休克患者__麻醉讲解.ppt

过敏性休克 定 义 过敏性休克是一种由IgE介导的严重速发型过敏反应，其特点是发作迅速、强烈，不可预见性，最严重的病例可在短时间内死亡。 类过敏性休克非IgE介导，临床表现相似。 过敏原 抗生素 肌肉松弛剂-阿曲库铵 胶体 乳胶 抑肽酶 鱼精蛋白 Neuromuscular-blocking agents (%) responsible for anaphylaxis in France (n=336) from January 1997 to December 1998. Cisatracurium 0.03% Succinylcholine 23.20% Atracurium 21.10% Mivacurium 2.70% Pancuronium 6% Vecuronium 17.60% Rocuronium 29.20% 特 点 早期首要症状表现为心血管系统的塌陷、顽固的严重低血压 典型皮肤症状出现较晚或并不常见，患者处于睡眠麻醉状态及手术敷料的影响，患者的主诉或皮肤改变被掩盖，给临床麻醉医生的早期诊断及治疗带来一定的难度 特 点 严重的低血压多为过敏反应早期唯一的表现，典型的皮肤改变常在低血压一段时间后出现，气道阻力增高、支气管痉挛常缺如，早期呈不典型性 缺乏对围麻醉期过敏性休克的足够认识，延误治疗时机，对病人的预后可能是致命的 Effects of Adrenaline (Epinephrine) Comparison of its cardiovascular effects (at 10?g/min IVI) with noradrenaline (?-dominant) and isoprenaline (?2-dominant). Other important (if not crucial) ?2 effects: Mast-cell stabilisation (against IgE activation) Bronchodilatation The Use of Adrenaline in Anaphylaxis The problems with its use: Variable Absorption - give I.m. AVOID s.c. Arrhythmogenic in high dose - NEVER give 1:1000 ADRENALINE I.v. If using ADRENALINE as an IVI, it must be diluted and do not delay administration of ADRENALINE to set up IVI and gain IV access. Therefore: 1. Give ADRENALINE I.m promptly (can repeat at 5-10 min intervals) 2. Gain IV access 3. If patient remains shocked resort to IVI thus …. Dilute 0.5ml of 1:1000 ADRENALINE in 50ml of N/saline (1:100,000) 4. Infuse at 0.1-2ml/min (1-20ug/min) until haemodynamically stable 5. If using prolonged IVI, add renal-dose of DOPAMINE IVI. Histamine (H1) receptor antagonists 第一代 苯海拉明 sedating (although paradoxical excitation in overdose) anticholinergic effects 第二代 哌啶类 特非那定 西替利嗪 Non-sedating (poor CNS penetration) No anticholinergic effects Risk of VT (尖端扭转性室性心动过速 ) with 息斯敏—阿斯咪唑 Other drugs used in Anaphylaxis Nebulised or IV ?2 agonist (e.g. salbutamol) - useful where bronchospasm is the major sign and fails to respond promptly to IM adrenaline. IV Glucocorticoid