休克的诊断及治疗进展.pptVIP

调整血管活性药物的标准 CI降低(15 – 20%)或SvO2 ( 65%) 考虑使用多巴酚丁胺 MAP ? 80 – 90 mmHg 儿茶酚胺类药物的选择 感染性休克患者治疗的目标 MAP ? 70 – 80 mmHg CI ? 3.5 – 4 L/min/m2或SvO2 ? 65 – 70% 尿量? 0.5 – 0.7 ml/kg/h 血乳酸水平降低 皮肤灌注和意识状况改善 儿茶酚胺类药物的选择 药物的选择 CI ? 3.5 – 4 L/min/m2或SvO2 ? 65 – 70% 多巴胺或去甲肾上腺素 CI 3.5 L/min/m2或SvO2 65% 多巴酚丁胺 如果MAP 70 mmHg，加用去甲肾上腺素或多巴胺 如无效 加用肾上腺素，苯肾上腺素 有层次监测 以微循环为中心 以心脏为中心的循环监测 以氧输送为中心 有侧重监护 心源性休克:泵功能衰竭 低血容量性休克:循环容量丢失 梗阻性休克:血流主要通道受阻 分布性休克:血管收缩舒张调节功能异常 监护影响结果的经典 263例严重感染或感染性休克患者在入急诊室后： 常规监测：心率、血压、尿量、脉搏氧饱和度、呼吸频率、CVP 特殊监测：上腔静脉血氧饱和度ScvO2 Rivers ，EGDT N Engl J Med, Vol. 345, No. 19.November 8, 2001；1368-1377 依据不同的监护参数制订了不同的治疗措施 对照组（n=133）目标： CVP 8-12 mmHg MAP≧65 mmHg 尿量≧0.5 ml/kg 研究组（n=130）增加了 ScvO2≧70% 住院死亡率: 研究组30.5% 对照组46.5% 在最初6小时内研究组输血量多、输液量多40%、应用正性肌力药多 监护的进展 有创——无创 复杂——简单 循环——代谢 整体--器官--组织--细胞--分子水平 谢谢 The immediate priority is to rapidly determine the cause of shock. This is easily done if one remembers the relationship between cardiac output, peripheral resistance and mean arterial pressure. If the mean arterial pressure is normal but peripheral resistance is high then the cardiac output must be low. Alternatively if the mean arterial pressure is low either the cardiac output must be low or the peripheral resistance must be low. As peripheral resistance is one of the two determinants of blood pressure it is clearly vital that we assess this, which we can do this by feeling the hands and feet and assessing the peripheral perfusion Cardiac output is determined by heart rate and stroke volume so it is vital to know the heart rate Stroke volume is determined by preload, afterload and contractility. Preload can be estimated from the JVP, CVP or pulmonary artery occlusion pressure but afterload and contractility are difficult to assess clinically. This is self-evident if remembers that there are homeostatic mechanisms which maintain blood pressure even when cardiac output falls. Thus a fall in cardiac output and blood pressure results in vasocons