美國胸腔醫學會(ATS)在2024/1/1發布了新一版的ARDS治療指引
內容跟之前的指引其實大同小異，主要還是依據ABG的PaO2/FiO2作為嚴重度之分級依據，在依據嚴重程度考慮給予何種處置。下圖是很好的整理。P/F ratio <300，就強烈建議要採取保護肺部之呼吸器設定，P/F <150就強烈建議要趴睡。
在加護病房的每日巡房時，光是見招拆招，把不穩定/不正常的狀況弄到穩定/正常還不夠，還需要完整的檢視病人目前的狀況，調整目前的處置，擬定處置的計畫，才能讓病人早日轉出。我們部落格之前介紹過FAST HUGS BID以及達叔的八炫法則(VPN IS RCC)，都是很好用的工具。
這裡再介紹另一個，這是在2022年，美國重症醫學會提出的，在每日巡房(daily care rounding)時可以使用之查檢表，列出了12個項目，並且簡要說明其原由。(見下圖)
- Spontaneous awakening trial (SAT) has been performed.
- Spontaneous breathing trial (SBT) has been performed.
- Sedation goals have been set.
- Patient has been mobilized.
- Assessment has been completed for central line needs.
- Assessment has been completed for bladder catheter needs.
- Nutrition needs have been discussed.
- Diagnostic tests have been reviewed.
- Assessment has been completed for transfusion needs.
- Assessment has been completed for antibiotic needs.
- Patient goals of care have been reviewed with patient and/or family or surrogate decision-maker.
- Code status has been documented.
翻成中文的話是:
- Spontaneous awakening trial (SAT) has been performed. 是否有進行中斷鎮靜藥物的使用的測試
- Spontaneous breathing trial (SBT) has been performed. 是否有進行呼吸器脫離的評估
- Sedation goals have been set. 訂定鎮靜藥物使用之目標
- Patient has been mobilized. 儘早讓病人活動
- Assessment has been completed for central line needs. 評估病人是否仍需中心靜脈導管
- Assessment has been completed for bladder catheter needs. 評估病人是否仍需導尿管
- Nutrition needs have been discussed. 是否已評估病人之營養需求
- Diagnostic tests have been reviewed. 檢驗/檢查結果是否已檢視過
- Assessment has been completed for transfusion needs. 評估病人是否需要輸血
- Assessment has been completed for antibiotic needs. 評估病人是否需要抗生素
- Patient goals of care have been reviewed with patient and/or family or surrogate decision-maker. 是否跟病人或者家屬檢視過目前治療的目標
- Code status has been documented. 要不要急救的決定是否有清楚記載在病歷中
美國重症醫學會在說明中提到，這12項都是有實證醫學的佐證，可以提供安全、高品質之重症醫療，並減少浪費。不過執行時也要把病人的臨床狀況、緊急程度一起考慮進去。我覺得，這個查檢表確實非常完整，比較困難的是沒有一個口訣來讓人背誦這12個項目。
