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Jingdong book

儿科重症医学理论与诊疗技术

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Jingdong book

儿科重症医学理论与诊疗技术

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重症医学是一门诞生于20世纪中期的临床医学，是一门理论上不断创新、充满实践活力的临床专业学科。重症医学主要研究急性脏器功能受损、复杂性感染炎症反应以及全身内环境紊乱的病理生理机制。临床上，以可能发生或者已经发生危及生命的器官功能障碍患者为诊治目标。
重症监护病房或单元（intensive careunit，ICU）是重症医学的临床基地。目前ICU已成为实践基础医学理论和临床医学高新技术的重要前沿阵地。重症医学专业的医师、护士和相关技术人员是ICU的主力军，他们需要更为广泛的基础医学知识、具有较强的技术操作能力和敏捷的反应性。由于我国人口众多，经济基础相对落后，广大农村地区医疗卫生的财力、人力资源受限，重症医学理论知识和技术还不够普及，ICU（尤其是儿科ICU）体制和组织建设与发达国家有较大差距。近年来，我国SARS、手足口病等疾病流行，以及地震、洪水等公共灾难事件的相继出现，更突显重症医学理论和ICU体制的重要性。基于上述认识，由具有儿科急危重症救治丰富经验的临床医生和相关科室的专家共同撰写了本书。
全书分为重症医学概论、儿科重症的病理生理基础理论、儿科重症监护技术和儿科重症?疗技术4篇，可供国内儿科急危重症专业医生、护士和相关人员阅读，也可供综合儿科医生和相关实验科室人员学习参考。书中内容反映了当前儿科重症医学的新理论进展和国内现状，但基于本领域理论、技术的日新月异，仍难免不够全面。某些内容、图示是作者实践经验的总结和思考，可能并不全面，仅供读者参考。
Catalogue

第一篇 重症医学基本问题
第一章 重症医学理论与临床实践
第二章 儿科重症医学概论
第三章 感染、炎症、免疫概念的沿革

第二篇 脏器功能衰竭
第一章 呼吸循环功能衰竭
第一节 儿科呼吸衰竭和急性呼吸窘迫综合征（ARDS）
第二节 小儿感染性休克
第三节 小儿心力衰竭
第四节 小儿急性肺水肿和肺出血
第五节 小儿严重心律失常
第六节 小儿重症哮喘和重症婴幼儿喘息
第七节 呼吸系统和血液循环系统功能的相互影响

第二章 颅内高压和脑水肿
第一节 颅内高压与重症中枢神经系统感染
第二节 感染相关性脑病综合征
第三节 脑死亡和器官捐赠
第三章 小儿危重症肾功能衰竭

第四章 小儿先天性心脏病围手术期
第一节 先天性心脏病与心肺功能互相作用
第二节 先天性心脏病术后循环和呼吸支持
第三节 常见先天性心脏病术后处理要点
第五章 小儿胃肠功能衰竭

第三篇 儿科重症的监护和内镜技术
第一章 心脏和循环功能监测
第一节 超声心动图学基本知识
第二节 多普勒超声心动图在小儿心功能评估上的应用
第三节 肺动脉导管和心输出量测定
第四节 脉波指示剂连续心排血量和血管外肺水的监测

第二章 支气管镜术和呼吸系统监测
第一节 支气管镜术在儿科，临床的应用
第二节 肺部超声的临床应用
第三节 PICU患者血管外肺水的监测

第三章 颅内压监测
第一节 头颅影像学监测颅高压
第二节 经颅多普勒脑血流监测在儿科ICU的应用
第三节 头颅超声在新生儿缺氧缺血性脑病诊断中的应用
第四节 创伤性颅内压监测

第四章 胃黏膜pH监测和胃肠内镜的应用
第一节 小儿胃黏膜pH测定
第二节 电子胃镜在儿科的应用
第三节 电子结肠镜在儿科重症的临床应用

第四篇 儿科重症治疗技术
第一章 循环支持
第一节 体外生命支持系统
第二节 心室辅助装置

第二章 呼吸支持
第一节 常规机械通气
第二节 高频振荡通气
第三节 无创通气
第三章 连续性肾脏替代治疗

第四章 输液技术
第一节 骨髓腔内输注技术在儿科领域中的应用
第二节 小儿经外周中心静脉置管术
Book Abstract

（三）手术要点
法洛四联征根治手术的步骤包括体外循环下右室流出道疏通及重建、室间隔缺损修补、大体肺侧支的结扎及其他合并畸形的矫治等。对于年龄小、心室及肺血管发育差或合并其他严重畸形而无法一期根治的患儿可先行姑息手术，包括：改良B-T分流术（锁骨下动脉与肺动脉架桥）、上腔静脉与右肺动脉吻合（Glenn术）、中心分流术（改良Brock术）、右室流出道球囊扩张等，其中前两者较常用。
（四）术后处理策略
（1）法洛四联征术后的正性肌力药辅助时间及机械通气时间要适当延长，对易发生渗漏综合征的患儿（如肥胖、术前紫绀程度与肺血管发育不平行等），要严格掌握拔管指征。
（2）由于术前低蛋白血症、血胶渗压降低、毛细血管通透性高及体外循环引起炎症损伤等因素使法洛四联症患儿术后易发生肺水肿及灌注肺，造成呼吸窘迫综合征。临床表现为严重低氧血症、胸片肺透过度下降、肺内大量湿哕音、血痰及不同程度的低心排表现。处理时应严格控制入量、保持出入量负平衡，予白蛋白等胶体液维持正常胶体渗透压，同时延长机械通气时间，加大PEEP，减少吸痰刺激。
（3）畸形矫正不满意、心肌损伤过大、残存右室流出道梗阻、血容量不足、左心负荷过重、严重心律失常、心包填塞等的因素均可导致术后低心排综合征的发生。循环波动的患儿应积极行超声心动图检查以明确病因。治疗原则为尽量避免诱因、使用正性肌力药增强心肌收缩、控制入量及适当使用扩血管药以降低前后负荷。
（4）术后出血、渗血过多或引流不畅可导致心包填塞，术后早期应特别注意胸腔引流量的变化。心包填塞的临床表现为无法用药物改善的低心排、心率增快、CVP增高、脉压差减小，伴有少尿、末梢灌注差、高乳酸血症及代谢性酸中毒等。怀疑有心包填塞时要积极行胸片及床旁超声检查，必要时开胸止血、清除心包积血。

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