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背景

答

除了在非常大的生育中心能夠掌握核心的重癥操作技能外，其他醫(yī)護(hù)人員很少有機(jī)會(huì)進(jìn)一步熟練或保持這些技能，雖然也有替代培訓(xùn)方法可行。有些技能可以在相應(yīng)場(chǎng)合下監(jiān)督培訓(xùn)（例如，氣道處理技術(shù)可以在手術(shù)室內(nèi)由麻醉醫(yī)生監(jiān)督操作），其他技能可以通過(guò)電子資源或網(wǎng)絡(luò)進(jìn)行訓(xùn)練（心電圖的判讀），還有一些則通過(guò)醫(yī)學(xué)模擬培訓(xùn)來(lái)進(jìn)行。

答

在開(kāi)放的ICU病房，任何醫(yī)生都可以開(kāi)醫(yī)囑或進(jìn)行診療操作，病人的管理或者會(huì)診不必由?？浦匕Y醫(yī)療醫(yī)生來(lái)完成。而在封閉的ICU病房，只有重癥醫(yī)療主治醫(yī)生才能開(kāi)醫(yī)囑及管理病人。在混合或過(guò)渡模式的ICU病房，允許所有的醫(yī)生開(kāi)醫(yī)囑，但要求有一個(gè)現(xiàn)任重癥醫(yī)療醫(yī)生會(huì)診、查房。

答

重癥醫(yī)療也可按醫(yī)生配備將ICU分為高強(qiáng)度（Closed ICU／High-intensity ICU，必須配備重癥醫(yī)療醫(yī)生咨詢）或低強(qiáng)度（Open ICU／Low-intensity ICU，重癥醫(yī)療醫(yī)生可有可無(wú)）兩種【13】。

與低強(qiáng)度的ICU醫(yī)生人員配備相比，高強(qiáng)度的ICU醫(yī)生人員配備使ICU病房和醫(yī)院死亡率降低，使病人在ICU和醫(yī)院的住院時(shí)間減少。雖然針對(duì)產(chǎn)科重癥監(jiān)護(hù)病人的數(shù)據(jù)有限，但是，這些研究結(jié)果也可能同樣適用于這一人群【14, 15】。

答

重癥治療需要多學(xué)科合作來(lái)達(dá)到最好結(jié)局【16】。通常ICU團(tuán)隊(duì)包括醫(yī)生、護(hù)士、藥劑師和呼吸治療師。在產(chǎn)科的ICU團(tuán)隊(duì)，還需要包括產(chǎn)科醫(yī)生、母胎醫(yī)學(xué)專科醫(yī)生、產(chǎn)科護(hù)士、新生兒醫(yī)生。

答

產(chǎn)科醫(yī)生將病人轉(zhuǎn)送到ICU時(shí)，需要熟悉醫(yī)院ICU的類型，比如普通內(nèi)科／外科ICU，或者心胸或神經(jīng)內(nèi)科或神經(jīng)外科?？艻CU，也需要知道產(chǎn)科醫(yī)生在ICU的作用【17】。

答

美國(guó)重癥醫(yī)學(xué)會(huì)( American College of Critical Care Medicine)描述了三級(jí)成人重癥醫(yī)療，第一級(jí)給予最高級(jí)別治療。替代傳統(tǒng)ICU的是高醫(yī)療依賴性病房，如次重癥監(jiān)護(hù)病房、心臟病人遙控監(jiān)護(hù)病房以及長(zhǎng)期使用呼吸機(jī)患者的專用病房 【10, 11, 18】。

答

因?yàn)镮CU病床有限，所以應(yīng)該保留給那些入住ICU能夠獲益的病人。大多數(shù)產(chǎn)科患者入住ICU 是根據(jù)分診時(shí)的客觀參數(shù)，符合特定標(biāo)準(zhǔn)的便可入住ICU，而不是取決于疾病的診斷。這些住院指標(biāo)是由專家共識(shí)來(lái)制定，并經(jīng)過(guò)美國(guó)聯(lián)合委員會(huì)（正式全稱為醫(yī)療保健組織審查聯(lián)合委員會(huì))審核，是公認(rèn)的必行標(biāo)準(zhǔn)。

這些指標(biāo)包括病人生命體征、實(shí)驗(yàn)室、影像和體檢的特異性異常結(jié)果。這些標(biāo)準(zhǔn)都列于下面的圖表“非孕期病人ICU入住客觀參數(shù)”中。懷孕病人化驗(yàn)值的主要正常變量列于另一表格“孕期變化的主要生理和化驗(yàn)數(shù)值”中。

答

孕產(chǎn)婦ICU入住標(biāo)準(zhǔn)需要參考女性非孕期入住指標(biāo)，結(jié)合孕產(chǎn)婦的一些主要生理和化驗(yàn)標(biāo)準(zhǔn)值而確定。見(jiàn)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)