多脏器功能障碍综合征及监护PPT课件

多脏器功能障碍综合征及监护,MODSandintensivecare,.,2,Denominationvariation,1973secondarysystemfunctionfailure-TilneySummarydataof18casesARFpatientsafterabdominalaorticaneurysmoperation,and17patientsdiedfromorganfailureduringdialysis.19751977MOFS，multipleorganfailuresyndrome-Baue，1975（Yetthetreatmentdidnotsavethelives.)MOF，multipleorganfailure-Eiseman，19771980sMSOF，multiplesystemorganfailure-Fry38/533pointouttherelationshipbetweenMSOFandsevereinfection1990sMODS,multipleorgandysfunctionsyndrome,.,3,Case1Male26yPost-subtotalexcisionofcolonIleocolonicstomaleakageMultipleintestinalfistula,.,4,Abdominalabscess,.,5,Long-termapplicationofhighcaloriaparenteralnutrition(fatemulsion)livertumefactionliverdysfunctionSGPT36SGOT144TB167.9DB102.8,.,6,HR170RR55PaCO223.8WBC18700,Positivebloodcultivation,.,7,Jan16thsepticshockJan17thRenalfunctionBUN20.5Cr337needinhalationofoxygenwithmaskcontinuoushemofiltrationJan19thtracheotomyventilatorapplication,.,8,Case2male59yExtensiveanteriorwallMyocardialinfarction20daysafteronset(2002/3/6)continuousventriculartachycardiaventricularfibrillationelectricdefibrillation5timesantiarrhythmicdrugscountershockdrugsventilatorapplication,.,9,HR120RR28PaCO226.8WBC12600,.,10,Repeatedlyventriculartachycardiaandfibrillation，totally21timeselectricdefibrillationContinuoushyperpyrexia、highWBC、HR90、RR22Cultivationnegative,antibioticsnoeffectivenessOrgandysfunctioncameincrowdsshockRespiratorydysfunctionDeteriorationofliverfunctionCastinurineroutinetestBUN、Croliguria、anuriaCoagulationabnormalitydeath,.,11,AcuteonsetManifestatinofexcessiveinflammationDeteriotationofptsconditionsdespiteactivetherapyMultipleorgandysfunction,Differentpts,Sameprogress,Case1:infectious,Case2:noninfectious,.,12,clinicalbehaviorAccumulativeSubstanceirreversibleMultipleorganlowfunctioncausedbyinteractionbetweenorgans,ChronicdiseaseMultipleorganlowfunction,.,13,MODSfollowedbyprimaryemergencydiseasein24hours,ClinicalmanifestationburstoutSimultaneousdiequicklyprimaryMODSIschemiaischemiaandreperfusionphysicalandchemicalinjuryfactor,.,14,Sequentialorgandysfunctionafteremergencydisease,MODS,ClinicalbehaviorDelayedSequentialReversibleMODSExcessiveinflammatorymediators,.,15,1.Directinjuryofischemia,OxygenactivateTandBcell;chemotaxisIncreasetheexpressionofadherentmoleculeActivatecomplementandcoagulationsystemIncreasepermeabilityofvessels,decreaseBPCausefeverandcatabolismofmuscle,.,21,ImportantmoleculeinMODS,Anti-inflammatorycytokines:IL-4、10etcMaintainandenhancethefunctionofactivatedNKcells,monocytes,BandTcells，InhibitproliferationofT,BcellInhibitpro-inflammatorycytokinesproduction,receptorexpressionandcytotoxicityofmonocytesInhibitadherentmoleculeexpressionofvascularendothelialcells(VECs)InhibitH2O2、NOproductionofmacrophageInhibitantigenpresentationandotherassistantfunctionsofmonocytesandmacrophage,.,22,ImportantcellsinMODS,Polymorphonuclearleucocyte（PMN）：Effectorcellofinflammatoryresponse.CouldreleaseseveralproteinenzymesandODFRtodestroyVECsandstromaVECs：Whenactivated,VECsexpresshigheradherencetoPMNandhigherclottingcompetence;alsotheyproducepro-inflammatorycytokinesandvasodilatingagenttomagnifyinflammatoryresponse;finally,capillaryleakagesyndromecomesifVECsweredestroyed.,.,23,ImportantorganinMODS,IntestinesBecauseofstress,fastingandcatabolism,theblood-mucosabarrierofintestinescouldbedestructed,thebacteriaandtoxintranlocatetobloodcirculationandthelattercouldenhanceinflammatoryresponsetoformviciouscycle.Sointestinesarecalled“motor”ofinflammatoryresponse,andaresourcesoflatestageinfectonsofMODSpts.,.,24,uncontrolledstress,carbohydratemetabolismdysfunction,Insulintolerance,withoutKetonemia,hyperkineticcirculatorystate,Hyperpyrexia,HighStrokevolume,Highoxygenconsumption,Proteinmetabolismdysfunction,highkatabolism,acutephaseprotein,.,25,T38or36HR90beat/minRR20/minorPaCO232mmHgWBC12000mm3or4000mm3orprematurecells10,Sepsis,SystemicInflammatoryResponseSyndrome(SIRS),(SIR+PositiveCulture),(SIRwithoutinfection),SystemicInflammatoryResponsesyndromeSIRS,.,26,Chaoticinternalmilieuduringacutephase,Disturbanceofelectrolytesandacid-basebalanceFeverCatabolism:emaciated,anemiaAcutedisseminatedintravascularcoagulationArrhythmiaHyperglycemia,noketonemia,.,27,Secondaryaldosteronism-highdensityurinewithoutProteinuria,oliguria-prerenalazotemia-swollen,Plasmaproteinleakage-Interstitialedema-Hypoproteinemia-bloodinspissasion-Hypovolemia,Capillaryleakagesyndrome,CLS,.,28,DiagnosisofCLS,PositivebodyfluidbalanceBloodvolumedeficiencyHypoproteinemiaOrganandtotalbodyInterstitialedemalungInterstitialedemacerebralInterstitialedema,.,29,Organsdysfunctionorfailure,Organorsystem,dysfunction,failure,lung,Liver,kidney,intestine,Blood,Hypoxemia,respiratoratlist3-5days,ARDS,PEEP10cmH2O,FiO20.5,Bilirubin2-3mg/dL,Liverfunction2normalvalue,Bilirubin2-3mg/dL,icterus,oliguria,dialysis,Untoleranceofenteralnutrition5days,Curlinglsulcerneedsbloodtransfusion,Acalculouscholecystitis,PTorPTTelongation,platelet95%KidneyARFonlyafew,.,32,AcuteRespiratoryDistressSyndrome,ARDS,PathologyoflungHighcapillarypermeabilityInterstitialedemaVasoconstriction,microthrombosiscommunicatingbranchopeningAlveolarandsmallbronchusAtelectasisDecreasedalveolarsurfactantEdemaItypeepithelialcellsinsteadbyIItypecellSymptomTachypnea,respiratorydistresscannotbeeasedbyoxygeninhalationNoralesNolungx-rayabnormality,1.Theearlystage,.,33,PathologyDeterioratedlungInterstitialinflammation,usuallycomplicatedwithSEPSISSymptomObviouslydyspnoeaandcyanosisneedsventilatorIncreasedrespiratorytractsecretion,ralesLungx-rayinfiltratesDisturbanceofconsciousnessFebrileorhighleucocyte,.Thesecondstage,.,34,3.Telophase,PathologyLungparenchymafibrosisMicrovascularocclusionIncreasedpreload,hypoxiaSymptomDeepcomaArrhythmiabradycardiacardiacarrest,.,35,Diagnosis,.,36,AcuteRenalFailure,ARF,EtiologyPrerenalHemorrhage,shock,fluidlosingwithoutappropriatefluidresuscitationpostrenalbothsideureterorurinaryflowblockedrenalkidneyischemia(hematorrhea,sepsis,allergicreaction)intoxication(aminoglycosideantibiotic,biotictoxin,chemical),.,37,1.HistoryandphysicalexaminationEtiologyprerenalpathogenpostrenalpathogen,DiagnosisofARF,.,38,2.DifferentiationDiagnosiswithprerenalARF,.,39,3.DifferentiationDiagnosiswithPostrenalARF,Btypeultrasound(renalenlargement,ureter)Abdominalx-rays(calcification,calculusorObstruction),.,40,4.LaboratoryUrinetest,UrinarycathetertorecordurinevolumeUrineacidity/density(1.010-1.014)UrinemicroscopicexaminationRBCandrenaltubuleepithelia(renalcortexandrenalmedullanecrosis)LargeBrowncasts(renalfailurecasts)Eosinophil(interstitialnephritis)Redcellcast(glomerulonephritis)Normal(prerenalorpostrenalfailureearlierperiod),.,41,5.renalfunctionexamination,Urineureanitrogen(175mmol/24h)Fractionalexcretionoffiltratedsodium1FENa（%）=（UNa/PNa）（PCr/UCr）100osmoticpressureofurine*ARF-400mOsm/LBUN(morethan3.89.4mmol/Lperday),CrUrine/PlasmaCr-1-ARF*1-prerenal,.,42,Intensivecare,OrganandsystemfunctionMonitoringandsupportObjectameliorateoxygenmetabolismamelioratenutrienstateTherapyaimedatstressandinflammatoryMediatorsTreatmentofcapillaryleakageTreatmentofprimarydisease,.,43,OxygenmetabolismMonitoring,CriticalDO2Assayofplasmalacticacid/pyruvicacid,.,44,Oxygenassociatedindex,DO2OxygenDelivery-OxygenofferedtothebodyinacertainperiodbycirculatorysystemDO2CO（1.38SaO2+0.003PaO2）VO2OxygenConsumption-Oxygenconsumptedbyallcellsinacertainperiod.VO2Ca-vDO2CO10,.,45,CriticalDO2,VO2,DO2,SepsisARDSMODS,Normal,Criticaldeliveryoxygen,.,46,LacticAcidandcellshypoxia,LacticAcid-latentcellshypoxialacticacidosis-tissueperfusiondeficiencyandcellshypoxiaLacticAcidnormalvalue-0.5-1.5mmol/L4-5mmol/LSBandPHlacticacidosisL/Prate-cellshypoxiaL/Pratenormalvalue-10:1,.,47,Strategyofameliorateoxygenmetabolism,Improvementofoxygendeliveryrespiratorysupport-toimprovearterialbloodoxygencontenthigherinhalatedoxygenconcentration,ventilatorincreasecardiacoutputHeartrate,cardiacrhythm,cardiaccontractility,preload/afterloadBloodsystemrisehemoglobinconcentration,.,48,Strategyofameliorateoxygenmetabolism,IncreaseoxygenextractionratioAmeliorateinterstitialedemaReducebloodcapilarypermeabilityAmeliorateoxygenextractionofcells,.,49,TreatmenofCLS,Limitationofwater-intakepremise:nevergetCOdownInfusionvolumedecidedbyurinevolumeperhourwhenlungandbraininterstitialedemahappen.RisecolloidosmoticpressureUsepowerfuldiureticUseglucocorticoid,.,50,Nutritionalsupport,MetabolismsupportOffernutritionalsubstratebutneverincreaseorganloading.MetabolismmodulationInhibitionofcatabolismhormonesPromoteproteinsynthesis,easenegativenitrogenbalance,.,51,Nutritionalsupport,AddaccessoriesPromoteproteinsynthesisandcellgrowthModulateimmunologicresponseEnteralnutritionProtectbowelblood-mucosabarrier(preventfrominfection),.,52,Discussionoftherapyforstressandinflammatorymediators,AntagonismandclearanceAimatexcessivecytokines-post-translationlevelsReductionofsynthesiskeepthebalancebetweenpro-andanti-cytokines-intranscriptionlevels-intranslationlevel,.,53,Cytokinesmodulation,IntranscriptionlevelAnti-mRNAexpression(NF-Bisinchargeofmanykindsofcytokineexpression.)TranslationlevelReducecytokinessynthesisPosttranslationlevelAnti-cytokines(antibodyorsolublereceptor)BlockreceptorofcytokinesClearanceofcytokines(plasmapheresis),.,54,TreatmenofARDS,CorrecthypoxemiaquicklyuseventilatorassoonaspossibleappropriatePEEP（regainalveolarfunctionandfunctionalresidualcapacity),.,55,TreatmenofARDS,MaintainCirculationandlunginterstitialedemaPropercrystal/colloidrateDiureticNegativewaterbalance(accordingtoCVP/PAWP,urineoutputandlungauscultation),.,56,TreatmenofARDS,PreventandtreatinfectionBlockSIRScorticoidintheinitialstagemediatorsinhibitor(Ibuprofen,Dentoxifylline,TNFantibody),.,57,TreatmentofARF,Oliguriaoranuriastage(7-10days,average5-6andmax.morethan1month)confinewaterintakeEqualwaterintakeandoutputfluidintakeperday=(dominantwaterlosing)+(nondominantwaterlosing)-(endogeneouswater)or0.5kgnutrientLowprotein,highcalorie,highVitaminproteinsynthesishormones,.,58,TreatmentofARF,correctelectrolytesimbalaHyperkalemiaHyponatremiaHypocalcemiaAcidosisCounterinfectionblood