1、2023-1-7美国重症医学的基础教程休克的诊断与治疗美国重症医学的基础教美国重症医学的基础教程休克的诊断与治疗程休克的诊断与治疗美国重症医学的基础教程休克的诊断与治疗Objectives 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 differential di
2、agnosis of oliguriaSHK 2美国重症医学的基础教程休克的诊断与治疗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美国重症医学的基础教程休克的诊断与治疗 Shock CategoriesSHK 4 Cardiog
3、enic Hypovolemic Distributive Obstructive美国重症医学的基础教程休克的诊断与治疗Cardiogenic Shock Decreased contractility Increased filling pressures,decreased LV stroke work,decreased cardiac output Increased systemic vascular resistance compensatory美国重症医学的基础教程休克的诊断与治疗Hypovolemic Shock Decreased cardiac output Decreas
4、ed filling pressures Compensatory increase in systemic vascular resistanceSHK 6美国重症医学的基础教程休克的诊断与治疗Distributive Shock Normal or increased cardiac output Low systemic vascular resistance Low to normal filling pressures Sepsis,anaphylaxis,neurogenic,and acute adrenal insufficiencySHK 7美国重症医学的基础教程休克的诊断与
5、治疗Obstructive Shock Decreased cardiac output Increased systemic vascular resistance Variable filling pressures dependent on etiology Cardiac tamponade,tension pneumothorax,massive pulmonary embolus美国重症医学的基础教程休克的诊断与治疗Cardiogenic Shock Management Treat arrhythmias Diastolic dysfunction may require inc
6、reased filling pressures Vasodilators if not hypotensive Inotrope administration美国重症医学的基础教程休克的诊断与治疗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 hypo
7、xemia if blood pressure adequate美国重症医学的基础教程休克的诊断与治疗Hypovolemic 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,crystalloid,colloidSHK
8、11美国重症医学的基础教程休克的诊断与治疗Distributive Shock Therapy Restore intravascular volume Hypotension despite volume therapyInotropes and/or vasopressors Vasopressors for MAP 10 g/kg/min)vasoconstriction Chronotropic effectSHK 16美国重症医学的基础教程休克的诊断与治疗Inotropic Agents Dobutamine5-20 g/kg/minInotropic and variable ch
9、ronotropic effectsDecrease in systemic vascular resistanceSHK 17美国重症医学的基础教程休克的诊断与治疗Inotropic/Vasopressor Agents Norepinephrine0.05 g/kg/min and titrate to effectInotropic and vasopressor effectsPotent vasopressor at high dosesSHK 18美国重症医学的基础教程休克的诊断与治疗Inotropic/Vasopressor Agents EpinephrineBoth and
10、actions for inotropic and vasopressor effects0.1 g/kg/min and titrateIncreases myocardial O2 consumptionSHK 19美国重症医学的基础教程休克的诊断与治疗 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/pr
11、event organ hypoperfusion美国重症医学的基础教程休克的诊断与治疗Oliguria Marker of hypoperfusion Urine output in adults 2 hrs Etiologies PrerenalRenalPostrenalSHK 21美国重症医学的基础教程休克的诊断与治疗Evaluation of Oliguria History and physical examination Laboratory evaluationUrine sodiumUrine osmolality or specific gravityBUN,creatin
12、ineSHK 22美国重症医学的基础教程休克的诊断与治疗Evaluation of OliguriaLaboratory TestPrerenal ATNBlood Urea Nitrogen/201020 Creatinine RatioUrine Specific Gravity1.020500350Urinary Sodium(mEq/L)40Fractional Excretion of Sodium(%)2美国重症医学的基础教程休克的诊断与治疗Therapy in Acute Renal Insufficiency Correct underlying cause Monitor u
13、rine 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美国重症医学的基础教程休克的诊断与治疗Pediatric Considerations BP not good indication of hypoperfusion Capillary refill,extr
14、emity 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 vasopressorsSHK 25美国重症医学的基础教程休克的诊断与治疗Pediatric 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 262023-1-7美国重症医学的基础教程休克的诊断与治疗
