外科学总论 MODS多器官衰竭

MultipleorgandysfunctionSyndrome外科教研室大纲多器官功能障碍的定义和特点掌握多器官功能障碍的临床演进熟悉多器官功能障碍的诊断熟悉急性肾功能衰竭的病因熟悉急性肾功能衰竭的定义和病因熟悉肾功能衰竭的临床表现、诊断和防治方法熟悉急性呼吸窘迫综合征的定义和病因熟悉急性呼吸窘迫综合征的临床表现、诊断和治疗熟悉2CascliniqueM.26years,whohashadacolectomywithananastomosisFeverat40degree,abdominaltendernessHemoculture:Escherichiacoli3T40℃HR170RR55PaCO223.8Whitecell18700Hemoc+41stday

chocSeconddya

anuriaetdyspnea (BUN20.5Crea337)

Thirddaymechanicalventilation5He+patomegalybecauseoflongtermparenteralnutrition

SGPT36SGOT144TB167.9DB102.8

6MODS7Name1973sequentialdysfunction1977Remoteorgandysfunction1986post-traumaticmultipleorgandysfunction1991Multipleorgandysfunctionsyndrome8Definition

sequentialorsimultaneous>2organsdysfunctioncausedbyprimitiveillnessoragression(inflammation)9EtiologySepsisetsepticshockTraumaandburnsMajorbleedingIschemiaandreperfusionIntra-abdominalinfectionAcutepancreatitis10DifferentfromdeathTerminalstage：StressabsentNaturalorgandegradationIrreversibleMODS：AcutestressInflammatorydamageReversible11ExempleRespiratoryandcirculatoryfailureleadingfromsepticshockheptorenalsyndromepulmonary

heart

diseasePulmonaryedema12PhysiopathologyPolytraumaSepticshock?MODS13?=SIRS

SystemicInflammatoryResponseSyndromeMorethan2pointsHRmorethan90RRmorethan20/minorPaCO2lessthan32mmHgBodytemperaturemorethan38℃orlessthan36℃；Whitecell>12000/mm3

or<4000/mm3,orprematureratiomorethan10%14inflammationBodydefenseresponsetobacteria,foreignbodyanddamageProandanti-inflammatorybalanceDolor,calor,rubor,tumor,functiolaesa15Cytokinendotheliumneutrophilemono-macrophageTNF-aIL-1、2、6v.sIL-10Amplifiedinflammation--SIRSDamageintroducedbyneutrophilandcytokinviolentstress16resultendotheliumdamageEndothéliumcontractionCapillaryleakhemodynamicinstabilitycoagulationminithrombosismicrocirculationfailureIschemiareperfusion17organinvolvedLungCardiovascularsystemkidneyliverdigestiveImmunologyhematologyneurology

18PreventionEtiologictreatmentEarlyidentificationTachypneashockOliguriaAntibiotic19Abdominalabces

20Intestinalfistula21AcutekidneyinjurySyndromeofazotemia,hydro-electroliticdisturbancecausedbyfunctionalororganicrenaldysfunction22etiologypre-renalhypovolemiaandhypoperfusionshockBleedingExtracellulardehydrationabdominalcompartmentsyndrome23etiologyrenalAcutetubularnecrosisGlomerulonephritisRhabdomyolysisMedicinepost-renalobstruction24mechanismeischemieTubularnecrosisObstructionischemiareperfusioninfection,medicine,endotoxine2526ClinicalManifestationoliguricSeveraldaysto3weekshydro-electrolticetacido-basicdisturbanceazotemiableeding:subcutaneous,gums,post-operative27Manifestationpolyuric（14

days）RecoverstylerapidprogressiveslowHomeostasisdisturbance28Diagnostic

historydehydrationVomiting,diarrhea,sweatbleedingCapillaryleakIatrogenicfactorHeartfailureSeveresepsis,septicshock29DiagnosticPre-renalTachycardiashockCVPdecreaseSkinmarbleandcoldMoistralesAbdominalhypertension30DiagnosticRenalemedicineHistoryofrenaldiseaseInsuffisancecardiaqueouhépatiquechroniqueSepsisProlongedischemia

31DiagnosticDifferentialIRfonctionnelleIRorganiqueetiology HypoperfusionInfectionConcentrationBaruriaIsosthenuriaNatriuriadecreased>40mmol/LbunIncreasealoneIncreasewithcreatininHydratationrecoverOliguriaLasilixeffectivenoneeffective32LaboratoryUrinaryUrinevolumepH,pycnometerMicroscopieBiochemistryazotemiaCreatinineclearanceratedecrease33LaboratoryHyperkaliemiaHypermagnesemiaHyperphosphoremiaHyponatremiaHypochloremiaHypocalcemiaAcidosisWaterIntoxication34PreventionresuscitationAlkalinizationofbloodDecompressionInotropic35TreatmentOliguriaLiquidrestrictionAvoidhypoperfusionAdequatecalorieProteinatleast1g/kg/d36TreatmentHomeostasisHyperkaliemiaacidosisAntibiotherapyAvoidnephortoxicmedicine37TreatmentContinuousrenalreplacetreatmentHemodialysisHemofiltrationHemodiafiltrationPeritonealDialysis383940TreatmentPolyuriaAvoidhypovolemiaMaintainelectrolyticbalanceProteinAntibiotherapy41AcuterespiratorydistresssyndromeARDSAcuterespiratoryfailurewithprogressivehypoxia,bilateralinfiltration,pulmonarycompliancedecreasecausedfromtrauma,sepsis,pancreatitis.42EtiologydirectedamageaspirationPulmonarycontusionInhalation:hotortoxicgasdrowning43EtiologyIndirectedamageSepsisorsepticshock

AcutepancreatitisVasttransfusionofbloodproductsTrauma

Polyfracture44mechanismeSIRSCapillaryleakAlveolarandinterstitialdestructionbyneutrophiloxygenationdysfunctionPulmonarycompliancedecreasePulmonaryhypertension45mechanismeshuntingAlveolarcollapseDeadspacevasoconstrictionandminithrombosisPneumocytedestructionsurfactantdecreaseHyalinemembraneFunctionalresidualcapacitydecrease4647ManifestationHypoxemiaprogressiveAcutestageTachypnea

l’oxygenotherapynotworkAuscultation:normalChestradio:normal48ProgressivestageSevererespiratoryfailure:mechanicalventilationRespiratorysecretion:raleandwheezeRadio─bilateralopacityObnubilationFeverandhyperleucocytosisTerminalstageComaArrhythmia→bradycardia→cardiacarrest4950DiagnosticBloodgasHypoxemiaPaO2decreasePaO2/FiO2decreaseHypercapniaMorecriticalHemodynamicSwan-Ganz,echocardiography51TreatmentetiologyInterstitialedemaCristalloidetcolloidDiuresisLiquidrestriction52TreatmentOxygenotherapyCannulaMaskVentilatio