美国重症医学FCCM的基础教程休克的诊断与治疗课件.ppt

1、Diagnosis and Management of ShockSHK 1?D i a g n o s i s a n d Ma n a g e me n t o f S hObjectives?Identify the major types of shock and principles of management?Review fluid resuscitation and use of vasopressor and inotropic agents?Understand concepts of O2 supply and demand?Discuss the differentia

2、l diagnosis of oliguriaSHK 2?O b j e c t i v e s?I d e n t i f y t h e ma j o r Shock?Always a symptom of primary cause?Inadequate blood flow to meet tissue oxygen demand?May be associated with hypotension?Associated with signs of hypoperfusion:mental status change,oliguria,acidosisSHK 3?S h o c k?A

3、 l w a y s a s y mp t o m o f p r i mShock CategoriesSHK 4?Cardiogenic?Hypovolemic?Distributive?Obstructive?S h o c k C a t e g o r i e s S H K 4?C a r d i o gSHK 5?Cardiogenic Shock?Decreased contractility?Increased filling pressures,decreased LV stroke work,decreased cardiac output?Increased syste

4、mic vascular resistance compensatoryS H K 5?C a r d i o g e n i c S h o c k?D e c r eHypovolemic Shock?Decreased cardiac output?Decreased filling pressures?Compensatory increase in systemic vascular resistanceSHK 6?H y p o v o l e mi c S h o c k?D e c r e a s e d c aSHK 7Distributive Shock?Normal or

5、 increased cardiac output?Low systemic vascular resistance?Low to normal filling pressures?Sepsis,anaphylaxis,neurogenic,and acute adrenal insufficiencySHK 7?S H K 7 D i s t r i b u t i v e S h o c k?N o r maSHK 8?Obstructive Shock?Decreased cardiac output?Increased systemic vascular resistance?Vari

6、able filling pressures dependent on etiology?Cardiac tamponade,tension pneumothorax,massive pulmonary embolusS H K 8?O b s t r u c t i v e S h o c k?D e c r eSHK 9?Cardiogenic Shock Management?Treat arrhythmias?Diastolic dysfunction may require increased filling pressures?Vasodilators if not hypoten

7、sive?Inotrope administrationS H K 9?C a r d i o g e n i c S h o c k Ma n a gSHK 10?Cardiogenic Shock Management?Vasopressor agent needed if hypotension present to raise aortic diastolic pressure?Consultation for mechanical assist device?Preload and afterload reduction to improve hypoxemia if blood p

8、ressure adequateS H K 1 0?C a r d i o g e n i c S h o c k Ma n aSHK 11Hypovolemic Shock Management?Volume resuscitation crystalloid,colloid?Initial crystalloid choices Lactated Ringers solution Normal saline(high chloride may produce hyperchloremic acidosis)?Match fluid given to fluid lost Blood,cry

9、stalloid,colloidSHK 11?S H K 1 1 H y p o v o l e mi c S h o c k Ma n a gDistributive Shock Therapy?Restore intravascular volume?Hypotension despite volume therapyInotropes and/or vasopressors?Vasopressors for MAP 10?g/kg/min)vasoconstriction Chronotropic effectSHK 16?S H K 1 6 I n o t r o p i c /V a

10、 s o p r e s s o rSHK 17Inotropic Agents?Dobutamine5-20?g/kg/minInotropic and variable chronotropic effectsDecrease in systemic vascular resistanceSHK 17?S H K 1 7 I n o t r o p i c A g e n t s?D o b u t aSHK 18Inotropic/Vasopressor Agents?Norepinephrine0.05?g/kg/min and titrate to effectInotropic a

11、nd vasopressor effectsPotent vasopressor at high dosesSHK 18?S H K 1 8 I n o t r o p i c /V a s o p r e s s o rSHK 19Inotropic/Vasopressor Agents?EpinephrineBoth?and?actions for inotropic and vasopressor effects0.1?g/kg/min and titrateIncreases myocardial O2consumptionSHK 19?S H K 1 9 I n o t r o p

12、i c /V a s o p r e s s o rSHK 20?Therapeutic Goals in Shock?Increase O2 delivery?Optimize O2 content of blood?Improve cardiac output and blood pressure?Match systemic O2 needs with O2 delivery?Reverse/prevent organ hypoperfusionS H K 2 0?T h e r a p e u t i c G o a l s i n SSHK 21Oliguria?Marker of

13、hypoperfusion?Urine output in adults 2 hrs?Etiologies PrerenalRenalPostrenalSHK 21?S H K 2 1 O l i g u r i a?Ma r k e r o f h y p oSHK 22Evaluation of Oliguria?History and physical examination?Laboratory evaluationUrine sodiumUrine osmolality or specific gravityBUN,creatinineSHK 22?S H K 2 2 E v a l

14、 u a t i o n o f O l i g u r i a?SHK 23?Evaluation of OliguriaLaboratory TestPrerenalATNBlood Urea Nitrogen/201020Creatinine RatioUrine Specific Gravity1.020500350Urinary Sodium(mEq/L)40Fractional Excretion of Sodium(%)2S H K 2 3?E v a l u a t i o n o f O l i g u r i aSHK 24Therapy in Acute Renal In

15、sufficiency?Correct underlying cause?Monitor urine output?Assure euvolemia?Diuretics not therapeutic?Low-dose dopamine may?urine flow?Adjust dosages of other drugs?Monitor electrolytes,BUN,creatinine?Consider dialysis or hemofiltrationSHK 24?S H K 2 4 T h e r a p y i n A c u t e R e n a l SHK 25Pedi

16、atric Considerations?BP not good indication of hypoperfusion?Capillary refill,extremity temperature bettersigns of poor systemic perfusion?Epinephrine preferable to norepinephrine due to more chronotropic benefit?Fluid boluses of 20 mL/kg titrated to BP or total 60 mL/kg,before inotropes or vasopres

17、sorsSHK 25?S H K 2 5 P e d i a t r i c C o n s i d e r a t i o nSHK 26Pediatric Considerations?Neonates consider congenitalobstructive left heart syndrome as cause of obstructive shock?Oliguria2 yrs old,urine volume 2 mL/kg/hrOlder children,urine volume 1 mL/kg/hrSHK 26?S H K 2 6 P e d i a t r i c C o n s i d e r a t i o nSHK 27?Key PointsS H K 2 7?K e y P o i n t s