《于志偉副主任醫(yī)師哈爾濱醫(yī)科大學(xué)附屬腫瘤醫(yī)院結(jié)直腸外科.ppt》由會員分享，可在線閱讀，更多相關(guān)《于志偉副主任醫(yī)師哈爾濱醫(yī)科大學(xué)附屬腫瘤醫(yī)院結(jié)直腸外科.ppt（49頁珍藏版）》請在裝配圖網(wǎng)上搜索。

1、于志偉副主任醫(yī)師哈爾濱醫(yī)科大學(xué)附屬腫瘤醫(yī)院，結(jié)直腸外科,休克ShockSyndrome,休克(Shock)的定義,休克是指任何原因引起有效循環(huán)血量減少,導(dǎo)致組織和器官氧合血液灌流不足,從而發(fā)生的代謝障礙和功能細(xì)胞受損的病理過程Shockisaconditioninwhichthecardiovascularsystemfailstoperfusetissuesadequately.Inadequatetissueperfusioncanresultin:generalizedcellularhypoxia(starvation)widespreadimpairmentofcellularmet

2、abolismtissuedamageorganfailuredeath維持有效循環(huán)血量的必要因素:充足的血容量Sufficientbloodvolume有效的心排出量Effectivecardiacpump良好的周圍血管張力Upstandingperipheralangiotasis,,Effectivecirculatingbloodvolume,休克的分類（TypesofShock）,分類疾病舉例低血容量性休克創(chuàng)傷出血、上消化道出血（hypovolemicshock）燒傷、腸梗阻感染性休克膽道感染等（SepticShock）心源性休克心梗（CardiogenicShock）過敏性休克青霉

3、素過敏、血清過敏（Anaphylacticshock）神經(jīng)源性休克疼痛刺激、脊髓損傷（NeurogenicShock）,,,,hemorrhageshockandtraumaticshock.,PATHOPHYSIOLOGYOFSHOCKSYNDROME,微循環(huán)改變MicrocirculationChange代謝變化MetabolismChange內(nèi)臟器官的繼發(fā)性損害Secondarydamageoninternalorgans,MicrocirculationChange,Decompensatedphase,Compensatedphase,Irreversiblephase,,,,Dea

4、th,Sympatheticnervoussystemactivates,CardiaceffectsIncreasedforceofcontractionsIncreasedheartrateIncreasedcardiacoutput,PeripheraleffectsArteriolarconstrictionPre-/post-capillarysphinctercontractionIncreasedperipheralresistanceShuntingofbloodtocoreorgans,DecreasedrenalbloodflowReninreleasedfromkidne

5、yarterioleRenin交感神經(jīng)活動增強(qiáng)1.神清(consciousness)，但煩躁(restlessness)，呼吸加快(quickenrespiration)2.皮膚蒼白(Paleskin)，手足厥冷(Coldhandsandfeet)3.心率快(Rapidrate)，血壓正常(NormalBP)或稍升高(IncreasingBP)，舒張壓(diastolicbloodpressure)升高，脈壓縮小(narrowpulsepressure)4.尿量(urineoutput)正?；驕p少,,休克抑制期：喪失血容量20%1.神志淡漠(Disturbanceofconsciousness

6、)昏迷(Coma)2.口唇(Orallip)、肢端(Limb)發(fā)紺(Cyanosis)，出冷汗(Coldsweat)3.脈細(xì)速(Rapidrateandthread/weakpulse)，血壓下降(FallingBP)，脈壓差(Pulsepressuredifference)明顯縮小4.5.尿量減少或無尿(Anuria),,休克的臨床表現(xiàn),重度休克：血容量喪失40%1.昏迷(Coma)2.全身皮膚粘膜紫紺(Cyanosis)，四肢冰冷3.脈搏摸不到，血壓測不出4.無尿(Anuria)5.器官功能衰竭的表現(xiàn),,休克的臨床表現(xiàn),休克的診斷DiagnosisofShock,早期診斷:病史：失血、失液

7、、創(chuàng)傷等臨床表現(xiàn)：興奮或煩躁，出冷汗，心率快，脈壓縮小，尿少抑制期診斷：依靠典型表現(xiàn)神志淡漠，反應(yīng)遲鈍，皮膚蒼白或紫紺，四肢濕冷，脈細(xì)速，呼吸淺快，收縮壓下降至12kPa（90mmHg）以下，尿少或無尿,,神志狀態(tài)(Mentalstatus)肢體溫度、色澤(Limbtemperatureandcolor)血壓(Bloodpressure)脈率(Pulse)尿量(Urineoutput),,休克的監(jiān)測一般監(jiān)測GeneralMonitor,休克的監(jiān)測特殊監(jiān)測SpecialMonitor,中心靜脈壓(CentralVenousPressure,CVP):血容量和心功能正常值：0.49-0.98kPa

8、(5-10cmH2O)CVP，血容量不足CVP，心功能不全或過度收縮（1.47kPa)充血性心力衰竭(CongestiveHeartFailure)(1.96kPa),,休克的監(jiān)測特殊監(jiān)測SpecialMonitor,肺動脈楔壓(PulmonaryCapillaryWedgePressure,PCWP)：可直接反映肺靜脈、左心房和左心室的壓力，了解肺循環(huán)阻力正常值：0.8-2.0kPa,低于正常值，提示血容量不足，4.0kPa，表示肺水腫心排出量和心臟指數(shù)：心排出量難以準(zhǔn)確測定，臨床應(yīng)用少動脈血氣分析(ArterialBloodGasAnalysis)：可了解呼吸功能和酸堿平衡的變化。PaO2

9、80-100mmHg,PaCO236-44mmHg,PaCO260mmHg,PaO2<60mmHg,,,休克的監(jiān)測特殊監(jiān)測SpecialMonitor,動脈血乳酸鹽測定：反映細(xì)胞血液灌流情況。正常值：1-2mmol/L，濃度越高，休克越嚴(yán)重。8mmol/L,死亡率100%。DIC的實驗室檢查確診依據(jù)：Plat3,副凝實驗(+);3P試驗陽性；血涂片中破碎紅細(xì)胞超過2%。,,休克的治療TreatmentofShock,一般緊急措施控制活動性大出血休克體位:頭和軀干抬高20-30度,下肢抬高5-20度吸氧，6-8L/min；保持呼吸道通暢保持安靜，避免搬動保暖，可用休克服,,休克的治療Treatm

10、entofShock,補(bǔ)充血容量(Restorecirculatingvolumeandtissueperfusion)：是抗休克的根本措施補(bǔ)充量：可根據(jù)CVP調(diào)節(jié)，應(yīng)補(bǔ)充喪失量和已擴(kuò)大的毛細(xì)血管床容量積極處理原發(fā)病(TreatReversibleCauses)：在恢復(fù)有效血容量后積極手術(shù)處理外科原發(fā)病。在原發(fā)病不除，休克不能糾正時，應(yīng)抗休克的同時，積極手術(shù)處理，以免喪失搶救時機(jī),,Shocktreatment,“Arudeunhingingofthemachineryoflife”,“Abriefpauseintheactofdying”,休克的治療TreatmentofShock,糾正酸堿

11、平衡失調(diào)：主要是酸中毒酸中毒的糾正有賴于休克的根本好轉(zhuǎn)補(bǔ)充血容量，改善組織灌流，休克嚴(yán)重者，應(yīng)給予堿性藥物如碳酸氫鈉心血管藥物的應(yīng)用(CirculatorySupport)Vasoconstrictor：去甲腎上腺素；間羥胺；苯腎上腺素；苯芐胺；芐胺唑啉；多巴胺；異丙腎上腺素；西地蘭等治療DIC改善微循環(huán)皮質(zhì)類固醇和其他藥物的應(yīng)用,,Insummary,TreatmentofShock,IdentifythepatientathighriskforshockControloreliminatethecauseImplementmeasurestoenhancetissueperfusionCo

12、rrectacidbaseimbalanceTreatcardiacdysrhythmias,失血性休克的治療(TreatmentofHemorrhagicShock),補(bǔ)充血容量：根據(jù)情況輸入晶體或/和膠體溶液出血量少，無活動性出血者，輸入晶體液出血量大，有活動性出血者，先輸晶體液，后輸血根據(jù)中心靜脈壓調(diào)整輸液量和速度止血：在補(bǔ)充血容量的同時積極止血要處理好休克和止血手術(shù)間的辨證關(guān)系,,中心靜脈壓和補(bǔ)液的關(guān)系,CVPBP原因處理原則低低血容量嚴(yán)重不足充分補(bǔ)液低正常血容量不足適當(dāng)補(bǔ)液高低心功能不全強(qiáng)心藥，糾酸，或血容量相對過多舒血管高正常容量血管過度收縮舒張血管正常低心功能不全補(bǔ)液實驗或血容量

13、不足,,,,損傷性休克的治療(TreatmentofTraumaticShock),補(bǔ)充血容量：應(yīng)根據(jù)監(jiān)測指標(biāo)的變化來決定補(bǔ)液量糾正酸堿平衡失調(diào)：堿中毒酸中毒適當(dāng)應(yīng)用堿性藥物手術(shù)治療：應(yīng)根據(jù)病情判斷是否需要手術(shù)以及手術(shù)時機(jī)的選擇藥物治療：大量抗生素，復(fù)合維生素等,,HypovolemicShock,Managementgoal:Restorecirculatingvolumeandtissueperfusion:ControlhemorrhageRestorecirculatingvolumeOptimizeoxygendeliveryVasoconstrictorifBPstilllowaf

14、tervolumeloading,Aimedatimprovementtissuehypoperfusion,InsertFoleycathetertomonitortheurineflow;Augmentsystolicbpto100mmHg:1.PlaceinreverseTrendelenburgposition;2.IVvolumeinfusion(500-1000mlbolus),unlesscardiogenicshocksuspected(beginwithnormalsaline,thenwholeblood,dextran,orpackedRBCs,ifanemic),con

15、tinuevolumereplacementasneededtorestorevascularvolume;Addvasoactivedrugsafterintrvascularvolumeisopmtimized;administervasopressorsifsystemicvascularresistanceisdecreased.Ifseveremetabolicacidosisispresented(pH<7.15),administerNaHCO3;Identifyandtreattheunderlyingcauseofshock.,感染性休克的特點Characteristicso

16、fSepticShock,內(nèi)毒素性休克微循環(huán)變化的不同階段常同時存在微循環(huán)變化和內(nèi)臟損害比較嚴(yán)重全身炎癥反應(yīng)綜合征,,感染性休克的類型TypesofSepticShock,高排低阻型（高動力型）：“Warm”shockhyperdynamicresponse,原因：感染灶釋放擴(kuò)血管物質(zhì)特點：周圍血管阻力降低，心排出量增加低排高阻型（低動力型）“Cold”shockhypodynamicresponse原因：血容量減少+繼發(fā)感染活性因子：兒茶酚胺、5-羥色胺、組織胺、緩激肽特點：周圍血管阻力增加，心排出量降低,,感染性休克的兩種臨床表現(xiàn),臨床表現(xiàn)冷休克(高阻力型)暖休克(低阻力型)神志躁動、淡漠

17、或嗜睡清醒皮膚色澤蒼白、紫紺或花斑樣紫紺淡紅或潮紅皮膚溫度濕冷或冷汗溫暖、干燥毛細(xì)血管充盈時間延長1-2秒脈搏細(xì)速慢、有力脈壓（kPa）4尿量(每小時)30ml,,,,SepticShock,Treatment:PreventionFindandkillthesourceoftheinfectionFluidresuscitationVasoconstrictorsInotropicdrugsMaximizeO2deliverySupportNutritionalSupport,TreatmentofSepticShock,Antibiotictreatment;Removalordraina

18、geofafocalsourceofinfection:Removeindwellingintravascularcathetersandsendtipsforquantitativeculture;replaceFoleyandotherdrainagecatheters;Hemodynamic,respiratory,andmetabolicsupport:.MaintainintravascularvolumewithIVfluids.Initiatetreatmentwith1-2Lofnormalsalineadministeredover1-2h,keepingpulmonaryc

19、apillarywedgepressureat12-16mmHgorcentralvenouspressureat8-12cmH2O,urineoutputat30mlperhour,meanarterialbloodpressureat65mmHg.,Addinotropicandvasopressortherapyifneeded.Maintaincentralvenousoxygensaturationat70%..Maintainoxygenationwithventilatorsupportasindicated.Othertreatments:Antiendotoxin,anti-

20、inflammatory,andanticoagulantdrugsarebeingstudiedinseveresepsistreatment.AnticoagulantrecombinantactivatedproteinC(aPC):constantinfusionof24ug/kgperhourfor96h.,TreatmentofSepticShock,感染性休克的治療,補(bǔ)充血容量：以平衡鹽溶液為主，配合適量的血漿和全血；并根據(jù)CVP調(diào)節(jié)輸液量和速度控制感染：處理原發(fā)感染灶；應(yīng)用抗菌藥物；改善病人的一般狀況；維持呼吸功能等糾正酸中毒：酸中毒發(fā)生早，嚴(yán)重，及早應(yīng)用堿性藥物心血管藥物應(yīng)用

21、：西地蘭；B-受體興奮劑和a受體抑制劑聯(lián)合應(yīng)用減輕細(xì)胞損害：皮質(zhì)類固醇，大劑量應(yīng)用；SOD，抑肽酶，PGI2，試用中,,,,THEEND,Clinicalexamples-1,An82-year-oldmanwasbroughttotheemergencyroombyhisgrandson,whoreportedthatthemanhadbeeneatingpoorlyfor2daysandhadbeendifficulttoarousethatmorning.Thepatienthadnospecificcomplaints.Onexam,thepatientwouldopenhiseyes

22、andmumbleincoherentlyinresponsetopain.Histemperaturewas38.6,BP75/40,HR124regular,respirations26.Hislungswereclear.Nomurmursorextrasoundswereappreciatedoncardiacexam.,Clinicalexamples-1,Hisskinwaswarm,withboundingperipheralpulses.HischestradiographandEKGwerenormal.Laboratorydata:whitebloodcellcount19

23、500(normallessthan10000).Abladdercatheterwasinserted(withdifficulty)andyieldedcloudyurine,whichwasnotedtocontainmanywhitecellsandbacteria.Urinewassentforculture.,Clinicalexamples-2,An35-year-oldwomanpresentedtoanemergencyroomcomplainingofaheadachepresentsinceamyelogramwhichhadbeenperformed4daysbefor

24、e.Herpastmedicalhistorywasunremarkableandherphysicalexaminationwasnormal.Shewasgivenaninjectionofmeperidineforherpain.Aftertheinjectionshebegantocomplainofnumbnessandtinglinginherfingertips,lightheadedness,shortnessofbreathanddiffuseitching.,Clinicalexamples-2,Herpulsewasnotedtobe140andbloodpressure

25、waspalpableat70/0mmHg.Faintwheezeswerenotedthroughoutthelungs.Althoughshehadinitiallydenieddrugallergies,shenowrememberedsimilarsymptomswhichhadfollowedaninjectionofpainmedicine”2yearsbefore.,Clinicalexamples-3,An67-year-oldfemalearrivedintheemergencyroomcomplainingofchestpainandsevereweaknessfor12h

26、ours.Thesesymptomshadbeenprecededbyseveraldaysofnauseaandvomiting,poorappetite,andsubjectivefever.Onexamination,shehadapulserateof110andBP85/50.Therewasnojugularvenousdistension.Herlungswereclearandnomurmurorgallopwereheardonauscultationoftheheart.Therewasnoextremityedema.,Clinicalexamples-3,EKGshow

27、ednewSTelevationintheinferiorleads,suggestinganevolvinginferiormyocardialinfarction.RightprecordialleadsdidnotshowevidenceofRVinfarctionatthattime.Thepatientwasgivensublingualnitroglycerinandwithinminutesbecameconfusedandunabletoresponsetoquestions.Systolicbloodpressuredroppedto60andpulseslowedto70.

28、herlegswereelevatedandrapidinfusionofintravenousfluidswasbegun.,Clinicalexamples-3,Hermentalstatusimprovedbutsheremainedhypotensive.Thedecisionwasmadetoplaceapulmonaryarterycathetertohelpwithmanagementofcardiogenicshock.InitialHemodynamicData:BP:80/50,mean60RA:4mmHg,RV22/3,PA22/10,PAOP6Cardiacoutput:1.9liters/minSVR:2350dynes-cm-5-sec(normal400-1900),