（精选课件）休克的液体复苏.pptVIP

羟乙基淀粉与明胶，哪个更安全？ * 如何评判液体复苏是否成功 血流动力学监测指标是临床判断液体复苏程度的基本依据 液体复苏往往随着病情的动态进展，血液动力学指标也发生相应的变化 液体复苏只是保证治疗过程中的组织灌注，它不能替代原发病的治疗 组织灌注及脏器功能的改善，才是真正评定液体复苏成功与否的标准。必须彻底治疗原发病，才能保证救治的成功 * 液体复苏失败的原因及处理 病情评估应持续在整个治疗过程中 诊断是否正确 液体复苏是否及时 液体的种类、数量、速度等是否适当 原发病是否有效控制 其它因素的干扰 严密监测下进行及时调整 组织灌注不足 要补液! 肺水肿 要利尿! * * * 首先来看血液制品。 血液制品的危害正在被越来越多的医师所熟悉.但很多人仍错误地以为尽管风险大,但它的扩容效力最强,同时由于其含红细胞,所以改善氧供效果最佳.实际上,.....… 综上所述, 试图使用任何血液制品为临床麻醉中的大多数常规患者来扩容, 是完全错误的. * * * Hypertonic saline has been advocated for resuscitation for many years. The concept is that very high concentrations of sodium chloride will reexpand the intravascular compartment very rapidly at the expense of the extracellular space. For short-term, but the resuscitation hypertonic saline has been shown to be beneficial in a number of circumstances, particularly where trauma is involved cerebral injury. It is, however, effective for a limited period only and the hyperchloraemia may have negative long-term consequences. Combine with either hydroxyethyl starch dextran, hypertonic saline has been shown to reduce excellent resuscitation with improved cerebral outcome. * * * Management : guidelines Initial resuscitation Diagnosis Antibiotic therapy Source control Fluid therapy Vasopressors Inotropic therapy Steroids Rh APC Blood product administration k. Mechanical ventilation l. Sedation m. Glucose control n. Renal replacement o. Bicarbonate therapy p. Deep vein thrombosis prophylaxis q. Stress ulcer prophylaxis Dellinger R Int Care Med 2004;30:536-555 * 早期复苏治疗 ??Early Goal-Directed Therapy?? 早期目标治疗 Rivers E N Engl J Med 2001;345:1368-77 单一中心临床研究 263 个急诊科收治病人 有严重感染或感染性休克 随机化: EGDT vs 常规治疗 结果 : 医院死亡率 (28d) * * 技术路线(2) 插入漂浮导管(Swan—Ganz导管) 肺毛压PCWP≥18mmHg 强心药(dobutamine 20ug/kg/min) 达到达标值 肺毛压PCWP＜18mmHg 继续补液 * Early Goal Directed Therapy : Results