休克诊治路围径胶州.ppt

* 严重创伤、大量失血、重大手术均会对大循环造成影响！ 当大循环功能障碍时：心、肝、脑、肾等重要脏器的灌注大幅下降。与此同时，由于血流动力学的紊乱，有效循环血量不足，进一步导致微循环的灌注不足，氧供给下降造成氧债，O2 供 与O2 耗的不均衡导致细胞破坏；最终可能发展成多脏器衰竭。 Angus et al studied the incidence, cost, and outcome of severe sepsis in the United States. In a study based on 1995 state hospital discharge records from 7 large states with population and hospital data from the US Census, Centers for Disease Control, HCFA, and the American Hospital Association, the investigators generated national sepsis data. In this study, they report that the incidence of severe sepsis is 300 cases/100,000 population. As shown on the slide, this is significantly greater than the incidence of other well recognized diseases as reported by the American Heart Association. Similarly, Angus et al reported that the annual mortality of severe sepsis in 1995 was 215,000. According to the American Heart Association, this is virtually identical to the number of people in the US who die suddenly of coronary heart disease without being hospitalized. American Cancer Society. 2000 Statistics. Available at: on 3/19/01. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association, 2000. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Incidence, cost, outcome of severe sepsis in the United States. Crit Care Med. 2001 (In Press). National Center for Health Statistics. Fast Stats (AIDS/HIV). Available at: /nchs/fastats/aids-hiv.htm on 3/19/01. * * * * （二）休克复苏流程及目标 第一期 Slavage 治疗原发病 基本监测 维持循环 MAP CO 第二期 Optimization 治疗原发病 恰当液体复苏 监测 乳酸 ScVO2 增加细胞氧供 第三期 Stabilization 器官功能 支持 防治MODS 第四期 Deescalation 撤离血管 活性要 减轻容量负荷  1第一阶段 MAP与容量管理 脓毒症早期目标指导性治疗 EGDT MAP 65mmHg 1 CVP ≥8-12mmHg 晶体液 30ml/kg 天然胶体，白蛋白 2 MAP ≥65mmHg 去甲肾上腺素 2 SSC 3 小时实现目标 3小时内实现目标 测量血乳酸浓度 使用抗生素前留取血细菌学培养 使用广谱抗生素（强广早静脉） 如果低血压或乳酸≧4 补充晶体液30ml/kg 3 SSC 6 小时实现目标 5. 低血压经液体复苏无效、使用缩血管药物 维持平均动脉压≧65mmHg （首选去甲肾上腺素） 脓毒症休克 且乳酸≧4mm0l/L 测量中心静脉压（CVP 8cmH20） 测量中心静脉氧饱和度