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

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,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,DecreasedrenalbloodflowReninreleasedfromkidneyarterioleRenin交感神经活动增强1.神清(consciousness)，但烦躁(restlessness)，呼吸加快(quickenrespiration)2.皮肤苍白(Paleskin)，手足厥冷(Coldhandsandfeet)3.心率快(Rapidrate)，血压正常(NormalBP)或稍升高(IncreasingBP)，舒张压(diastolicbloodpressure)升高，脉压缩小(narrowpulsepressure)4.尿量(urineoutput)正常或减少,休克抑制期：丧失血容量20%1.神志淡漠(Disturbanceofconsciousness)昏迷(Coma)2.口唇(Orallip)、肢端(Limb)发绀(Cyanosis)，出冷汗(Coldsweat)3.脉细速(Rapidrateandthread/weakpulse)，血压下降(FallingBP)，脉压差(Pulsepressuredifference)明显缩小4.5.尿量减少或无尿(Anuria),休克的临床表现,重度休克：血容量丧失40%1.昏迷(Coma)2.全身皮肤粘膜紫绀(Cyanosis)，四肢冰冷3.脉搏摸不到，血压测不出4.无尿(Anuria)5.器官功能衰竭的表现,休克的临床表现,休克的诊断DiagnosisofShock,早期诊断:病史：失血、失液、创伤等临床表现：兴奋或烦躁，出冷汗，心率快，脉压缩小，尿少抑制期诊断：依靠典型表现神志淡漠，反应迟钝，皮肤苍白或紫绀，四肢湿冷，脉细速，呼吸浅快，收缩压下降至12kPa（90mmHg）以下，尿少或无尿,神志状态(Mentalstatus)肢体温度、色泽(Limbtemperatureandcolor)血压(Bloodpressure)脉率(Pulse)尿量(Urineoutput),休克的监测一般监测GeneralMonitor,休克的监测特殊监测SpecialMonitor,中心静脉压(CentralVenousPressure,CVP):血容量和心功能正常值：0.49-0.98kPa(5-10cmH2O)CVP，血容量不足CVP，心功能不全或过度收缩（1.47kPa)充血性心力衰竭(CongestiveHeartFailure)(1.96kPa),休克的监测特殊监测SpecialMonitor,肺动脉楔压(PulmonaryCapillaryWedgePressure,PCWP)：可直接反映肺静脉、左心房和左心室的压力，了解肺循环阻力正常值：0.8-2.0kPa,低于正常值，提示血容量不足，4.0kPa，表示肺水肿心排出量和心脏指数：心排出量难以准确测定，临床应用少动脉血气分析(ArterialBloodGasAnalysis)：可了解呼吸功能和酸碱平衡的变化。PaO280-100mmHg,PaCO236-44mmHg,PaCO260mmHg,PaO260mmHg,休克的监测特殊监测SpecialMonitor,动脉血乳酸盐测定：反映细胞血液灌流情况。正常值：1-2mmol/L，浓度越高，休克越严重。8mmol/L,死亡率100%。DIC的实验室检查确诊依据：Plat3,副凝实验(+);3P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(pH7.15),administerNaHCO3;Identifyandtreattheunderlyingcauseofshock.,感染性休克的特点CharacteristicsofSepticShock,内毒素性休克微循环变化的不同阶段常同时存在微循环变化和内脏损害比较严重全身炎症反应综合征,感染性休克的类型TypesofSepticShock,高排低阻型（高动力型）：“Warm”shockhyperdynamicresponse,原因：感染灶释放扩血管物质特点：周围血管阻力降低，心排出量增加低排高阻型（低动力型）“Cold”shockhypodynamicresponse原因：血容量减少+继发感染活性因子：儿茶酚胺、5-羟色胺、组织胺、缓激肽特点：周围血管阻力增加，心排出量降低,感染性休克的两种临床表现,临床表现冷休克(高阻力型)暖休克(低阻力型)神志躁动、淡漠或嗜睡清醒皮肤色泽苍白、紫绀或花斑样紫绀淡红或潮红皮肤温度湿冷或冷汗温暖、干燥毛细血管充盈时间延长1-2秒脉搏细速慢、有力脉压（kPa）4尿量(每小时)30ml,SepticShock,Treatment:PreventionFindandkillthesourceoftheinfectionFluidresuscitationVasoconstrictorsInotropicdrugsMaximizeO2deliverySupportNutritionalSupport,TreatmentofSepticShock,Antibiotictreatment;Removalordrainageofafocalsourceofinfection:Removeindwellingintravascularcathetersandsendtipsforquantitativeculture;replaceFoleyandotherdrainagecatheters;Hemodynamic,respiratory,andmetabolicsupport:.MaintainintravascularvolumewithIVfluids.Initiatetreatmentwith1-2Lofnormalsalineadministeredover1-2h,keepingpulmonarycapillarywedgepressureat12-16mmHgorcentralvenouspressureat8-12cmH2O,urineoutputat30mlperhour,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.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),