美国重症医学(FCCM)的基础教程 休克的诊断与治疗

SHK1®DiagnosisandManagementofShockSHK1®SHK2®Objectives•Identifythemajortypesofshockandprinciplesofmanagement•Reviewfluidresuscitationanduseofvasopressorandinotropicagents•UnderstandconceptsofO2supplyanddemand•DiscussthedifferentialdiagnosisofoliguriaSHK2®SHK3®Shock•Alwaysasymptomofprimarycause•Inadequatebloodflowtomeettissueoxygendemand•Maybeassociatedwithhypotension•Associatedwithsignsofhypoperfusion:mentalstatuschange,oliguria,acidosisSHK3®SHK4®ShockCategoriesSHK4•Cardiogenic•Hypovolemic•Distributive•Obstructive®SHK5®CardiogenicShock•Decreasedcontractility•Increasedfillingpressures,decreasedLVstrokework,decreasedcardiacoutput•Increasedsystemicvascularresistance–compensatorySHK6®HypovolemicShock•Decreasedcardiacoutput•Decreasedfillingpressures•CompensatoryincreaseinsystemicvascularresistanceSHK6®SHK7®DistributiveShock•Normalorincreasedcardiacoutput•Lowsystemicvascularresistance•Lowtonormalfillingpressures•Sepsis,anaphylaxis,neurogenic,andacuteadrenalinsufficiencySHK7®SHK8®ObstructiveShock•Decreasedcardiacoutput•Increasedsystemicvascularresistance•Variablefillingpressuresdependentonetiology•Cardiactamponade,tensionpneumothorax,massivepulmonaryembolusSHK9®CardiogenicShockManagement•Treatarrhythmias•Diastolicdysfunctionmayrequireincreasedfillingpressures•Vasodilatorsifnothypotensive•InotropeadministrationSHK10®CardiogenicShockManagement•Vasopressoragentneededifhypotensionpresenttoraiseaorticdiastolicpressure•Consultationformechanicalassistdevice•PreloadandafterloadreductiontoimprovehypoxemiaifbloodpressureadequateSHK11®HypovolemicShockManagement•Volumeresuscitation–crystalloid,colloid•Initialcrystalloidchoices–LactatedRinger’ssolution–Normalsaline(highchloridemayproducehyperchloremicacidosis)•Matchfluidgiventofluidlost–Blood,crystalloid,colloidSHK11®SHK12®DistributiveShockTherapy•Restoreintravascularvolume•Hypotensiondespitevolumetherapy–Inotropesand/orvasopressors•VasopressorsforMAP60mmHg•AdjunctiveinterventionsdependentonetiologySHK12®SHK13®ObstructiveShockTreatment•Relieveobstruction–Pericardiocentesis–Tubethoracostomy–Treatpulmonaryembolus•TemporarybenefitfromfluidorinotropeadministrationSHK14®FluidTherapy•Crystalloids–LactatedRinger’ssolution–Normalsaline•Colloids–Hetastarch–Albumin–Gelatins•Packedredbloodcells•InfusetophysiologicendpointsSHK14®SHK15®FluidTherapy•Correcthypotensionfirst•Decreaseheartrate•Correcthypoperfusionabnormalities•MonitorfordeteriorationofoxygenationSHK15®SHK16®Inotropic/VasopressorAgents•Dopamine–Lowdose(2-3g/kg/min)–mildinotropeplusrenaleffect–Intermediatedose(4-10g/kg/min)–inotropiceffect–Highdose(10g/kg/min)–vasoconstriction–ChronotropiceffectSHK16®SHK17®InotropicAgents•Dobutamine–5-20g/kg/min–Inotropicandvariablechronotropiceffects–DecreaseinsystemicvascularresistanceSHK17®SHK18®Inotropic/VasopressorAgents•Norepinephrine–0.05g/kg/minandtitratetoeffect–Inotropicandvasopressoreffects–PotentvasopressorathighdosesSHK18®SHK19®Inotropic/VasopressorAgents•Epinephrine–Bothandactionsforinotropicandvasopressoreffects–0.1g/kg/minandtitrate–IncreasesmyocardialO2consumptionSHK19®SHK20®TherapeuticGoalsinShock•IncreaseO2delivery•OptimizeO2contentofblood•Improvecardiacoutputandbloodpressure•MatchsystemicO2needswithO2delivery•Reverse/preventorganhypoperfusionSHK21®Oliguria•Markerofhypoperfusion•Urineoutputinadults0.5mL/kg/hrfor2hrs•Etiologies–Prerenal–Renal–PostrenalSHK21®SHK22®EvaluationofOliguria•Historyandphysicalexamination•Laboratoryevaluation–Urinesodium–Urineosmolalityorspecificgravity–BUN,creatinineSHK22®SHK23®EvaluationofOliguriaLaboratoryTestPrerenalATNBloodUreaNitrogen/2010–20CreatinineRatioUrineSpecificGravity1.0201.010UrineOsmolality(mOsm/L)500350UrinarySodium(mEq/L)2040FractionalExcretionofSodium(%)12SHK24®TherapyinAcuteRenalInsufficiency•Correctunderlyingcause•Monitorurineoutput•Assureeuvolemia•Diureticsnottherapeutic•Low-dosedopaminemayurineflow•Adjustdosagesofotherdrugs•Monitorelectrolytes,BUN,creatinine•ConsiderdialysisorhemofiltrationSHK24®SHK25®PediatricConsiderations•BPnotgoodindicationofhypoperfusion•Capillaryrefill,extremitytemperaturebettersignsofpoorsystemicperfusion•Epinephrinepreferabletonorepinephrineduetomorechronotropicbenefit•Fluidbolusesof20mL/kgtitratedtoBPortotal60mL/kg,beforeinotropesorvasopressorsSHK25®SHK26®PediatricConsiderations•Neonates–considercongenitalobstructiveleftheartsyndromeascauseofobstructiveshock•Oliguria–2yrsold,urinevolume2mL/kg/hr–Olderchildren,urinevolume1mL/kg/hrSHK26®SHK27®KeyPoints