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美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療2022/12/18美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療2022/12/14美1ObjectivesIdentifythemajortypesofshockandprinciplesofmanagementReviewfluidresuscitationanduseofvasopressorandinotropicagentsUnderstandconceptsofO2supplyanddemandDiscussthedifferentialdiagnosisofoliguriaSHK2
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObjectivesIdentifythemajort2ShockAlwaysasymptomofprimarycauseInadequatebloodflowtomeettissueoxygendemandMaybeassociatedwithhypotensionAssociatedwithsignsofhypoperfusion:mentalstatuschange,oliguria,acidosisSHK3
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ShockAlwaysasymptomofprima3
ShockCategoriesSHK4
CardiogenicHypovolemicDistributiveObstructive?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ShockCategories4CardiogenicShockDecreasedcontractilityIncreasedfillingpressures,decreasedLVstrokework,decreasedcardiacoutputIncreasedsystemic
vascularresistance–compensatory美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockDecreasedcon5HypovolemicShockDecreasedcardiacoutputDecreasedfillingpressuresCompensatoryincreaseinsystemicvascularresistanceSHK6
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療HypovolemicShockDecreasedcar6DistributiveShockNormalorincreasedcardiacoutputLowsystemicvascularresistanceLowtonormalfillingpressuresSepsis,anaphylaxis,neurogenic,
andacuteadrenalinsufficiencySHK7
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療DistributiveShockNormalorin7ObstructiveShockDecreasedcardiacoutputIncreasedsystemicvascularresistanceVariablefillingpressuresdependentonetiologyCardiactamponade,tensionpneumothorax,massivepulmonaryembolus美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObstructiveShockDecreasedcar8CardiogenicShockManagementTreatarrhythmiasDiastolicdysfunctionmayrequireincreasedfillingpressuresVasodilatorsifnothypotensiveInotropeadministration美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockManagementTr9CardiogenicShockManagementVasopressoragentneededifhypotensionpresenttoraiseaorticdiastolicpressureConsultationformechanicalassistdevicePreloadandafterloadreductiontoimprovehypoxemiaifbloodpressureadequate美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockManagementVa10HypovolemicShock
ManagementVolumeresuscitation–crystalloid,colloidInitialcrystalloidchoicesLactatedRinger’ssolutionNormalsaline(highchloridemayproducehyperchloremicacidosis)MatchfluidgiventofluidlostBlood,crystalloid,colloidSHK11
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療HypovolemicShock
Management11DistributiveShockTherapyRestoreintravascularvolumeHypotensiondespitevolumetherapyInotropesand/orvasopressorsVasopressorsforMAP<60mmHgAdjunctiveinterventionsdependentonetiologySHK12
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療DistributiveShockTherapyRest12ObstructiveShockTreatmentRelieveobstructionPericardiocentesisTubethoracostomyTreatpulmonaryembolusTemporarybenefitfromfluidorinotropeadministration美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObstructiveShockTreatmentRel13FluidTherapyCrystalloidsLactatedRinger’ssolutionNormalsalineColloidsHetastarchAlbuminGelatinsPackedredbloodcellsInfusetophysiologicendpointsSHK14
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療FluidTherapyCrystalloidsSHK14FluidTherapyCorrecthypotensionfirstDecreaseheartrateCorrecthypoperfusionabnormalitiesMonitorfordeteriorationofoxygenationSHK15
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療FluidTherapyCorrecthypotensi15Inotropic/VasopressorAgentsDopamineLowdose(2-3g/kg/min)–mildinotrope
plusrenaleffectIntermediatedose(4-10g/kg/min)–
inotropiceffectHighdose(>10g/kg/min)–
vasoconstrictionChronotropiceffectSHK16
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents16InotropicAgentsDobutamine5-20g/kg/minInotropicandvariablechronotropiceffectsDecreaseinsystemicvascularresistanceSHK17
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療InotropicAgentsDobutamineSHK17Inotropic/VasopressorAgentsNorepinephrine0.05g/kg/minandtitratetoeffectInotropicandvasopressoreffectsPotentvasopressorathighdosesSHK18
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents18Inotropic/VasopressorAgentsEpinephrineBothandactionsforinotropicandvasopressoreffects0.1g/kg/minandtitrateIncreasesmyocardialO2consumptionSHK19
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents19
TherapeuticGoalsinShockIncreaseO2deliveryOptimizeO2contentofbloodImprovecardiacoutputand
bloodpressureMatchsystemicO2needswithO2deliveryReverse/preventorganhypoperfusion
美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療TherapeuticGoalsinShockIn20OliguriaMarkerofhypoperfusionUrineoutputinadults
<0.5mL/kg/hrfor>2hrsEtiologiesPrerenalRenalPostrenalSHK21
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療OliguriaMarkerofhypoperfusio21EvaluationofOliguria
HistoryandphysicalexaminationLaboratoryevaluationUrinesodiumUrineosmolalityorspecificgravityBUN,creatinineSHK22
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療EvaluationofOliguriaHistory22EvaluationofOliguriaLaboratoryTest Prerenal ATNBloodUreaNitrogen/ >20 10–20
CreatinineRatio UrineSpecificGravity >1.020 <1.010UrineOsmolality(mOsm/L) >500 <350 UrinarySodium(mEq/L) <20 >40FractionalExcretionofSodium(%) <1 >2美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療EvaluationofOliguriaLaborato23TherapyinAcuteRenalInsufficiencyCorrectunderlyingcauseMonitorurineoutputAssureeuvolemiaDiureticsnottherapeuticLow-dosedopaminemayurineflowAdjustdosagesofotherdrugsMonitorelectrolytes,BUN,creatinineConsiderdialysisorhemofiltrationSHK24
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療TherapyinAcuteRenalInsuffi24PediatricConsiderationsBPnotgoodindicationofhypoperfusionCapillaryrefill,extremitytemperaturebetter
signsofpoorsystemicperfusionEpinephrinepreferabletonorepinephrineduetomorechronotropicbenefitFluidbolusesof20mL/kgtitratedtoBPortotal60mL/kg,beforeinotropesorvasopressorsSHK25
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療PediatricConsiderationsBPnot25PediatricConsiderationsNeonates–considercongenital
obstructiveleftheartsyndromeascauseofobstructiveshockOliguria<2yrsold,urinevolume<2mL/kg/hrOlderchildren,urinevolume
<1mL/kg/hrSHK26
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療PediatricConsiderationsNeonat26演講完畢，謝謝聽講!再見，seeyouagain3rew2022/12/18美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療演講完畢，謝謝聽講!再見，seeyouagain3rew27美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療2022/12/18美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療2022/12/14美28ObjectivesIdentifythemajortypesofshockandprinciplesofmanagementReviewfluidresuscitationanduseofvasopressorandinotropicagentsUnderstandconceptsofO2supplyanddemandDiscussthedifferentialdiagnosisofoliguriaSHK29
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObjectivesIdentifythemajort29ShockAlwaysasymptomofprimarycauseInadequatebloodflowtomeettissueoxygendemandMaybeassociatedwithhypotensionAssociatedwithsignsofhypoperfusion:mentalstatuschange,oliguria,acidosisSHK30
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ShockAlwaysasymptomofprima30
ShockCategoriesSHK31
CardiogenicHypovolemicDistributiveObstructive?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ShockCategories31CardiogenicShockDecreasedcontractilityIncreasedfillingpressures,decreasedLVstrokework,decreasedcardiacoutputIncreasedsystemic
vascularresistance–compensatory美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockDecreasedcon32HypovolemicShockDecreasedcardiacoutputDecreasedfillingpressuresCompensatoryincreaseinsystemicvascularresistanceSHK33
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療HypovolemicShockDecreasedcar33DistributiveShockNormalorincreasedcardiacoutputLowsystemicvascularresistanceLowtonormalfillingpressuresSepsis,anaphylaxis,neurogenic,
andacuteadrenalinsufficiencySHK34
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療DistributiveShockNormalorin34ObstructiveShockDecreasedcardiacoutputIncreasedsystemicvascularresistanceVariablefillingpressuresdependentonetiologyCardiactamponade,tensionpneumothorax,massivepulmonaryembolus美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObstructiveShockDecreasedcar35CardiogenicShockManagementTreatarrhythmiasDiastolicdysfunctionmayrequireincreasedfillingpressuresVasodilatorsifnothypotensiveInotropeadministration美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockManagementTr36CardiogenicShockManagementVasopressoragentneededifhypotensionpresenttoraiseaorticdiastolicpressureConsultationformechanicalassistdevicePreloadandafterloadreductiontoimprovehypoxemiaifbloodpressureadequate美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療CardiogenicShockManagementVa37HypovolemicShock
ManagementVolumeresuscitation–crystalloid,colloidInitialcrystalloidchoicesLactatedRinger’ssolutionNormalsaline(highchloridemayproducehyperchloremicacidosis)MatchfluidgiventofluidlostBlood,crystalloid,colloidSHK38
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療HypovolemicShock
Management38DistributiveShockTherapyRestoreintravascularvolumeHypotensiondespitevolumetherapyInotropesand/orvasopressorsVasopressorsforMAP<60mmHgAdjunctiveinterventionsdependentonetiologySHK39
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療DistributiveShockTherapyRest39ObstructiveShockTreatmentRelieveobstructionPericardiocentesisTubethoracostomyTreatpulmonaryembolusTemporarybenefitfromfluidorinotropeadministration美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療ObstructiveShockTreatmentRel40FluidTherapyCrystalloidsLactatedRinger’ssolutionNormalsalineColloidsHetastarchAlbuminGelatinsPackedredbloodcellsInfusetophysiologicendpointsSHK41
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療FluidTherapyCrystalloidsSHK41FluidTherapyCorrecthypotensionfirstDecreaseheartrateCorrecthypoperfusionabnormalitiesMonitorfordeteriorationofoxygenationSHK42
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療FluidTherapyCorrecthypotensi42Inotropic/VasopressorAgentsDopamineLowdose(2-3g/kg/min)–mildinotrope
plusrenaleffectIntermediatedose(4-10g/kg/min)–
inotropiceffectHighdose(>10g/kg/min)–
vasoconstrictionChronotropiceffectSHK43
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents43InotropicAgentsDobutamine5-20g/kg/minInotropicandvariablechronotropiceffectsDecreaseinsystemicvascularresistanceSHK44
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療InotropicAgentsDobutamineSHK44Inotropic/VasopressorAgentsNorepinephrine0.05g/kg/minandtitratetoeffectInotropicandvasopressoreffectsPotentvasopressorathighdosesSHK45
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents45Inotropic/VasopressorAgentsEpinephrineBothandactionsforinotropicandvasopressoreffects0.1g/kg/minandtitrateIncreasesmyocardialO2consumptionSHK46
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療Inotropic/VasopressorAgents46
TherapeuticGoalsinShockIncreaseO2deliveryOptimizeO2contentofbloodImprovecardiacoutputand
bloodpressureMatchsystemicO2needswithO2deliveryReverse/preventorganhypoperfusion
美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療TherapeuticGoalsinShockIn47OliguriaMarkerofhypoperfusionUrineoutputinadults
<0.5mL/kg/hrfor>2hrsEtiologiesPrerenalRenalPostrenalSHK48
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療OliguriaMarkerofhypoperfusio48EvaluationofOliguria
HistoryandphysicalexaminationLaboratoryevaluationUrinesodiumUrineosmolalityorspecificgravityBUN,creatinineSHK49
?美國(guó)重癥醫(yī)學(xué)的基礎(chǔ)教程休克的診斷與治療EvaluationofOliguriaHistory49EvaluationofOliguriaLaboratoryTest Prerenal ATNBloodUreaNitrogen/ >20 10–20
CreatinineR
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