外科學(xué)教學(xué)課件：外科休克

1、shock outline o 1、physiopathology and clinical manifestation o 2、classification o 3、diagnosis and monitoring o 4、treatement misunderstanding osyncope oSimple low BP Definition o Sabinston：休克是不論任何原因所導(dǎo)致的組織 灌注不足而產(chǎn)生的臨床綜合征，即組織灌注難以滿 足組織代謝的需要 o 2014歐洲指南：歐洲指南：循環(huán)衰竭導(dǎo)致氧輸送障礙引發(fā)的 細(xì)胞缺氧，不強(qiáng)調(diào)低血壓 Dfinition o Oxygen de

2、liver deficiency, hypoxemia et tissue damage Classification 外科休克外科休克 hemodynamic classification o 低血容量性休克 hypovolemic o 心源性休克 cardiogenic o 分布性休克 distributive o 梗阻性休克 obstructive Physiopathology FactorFactor HypovolemiaHypovolemia microcirulationmicrocirulation dysfonctiondysfonction Early stage o 總

3、循環(huán)血量降低 o 壓力感受器、兒茶酚胺、腎素-血管緊張素 使外周、內(nèi)臟小血管收縮以保證心腦血供 o 少灌少流 灌少于流 mechanisme o Thromboxane A2：vasoconstrictor o myocardial depressive factor ：收縮內(nèi) 臟小血管，心肌收縮減弱 o Endotheline o Leucotriene goal o maintain AP n peripheric resistance n Cardiac output n Returned blood volume o Maintain the cerebral and myocardi

4、al perfusion 休克早期的臨床表現(xiàn)及機(jī)制 致休克的動因 交感-腎上腺髓質(zhì)系統(tǒng)興奮 心率加快 心肌收縮 力加強(qiáng) 脈搏細(xì)速 脈壓減少 腹腔內(nèi)臟、皮 膚等小血管強(qiáng) 烈收縮，腹腔 內(nèi)臟缺血 尿量減少 肛溫降低 兒茶 酚胺 分泌 皮膚缺血 臉色蒼白 四肢冰冷 汗腺 分泌 增加 中樞神經(jīng) 系統(tǒng)高級 部位興奮 出汗 煩躁不安 注意注意: : 血壓變化，可正常、可降低血壓變化，可正常、可降低 o Principal ：hypovolemia 、 vasoconstriction o Reversible n Etiologic treatement n Fluid resuscitation Mid

5、dle stage o 毛細(xì)血管前括約肌舒張 o 微靜脈保持收縮 o 血液滯留、靜水壓高、通透性增加、血液濃縮 o 多灌少流，灌大于流 mechanisme o Acidosis o Release of histamine and potassium o NO o hemoconcentration o minithrombose o Autoperfusion stop ：augmentation hydrostatic pression increase and capillary leak o Third-space fluid loss 主要臨床表現(xiàn)主要臨床表現(xiàn) 休克可逆期 血壓進(jìn)行

6、性下降 休克淤血性缺氧期的臨床表現(xiàn)及機(jī)制休克淤血性缺氧期的臨床表現(xiàn)及機(jī)制 微循環(huán)淤血 腎淤血 回心血量 淤血血細(xì) 胞粘附 心輸出量 腎血流量 動脈血壓 腦缺血缺氧 神志淡漠昏迷 少尿無尿 皮膚紫紺 出現(xiàn)花斑 Later stage o 微血管麻痹性擴(kuò)張 o 毛細(xì)血管內(nèi)形成血凝塊 o 血流完全受阻 不灌不流 Physiopathology o Catecholamine ineffective o Thrombosis of white and red cells o DIC 休克分期 分期 血量血管灌注皮膚 意識可逆 早期 降低 毛細(xì)血管前括約肌 收縮 少灌少流 灌少于流 蒼白 躁動是 中期

7、繼續(xù) 降低 括約肌舒張 微靜脈收縮 血管通透性增加 形成微栓 多灌少流 灌大于流 花斑 淡漠是 晚期 顯著 降低 前后擴(kuò)張 毛細(xì)血管血栓 不灌不流淤斑 昏迷否 Metabolism o Energy deficiency n Anaerobic metabolism n Liver dysfunction o Na pump dysfunction n Intracellular edema n calcium entry o lactate 休克的臨床表現(xiàn)休克的臨床表現(xiàn) 代償期代償期 抑制期抑制期 程度程度 輕度輕度 中度中度 重度重度 神志神志 清楚、不安清楚、不安 淡漠淡漠 模糊、昏迷模

8、糊、昏迷 口渴口渴 有有 較重較重 嚴(yán)重嚴(yán)重 膚色膚色 稍白稍白 蒼白蒼白 蒼白、青紫蒼白、青紫 肢溫肢溫 正?；虬l(fā)涼正常或發(fā)涼 發(fā)涼發(fā)涼 冰冷冰冷 血壓血壓 正常、脈壓小正常、脈壓小 收縮壓低、脈壓更小收縮壓低、脈壓更小 血壓更低或測不出血壓更低或測不出 脈搏脈搏 增快、有力增快、有力 更快更快 細(xì)速或摸不清細(xì)速或摸不清 呼吸呼吸 深快深快 淺快淺快 表淺、不規(guī)則表淺、不規(guī)則 壓甲壓甲 1 1秒秒 遲緩遲緩 更遲緩更遲緩 頸靜脈頸靜脈 充盈充盈 塌陷塌陷 空虛空虛 尿量尿量 正常正常 少尿少尿 少尿或無尿少尿或無尿 失血量（失血量（% %） 151520 35 4520 35 45 Clin

9、ical manifestation o hypotension o DIC o MODS n heart n brain n lung n kidney n Intestin ARDS o Interstitial edema o Alveolar collapsus o shunting 有血無氣 o Dead space increase 有氣無血 o Progressive hypoxia Acute kidney injury o Hypoperfusion o Water and sodium reabsorption o Oliguria et anuria o Necrosis

10、 of renal cortex Myocardial dysfunction o Less coronary vasoconstriction at beginning o Tachycardia with diastolic hypotension o Myocardial hypoxemia o Myocardial dysfunction related to dysfunction of ATPase o Acidosis, hyperkaliemia and myocardial depressive factor o Local necrosis Cerebral dysfunc

11、tion o Non-apparent at begining o hypoperfusion（MAP50mmHg） o Store-operated calcium entry o DIC, cerebral edema, intracranial hypertension, cerebral hernia Digestive dysfunction o erosion, bleeding, mucus, bowel sound decrease o Bacteria translocation into blood o sepsis Liver dysfunction o Kupffer

12、cell activated o Inhibition of macrophage o Minithrombose in the central vein and the hepatic sinus o Necrosis of hepatic lobules Monitoring o General o Special general o consciousness n Normal n anxious, somnolence, coma n Confusion o pulse n Tachycardia n Shock index Arterial Pression oAP =circula

13、tion volume * cardiac ejection * vascular tension o Arterial pression n Normal at beginning and decreases laterly because of decompensation o Skin n White, cold, wet, marble o Urine output n 0.51ml/Kg/h n Oliguria or anuria after fluid resuscitation means AKI Special o CVP o PCWP o Cardiac output an

14、d cardiac index o Oxygen delivery and oxygen consumption o Blood gas o lactate o DIC o pH intramucusal CVP的影響因素 o 升高 n 右心及左右心室衰竭 n 容量過多 n 導(dǎo)管過淺或進(jìn)入頸內(nèi)靜 脈 n 血管收縮 n 胸腹腔壓力增加 n 膠體應(yīng)用 o 降低 n 容量過少 n 血管擴(kuò)張 n 導(dǎo)管位置過深 n 測量系統(tǒng)密閉性喪失 Swan-ganz oPCWP 0.8-1.6KPa n Left heart function and precharge n 2.4KPa：left heart dy

15、sfunction n 4.0Kpa：pulmonary edema o CO n Ejection volume per minute : 4-6L/min n Stroke volume heart rate n Left heart function o cardiac index n CO/body surface : 2.5-3.2 n 2.5L/minm2 heart dysfunction n 1.8L/minm2 cardiogenic shock o Systemic Vascular Resistance Index n postcharge n (MAP-CVP)/CO

16、n CO encreases when SVRI decreases oArterial oxygen delivery n 520-720ml / (minm2) n CO arterial oxygen content （saturation and hemoglobin ） Transport doxygne oOxygen consumption n Oxygen consumed in Microcirculation n 100-180ml/（minm2）in peace n Tissular needs n If oxygen consumption 2% o From hype

17、rcoagulability to hypocoagulability Treatment o Hemostasis o lift lower limbs o Fluid resuscitation n Peripheral and central vein access： catheter n Fluid speed depends on access calibre o Oxygenotherapy o Keep warm Fluid resuscitation o important ！ n Speed not fixed n Pulmonary edema if too fast n

18、Low BP if too slow n Need precised survey o Type of fluid n Crystalloid and colloid? n Same according to SAFE TRIPS study Etiologic treatment o Most important ！ o surgical shock n Hemostasis n Foci of infection o Biliary lithiase, ileus, liver abces, pancreatitis, acute appendicitis Metabolic acidos

19、is Vasopressor o 縮血管 o 擴(kuò)血管 o 縮血管 o 擴(kuò)血管+縮血管 Whats the vascular state？ 正常低容量感染性休克 血容量正常低低 血管狀態(tài)正常收縮收縮/擴(kuò)張 補(bǔ)液后血管擴(kuò)張正常、擴(kuò)張正常、擴(kuò)張 張力好好（短時間）差 后果血壓正常血壓不升 處理 擴(kuò)張內(nèi)臟血管 多巴胺 增加血管張力 去甲腎上腺素 o Dopamin n 15mg/kg/min : vasoconstriction o Noradrenalin n a1: peripheral vasoconstriction n b1:heart contraction n Especially in

20、 septic shock n Dose：0.031mg/kgmin n Lactate accumulation leading from overdose o adrenalin n CPR o Vasopressin n if noradrenalin doesnt work n 0.04u/min o Dobutamin n Agoniste nonselective of b receptor n b1:inotropic n b2:redistribution du sang des intestin n Associated with noradrenalin in case o

21、f septic shock with heart failure n 2.510mg/kgmin Anticoagulation o unfractionated heparin o Low molecular weight heparin hemorragic shock o Blood lose 20% o Hypovolemia with vasoconstriction o Pale o CVP decrease treatment o Resuscitation and hemostasis n Plasma and red cell o speed ： n Quick at be

22、ginning n Regulation by response n Avoid hypertension hemostasis o Compression o Operation traumatic shock o bleeding o Local or systemic inflammation o Capillary leak o neuro-endocrinologic response treatment o resuscitation o evaluation n CT scan o Life support n Pulmonary contusion, ARDS o Operation n General surgery, chest , orthopedic , neuro-surgery , urology Septic shock o SIRS o