于志伟副主任医师哈尔滨医科大学附属肿瘤医院,结直肠外科.ppt

副主任医师,休克ShockSyndrome,休克(Shock)的定义,休克是指任何原因引起有效循环血量减少,导致组织和器官氧合血液灌流不足,从而发生的代谢障碍和功能细胞受损的病理过程Shockisaconditioninwhichthecardiovascularsystemfailstoperfusetissuesadequately.Inadequatetissueperfusioncanresultin:generalizedcellularhypoxia(starvation)widespreadimpairmentofcellularmetabolismtissuedamageorganfailuredeath维持有效循环血量的必要因素:充足的血容量Sufficientbloodvolume有效的心排出量Effectivecardiacpump良好的周围血管张力Upstandingperipheralangiotasis,Effectivecirculatingbloodvolume,休克的分类（TypesofShock）,分类疾病举例低血容量性休克创伤出血、上消化道出血（hypovolemicshock）烧伤、肠梗阻感染性休克胆道感染等（SepticShock）心源性休克心梗（CardiogenicShock）过敏性休克青霉素过敏、血清过敏（Anaphylacticshock）神经源性休克疼痛刺激、脊髓损伤（NeurogenicShock）,hemorrhageshockandtraumaticshock.,PATHOPHYSIOLOGYOFSHOCKSYNDROME,微循环改变MicrocirculationChange代谢变化MetabolismChange内脏器官的继发性损害Secondarydamageoninternalorgans,MicrocirculationChange,Decompensatedphase,Compensatedphase,Irreversiblephase,Death,Sympatheticnervoussystemactivates,CardiaceffectsIncreasedforceofcontractionsIncreasedheartrateIncreasedcardiacoutput,PeripheraleffectsArteriolarconstrictionPre-/post-capillarysphinctercontractionIncreasedperipheralresistanceShuntingofbloodtocoreorgans,DecreasedrenalbloodflowReninreleasedfromkidneyarterioleRenin3P试验阳性；血涂片中破碎红细胞超过2%。,休克的治疗TreatmentofShock,一般紧急措施控制活动性大出血休克体位:头和躯干抬高20-30度,下肢抬高5-20度吸氧，6-8L/min；保持呼吸道通畅保持安静，避免搬动保暖，可用休克服,休克的治疗TreatmentofShock,补充血容量(Restorecirculatingvolumeandtissueperfusion)：是抗休克的根本措施补充量：可根据CVP调节，应补充丧失量和已扩大的毛细血管床容量积极处理原发病(TreatReversibleCauses)：在恢复有效血容量后积极手术处理外科原发病。在原发病不除，休克不能纠正时，应抗休克的同时，积极手术处理，以免丧失抢救时机,Shocktreatment,“Arudeunhingingofthemachineryoflife”,“Abriefpauseintheactofdying”,休克的治疗TreatmentofShock,纠正酸碱平衡失调：主要是酸中毒酸中毒的纠正有赖于休克的根本好转补充血容量，改善组织灌流，休克严重者，应给予碱性药物如碳酸氢钠心血管药物的应用(CirculatorySupport)Vasoconstrictor：去甲肾上腺素；间羟胺；苯肾上腺素；苯苄胺；苄胺唑啉；多巴胺；异丙肾上腺素；西地兰等治疗DIC改善微循环皮质类固醇和其他药物的应用,Insummary,TreatmentofShock,IdentifythepatientathighriskforshockControloreliminatethecauseImplementmeasurestoenhancetissueperfusionCorrectacidbaseimbalanceTreatcardiacdysrhythmias,失血性休克的治疗(TreatmentofHemorrhagicShock),补充血容量：根据情况输入晶体或/和胶体溶液出血量少，无活动性出血者，输入晶体液出血量大，有活动性出血者，先输晶体液，后输血根据中心静脉压调整输液量和速度止血：在补充血容量的同时积极止血要处理好休克和止血手术间的辨证关系,中心静脉压和补液的关系,CVPBP原因处理原则低低血容量严重不足充分补液低正常血容量不足适当补液高低心功能不全强心药，纠酸，或血容量相对过多舒血管高正常容量血管过度收缩舒张血管正常低心功能不全补液实验或血容量不足,损伤性休克的治疗(TreatmentofTraumaticShock),补充血容量：应根据监测指标的变化来决定补液量纠正酸碱平衡失调：碱中毒酸中毒适当应用碱性药物手术治疗：应根据病情判断是否需要手术以及手术时机的选择药物治疗：大量抗生素，复合维生素等,HypovolemicShock,Managementgoal:Restorecirculatingvolumeandtissueperfusion:ControlhemorrhageRestorecirculatingvolumeOptimizeoxygendeliveryVasoconstrictorifBPstilllowaftervolumeloading,Aimedatimprovementtissuehypoperfusion,InsertFoleycathetertomonitortheurineflow;Augmentsystolicbpto100mmHg:1.PlaceinreverseTrendelenburgposition;2.IVvolumeinfusion(500-1000mlbolus),unlesscardiogenicshocksuspected(beginwithnormalsaline,thenwholeblood,dextran,orpackedRBCs,ifanemic),continuevolumereplacementasneededtorestorevascularvolume;Addvasoactivedrugsafterintrvascularvolumeisopmtimized;administervasopressorsifsystemicvascularresistanceisdecreased.Ifseveremetabolicacidosisispresented(pH30mlperhour,meanarterialbloodpressureat65mmHg.,Addinotropicandvasopressortherapyifneeded.Maintaincentralvenousoxygensaturationat70%.Maintainoxygenationwithventilatorsupportasindicated.Othertreatments:Antiendotoxin,anti-inflammatory,andanticoagulantdrugsarebeingstudiedinseveresepsistreatment.AnticoagulantrecombinantactivatedproteinC(aPC):constantinfusionof24ug/kgperhourfor96h.,TreatmentofSepticShock,感染性休克的治疗,补充血容量：以平衡盐溶液为主，配合适量的血浆和全血；并根据CVP调节输液量和速度控制感染：处理原发感染灶；应用抗菌药物；改善病人的一般状况；维持呼吸功能等纠正酸中毒：酸中毒发生早，严重，及早应用碱性药物心血管药物应用：西地兰；B-受体兴奋剂和a受体抑制剂联合应用减轻细胞损害：皮质类固醇，大剂量应用；SOD，抑肽酶，PGI2，试用中,THEEND,Clinicalexamples-1,An82-year-oldmanwasbroughttotheemergencyroombyhisgrandson,whoreportedthatthemanhadbeeneatingpoorlyfor2daysandhadbeendifficulttoarousethatmorning.Thepatienthadnospecificcomplaints.Onexam,thepatientwouldopenhiseyesandmumbleincoherentlyinresponsetopain.Histemperaturewas38.6,BP75/40,HR124regular,respirations26.Hislungswereclear.Nomurmursorextrasoundswereappreciatedoncardiacexam.,Clinicalexamples-1,Hisskinwaswarm,withboundingperipheralpulses.HischestradiographandEKGwerenormal.Laboratorydata:whitebloodcellcount19500(normallessthan10000).Abladdercatheterwasinserted(withdifficulty)andyieldedcloudyurine,whichwasnotedtocontainmanywhitecellsandbacteria.Urinewassentforculture.,Clinicalexamples-2,An35-year-oldwomanpresentedtoanemergencyroomcomplainingofaheadachepresentsinceamyelogramwhichhadbeenperformed4daysbefore.Herpastmedicalhistorywasunremarkableandherphysicalexaminationwasnormal.Shewasgivenaninjectionofmeperidineforherpain.Aftertheinjectionshebegantocomplainofnumbnessandtinglinginherfingertips,lightheadedness,shortnessofbreathanddiffuseitching.,Clinicalexamples-2,Herpulsewasnotedtobe140andbloodpressurewaspalpableat70/0mmHg.Faintwheezeswerenotedthroughoutthelungs.Althoughshehadinitiallydenieddrugallergies,shenowrememberedsimilarsymptomswhichhadfollowedaninjectionofpainmedicine”2yearsbefore.,Clinicalexamples-3,An67-year-oldfemalearrivedintheemergencyroomcomplainingofchestpainandsevereweaknessfor12hours.Thesesymptomshadbeenprecededbyseveraldaysofnauseaandvomiting,poorappetite,andsubjectivefever.Onexamination,shehadapulserateof110andBP85/50.Therewasnojugularvenousdistension.Herlungswereclearandnomurmurorgallopwereheardonauscultationoftheheart.Therewasnoextremityedema.,Clinicalexamples-3,EKGshowednewSTelevationintheinferiorleads,suggestinganevolvinginferiormyocardialinfarction.RightprecordialleadsdidnotshowevidenceofRVinfarctionatthattime.Thepatientwasgivensublingualnitroglycerinandwithinminutesbecameconfusedandunabletoresponsetoquestions.Systolicbloodpressuredroppedto60andpulseslowedto70.herlegswereelevatedandrapidinfusionofintravenousfluids