中受益。|
|The ICU Team||ICU小组|
|The more things get busy, the more you will appreciate that each team member in the ICU has a specific role.
The team leader is a physician. Students typically are assigned to train in intensive care units where the team leader is an intensivist physician who has received advanced training in the art and science of critical care medicine. In North America, added qualifications in critical care medicine are obtained after board certification in a primary specialty such as pediatrics, internal medicine, surgery, or anesthesiology. Many countries have established critical care medicine as an independent specialty.
Irrespective of the training pathway, your team leader embraces the philosophy of critical care medicine, namely that a physician-led, multidisciplinary team can provide optimal care to the critically ill patient.
|The term "multidisciplinary" refers not only to other physicians who may participate as consultants or coattendings in the ICU, but also to the other health care professionals who work side by side, around the clock in the ICU. The most numerous of these are the critical care nurses, many of whom also have advanced training and certification in critical care and are recognized as CCRNs. Some have achieved even greater recognition and responsibility. They are the acute care nurse practitioners and clinical nurse specialists who complement the physician staff in establishing plans, writing orders, and directing management. Physician assistants also provide care in the ICU.||“多学科”一词并不仅仅是指以会诊医师或合作主治医师身份加入ICU的其他医生，它同时也指在ICU内并肩工作24小时的其他卫生保健专业人员，人数最多的是重症监护护士。这些护士多数在重症护理方面受过高级培训，并获得相应的证书，是公认的“重症监护注册护士”。有些护士所获得的认可不尽于此，他们的职责也更重大。他们是急症护理医生和临床护理专家，也可以制定计划、写医嘱和指导治疗，是医生的补充。医生助理也提供ICU护理。|
|Respiratory therapists are experts in many forms of pulmonary diagnosis and intervention. In addition to operating the mechanical ventilator, therapists often obtain and analyze arterial blood for blood gases and test patients' breathing strength by obtaining forced vital capacity, negative inspiratory pressure, and other parameters. In some hospitals, respiratory therapists perform endotracheal intubation in addition to supporting ventilation with "bag-and-mask" devices. The ICU team typically includes a pharmacist who helps you review medication profiles and determine if your patient is predisposed to side effects or drug interactions.
The pharmacist will help you calculate clearance rates from measured drug levels and plan dosing schedules for many of the medications used in the ICU.
|The team also typically includes someone who is an expert in nutrition support such as a dietitian who has advanced training in enteral （gut） and parenteral （intravenous） nutritional support strategies and pitfalls. Other important members of the ICU team are the medical social worker, who provides ongoing psychosocial assessments and support; representatives of the chaplaincy staff, who are available on call to offer spiritual support to patients, families, and ICU staff members; and a unit secretary, who manages administrative tasks such as reception, telecommunications, and chart maintenance. In addition, the ICU staff generally includes many other trainees who are there to learn with you such as fellows, residents, nursing students, and dietetics students.||典型的ICU小组还会包括一位营养专家，如在肠道和非肠道（静脉内）营养支持方法及缺陷方面受过高级培训的营养师等。ICU小组其他重要成员有医务社会工作者，他为病人提供不断的心理社会评估和支持；牧师代表，可以随时招他为病人、家属和ICU成员提供精神上的帮助；以及一位病房秘书，处理一些行政性工作，如接待、联系及图表保管。此外，ICU成员通常包括其他很多在此学习的实习人员，如同行、居民、护生及营养学学生等。|
|Patients are admitted to the intensive care unit either because they require high-intensity monitoring and life support by specially trained health care providers or because they require high-intensity nursing care that cannot be provided on a general medical or surgical ward. As noted previously, surgical patients are admitted to the surgical intensive care unit and medical patients to the medical or coronary intensive care units.
Many surgical patients are admitted with medical problems such as pneumonia or sepsis.
|Patients come to the ICU from several areas:l Operating room （OR） or post-anesthesia care unit （PACU） -- Surgical patients who require invasive monitoring, mechanical ventilation, or resuscitation after surgery may be transported directly to the ICU from the OR or the PACU after a period of observation. Such direct transport is considered a transfer from one critical care area to another. Therefore, their ICU management is a continuation of care that they received from the anesthesiology team in the operating room or PACU.||ICU病人来自下例科室：手术室（OR）或麻醉后监护病房（RACU）—术后需要侵入性监测、机械通气或复苏的病人在经过一段观察后可以直接从手术室或麻醉后监护病房送到ICU，这种直接运送方式也就是由一个危重病护理区转到另一个危重病护理区，因此，其ICU处理只是OR或PACU麻醉小组护理的继续。|
|l Emergent care center （ECC） or emergency room -- Medical, surgical, trauma, or burn patients can be admitted to the ICU from the ECC or emergency room. These patients typically undergo a series of diagnostic tests prior to their transfer, and the etiology of their illness may or may not be known by the time they come to the ICU. They are admitted to manage their acute illness.||急诊护理中心（ECC）或急诊室—内科、外科、创伤或灼伤病人可以由ECC或急诊室收住ICU。这些病人在转来之前通常都做过一系列的诊断检查，到ICU时，其病因可能已经知道，也可能还不知道。他们住进ICU是因为有急病要处理。|
|l Medical or surgical ward -- Patients may be admitted to the ICU from a general medical or surgical ward. These are patients who were initially stable but who developed respiratory distress, low blood pressure, shock, cardiopulmonary arrest, or other physiologic instabilities on the ward. They require aggressive resuscitation, treatment, and invasive monitoring and are transferred to the ICU for closer observation, more frequent measurement of vital signs, invasive monitoring, or mechanical ventilation.||内科或外科病房—病人可以从普通内科或外科病房收住ICU。这些病人开始时的病情都很稳定，但在病房时发生了呼吸窘迫、低血压、休克、心肺停止或其他的生理不稳定情况，需要超常规的复苏、治疗和侵入性监护，转到ICU进行更密切的观察、增加生命体征测量、采取侵入性监护或进行机械通气。
|l Other facilities -- Patients may also be transferred from another facility that does not have the resources to provide the level or type of care they require.||其他机构—病人也可以从另一个机构转到这里，因为该机构没法提供所需的护理。|
|Common Reasons for Admission to the ICU:l Respiratory compromise--Patients with respiratory distress, manifested either as an inability to oxygenate or an inability to ventilate, are transferred to the ICU for supplemental oxygen and mechanical ventilation. Etiologies of respiratory distress are numerous and include pneumonia, acute respiratory distress syndrome, pulmonary embolism, and exacerbations of chronic obstructive lung disease.||ICU入院常见原因呼吸系统损伤—呼吸窘迫病人可表现为无法氧合或通气不能，转到ICU就是为了补充氧气、机械通气。呼吸窘迫病因很多，包括肺炎、急性呼吸窘迫综合症、肺栓塞和慢性阻塞性肺部疾病等。|
|l Hemodynamic compromise--Patients with hemodynamic instability are admitted for management of arrhythmias, hypotension, or hypertension. Patients with hypotension are typically resuscitated with fluid or medications （e.g., vasopressors or inotropes） to increase vascular tone. If a predetermined minimal mean blood pressure cannot be maintained, or if the patient has signs of inadequate oxygen delivery to the tissues （i.e., altered mental status, decreased urine output, cool skin, and lactic acidosis）, a pulmonary artery catheter （PAC） may be inserted to monitor cardiac output. Measurements obtained from the PAC aid the clinician in deciding, for example, whether to treat the patient with more fluids to improve preload—the filling pressure of the left ventricle--or to initiate inotropes to improve contractility. In these instances, an arterial catheter is often inserted to monitor systemic blood pressure continuously. Patients with severe hypertension are generally managed with titratable intravenous medications.||血液动力学功能损伤—血液动力学功能不稳病人收住ICU以处理心律失常、低血压或高血压。低血压病人主要是通过液体或药物进行复苏（如血管升压类药物或收缩性药物），增加血管张力。如果无法保持预定的最低平均血压，如果病人出现组织供氧不足症状（如精神状态改变、排尿量减少、皮肤发冷和乳酸性酸中毒），就可能需要施行肺动脉导管（PAC）以监测心排血量。PAC测量结果可以帮助临床医生作出决定，如是否需要增加输液改善前负荷—即左室充盈压—或使用收缩性药物以提高收缩性。在上术情况中，常常要通过插入动脉导管来连续监测体循环血压。有严重高血压的病人通常采用可滴定静脉给药法进行处理。|
|l Myocardial ischemia or infarction -- Patients with inadequate oxygen delivery to their myocardium are admitted for the management of angina and myocardial infarction. They may require titration of nitroglycerin, beta blockers, and morphine. Each medication can result in further complications such as hypotension, decreased heart rate, bronchospasm, or decreased respiratory drive, respectively. These patients are often candidates for thrombolytic agents and cardiac catheterization. The goal of admission, to reverse ischemia and minimize myocardial injury, requires close monitoring and rapid intervention.||心肌缺血或梗死—心肌供氧不足病人入院处理心绞痛或心肌梗死。这些病人可能需要甘油滴定、β-阻止剂或吗啡。每种药物都可能导致进一步的并发症，如低血压、心率减慢、支气管痉挛或呼吸动力减弱等。这些病人常常是血栓溶解剂和心导管插管的使用对象。收治目的是逆转心肌缺血减少心肌损伤，这需要密切的监护，并迅速采取措施。|
|l Neurological compromise -- Patients with alterations in mental status are admitted to the ICU for frequent neurologic checks. If their condition deteriorates, they may need to have an endotracheal tube placed to protect their airway.||神经损伤—精神状态变化病人住进ICU进行频繁的神经检查。如果病情恶化，就可能需要放置气管内插管以保护气道。
|l Gastrointestinal -- Patients with life-threatening gastrointestinal bleeding are admitted to treat hypotension with IV fluids, blood and blood products. Diagnostic tests such as endoscopy will likely be performed to locate and treat the source of bleeding in unstable patients in the ICU.||胃肠—出现危及性命的胃肠出血病人住进ICU，通过IV输液、全血或血液制品治疗低血压。有可能在ICU通过内窥镜之类的诊断检查来定位和治疗不稳定病人的出血。|
|l Renal and metabolic -- Patients may be admitted for treatment of the complications of renal failure, including acidosis, volume overload, and electrolyte abnormalities. More often, patients develop renal failure in the ICU secondary to hypotension and sepsis. Treatment with careful attention to acid-base balance, electrolytes, and volume status is provided in the ICU. Other metabolic crises, such as hypercalcemia, unrelated to renal failure, may result in a patient's admission to the ICU.||肾和代谢问题—病人入院也可能是为了治疗肾衰引发的各种并发症，包括酸中毒、容量过度负荷、电解质异常等。更常见的情况是，病人在ICU时因低血压和脓毒症而继发肾衰。ICU治疗时应密切注意酸碱平衡、电解质和容积状况。其他代谢性危象如高钙血症等，尽管与肾衰无关，但也可能导致病人收住 ICU|
|l Postoperative -- There are many reasons for admitting patients to the ICU. They may still be on a ventilator, or they may have other invasive monitoring. They may have a history of coronary artery disease and therefore be at risk for a perioperative MI. They may have had extensive bleeding and require frequent observation. They may have had an extensive surgical procedure, including open-heart surgery, organ transplantation, vascular surgery, or general abdominal surgery. Each surgical intervention has specific perioperative issues that require observation and treatment in the ICU. Patients with trauma, orthopedic injuries, and extensive thermal injuries are also admitted to ICUs.||术后—很多原因可以使病人住进ICU。他们可能仍在使用呼吸机，也可能是在接受其他入侵性监测。他们可能有冠状动脉疾病史，因此有围手术期心肌梗死危险。病人也可能有大出血，需要密切观察。病人可能接受过大型外科手术，如开胸手术、器管移植、血管手术、或腹部手术。每次手术都有特定的围手术期问题需要在ICU进行观察和治疗。创伤、骨伤和大面积热损伤病人也会收住ICU。|
|Transporting the Patient to the ICUOnce it is clear that a patient requires management in the intensive care unit, the ICU personnel should be notified. An attending, fellow, or resident should call the ICU charge nurse and indicate the patient's name, illness, reason for transfer to the ICU, and immediate plans for treatment. Alerting the staff in the ICU prior to patient transport allows them to prepare for the patient's arrival. Advance communication with the ICU physician ensures that the appropriate support is available when the patient arrives. It is essential that the appropriate personnel, equipment, and monitors are available for all transfers to the ICU.||运送病人到ICU一旦明确病人需要由ICU处理，就应通知ICU医护人员。由主治医师、普通医生或住院医师呼叫ICU主管护师，弄清病人的姓名、疾病、转室原因，立即制订治疗计划。在病人送到前提醒ICU工作人员可以使他们为病人到来作好准备。事先与ICU医师沟通可确保病人到达时得到合适的支持。使转到ICU的所有病人都有合适的人手、器械和监护，这一点极为重要。|
|The Equipment||设 备|
|The vast array of technology present in an average patient's room can be overwhelming. Even the beds have become incredibly complex, costing tens of thousands of dollars and requiring detailed operating instructions. It is stressful enough just to be in the room of a patient who is critically ill, let alone to cope with the anxiety that the equipment might alarm or malfunction and require an intervention. In reality, the machines in the ICU have many fail-safe backup systems so that mechanical failure is rare. Furthermore, devices that require more supervision are usually accompanied by an individual with expertise, such as a cardiac technician for an intra-aortic balloon pump or a hemodialysis technician for a hemodialysis machine. Respiratory therapists are in close proximity to patients' rooms and intervene quickly if a mechanical ventilator alarms or malfunctions. The best way to resolve anxiety is to become familiar with all of the different devices.||普通病人病房里的技术多得使人晕头转向，连床铺也复杂得令人难以置信，不但要花数万美元，还要有详细的操作说明。在危重病人病房里就已够紧张的了，更不用说还要应付器械告警或故障需要处理这样令人焦虑的事。在现实中，ICU机器都有很多故障保险备份系统，因此，出现机械故障的可能性很小。而且，需要监督的装置通常都由专业人员看着，如由心脏科技师负责主动脉内气囊泵或血透技师负责血液透析机等。呼吸治疗师离病人房间很近，一旦机械呼吸机告警或故障，他可以很快进行处理。减轻焦虑的最佳方法是熟悉各种装置。|
|Bedside monitorsAll patients are connected to a bedside monitor whose screen displays several parameters. Channels I and II typically display two EKG leads providing continuous monitoring of the patient's heart rhythm. The patient's blood pressure is displayed either continuously from a catheter in the patient's arterial system or intermittently from an automatically inflating blood pressure cuff on channel III. The arterial line allows beat-to-beat measurement of blood pressure. An A-line is also inserted in patients who require numerous arterial blood gases in order to avoid repeated punctures.||床边监测仪所有病人都接有一个床边监测仪，它可以显示多种参数。其中通道I、II 主要显示两台EKG 导联仪，对病人心律进行连续监测。病人血压监测有连续和间断两种，前者通过病人动脉系统插管监测，后者通过通道III自动充气血压袖带监测。动脉插管可以测量每一搏动的血压情况，它可以用于需要大量动脉血气的病人，避免重复穿刺。|
|Patients may have a central venous catheter placed in the superior vena cava through the internal jugular or subclavian vein. A central venous catheter allows measurement of central venous pressure （CVP）. The CVP serves as an estimate of the patient's volume status. Central lines are also used to rapidly infuse fluid and to administer substances that cannot be infused into a peripheral vein such as hypertonic parenteral fluids and medications such as vasopressors.||病人也可以经由颈内静脉或锁骨下静脉放置上腔静脉中心静脉插管，测定中心静脉压（CVP），由此估计病人的容积状态。中心静脉插管也可用于快速输液和给药。一些周围静脉难以输入的药物或液体，如高渗非肠道液体、血管升压类药物等，都可以通过该插管输入。|
|When more data about a patient's hemodynamic physiology is required, a pulmonary artery catheter can be inserted and advanced through the right ventricle into the pulmonary artery. The PAC allows continuous display of pulmonary artery pressure, and variables such as cardiac output and pulmonary artery occlusion pressure, or wedge pressure, can be intermittently obtained. The "wedge pressure" is a measurement that reflects the patient's preload. The catheter is used to diagnose and manage hemodynamic instability.||如需要更多的病人血液动力生理学资料，就可以施行肺动脉插管（PAC），经由右室插入肺动脉。PAC可以连续显示肺动脉压及其他多种变量，如心排血量，也可以间断性显示肺动脉闭塞压或楔压。楔压反映了病人的前负荷情况，插管用于诊断和处理血液动力学的不稳定性。|
|The respiratory rate and the pulse oximeter reading, which indicates the patient's oxygen saturation, are also displayed on the monitor. The pulse oximeter is a noninvasive monitor attached to the patient's finger or earlobe to measure oxygen saturation continuously. Bedside monitors can be set to alarm for bradycardia or tachycardia, hypotension or hypertension, tachypnea, and/or oxygen desaturation.||监测仪还可显示呼吸频率和脉氧值。脉氧仪显示病人氧饱和度，这是一种非侵入式监测仪，套在病人指头或耳垂上连续监测氧饱和度。经过设置，床边监测仪可以警示下列情况：心动过缓或过速，低或高血压、呼吸急促和/或氧减饱和。|
|Mechanical ventilatorsPatients are mechanically ventilated for several reasons. If they are unable to protect their airway due to encephalopathy or massive stroke, they may be intubated （have an endotracheal tube placed through their mouth or nose into the trachea） to minimize the possibility of aspiration. If they have refractory hypoxemia （low oxygen saturation that does not respond to oxygen delivered by face mask）, the ventilator will allow higher concentrations of FIO2 to be delivered to the alveoli, and pressure can be delivered through the ventilator to open alveoli that have collapsed. If they have respiratory failure and are unable to take adequate tidal volume, the ventilator can deliver a preselected tidal volume and respiratory rate. Patients remain on the ventilator until the underlying disease is resolved. When this occurs, the doctors and respiratory therapists begin the process of decreasing, or "weaning," ventilator support until the endotracheal tube can be removed, a process known as extubation.||机械呼吸机病人因多种原因需要进行机械通气。如果病人因脑病或大面积中风无法保护气道，这时就需要插管（即经口或鼻施行气管内插管），最大限度地减少抽吸可能性。如果病人有难治性低氧血症（低氧饱和度，面罩供氧无效），呼吸机就可以将高浓度的吸入氧输送到肺泡，并通过呼吸机输送的压力张开塌陷的肺泡。如果病人呼吸衰竭潮气量不足，呼吸机就可以按预先设置的潮气量和呼吸率进行输送。在疾病消失前，病人都要使用呼吸机。如要除去呼吸机，医生和呼吸治疗师通常要先逐渐减少或“断奶”呼吸机支持，最后才拨掉气管内插管，即拨管。|
|Other common devicesIntravenous medication pumps allow the nursing staff to titrate medications; Foley catheters and urine collection bags aid in monitoring urine output; sequential compression devices squeeze the lower extremities and reduce the incidence of deep venous thrombosis; transvenous pacemakers stimulate the patient's heart to beat; dialysis machines remove fluid and correct electrolyte and acid-base disturbances; intraaortic balloon pumps assist the heart's contractility; and neurologic monitoring systems measure intracranial pressure.||其他常用装置静脉内给药泵由普通护士用于滴定药物；弗利氏导管和集尿袋帮助监测排尿量；连续压迫装置挤压下肢，减少深部静脉血栓形成；经静脉起搏器刺激病人心脏跳动；透析仪除去液体，纠正电解质和酸碱紊乱；主动脉内气囊泵支持心脏收缩；神经病学监测系统测定颅内压。|