于志偉副主任醫(yī)師哈爾濱醫(yī)科大學(xué)附屬腫瘤醫(yī)院，結(jié)直腸外科,休克ShockSyndrome,休克(Shock)的定義,休克是指任何原因引起有效循環(huán)血量減少,導(dǎo)致組織和器官氧合血液灌流不足,從而發(fā)生的代謝障礙和功能細(xì)胞受損的病理過(guò)程Shockisaconditioninwhichthecardiovascularsystemfailstoperfusetissuesadequately.Inadequatetissueperfusioncanresultin:generalizedcellularhypoxia(starvation)widespreadimpairmentofcellularmetabolismtissuedamageorganfailuredeath維持有效循環(huán)血量的必要因素:充足的血容量Sufficientbloodvolume有效的心排出量Effectivecardiacpump良好的周圍血管張力Upstandingperipheralangiotasis,Effectivecirculatingbloodvolume,休克的分類（TypesofShock）,分類疾病舉例低血容量性休克創(chuàng)傷出血、上消化道出血（hypovolemicshock）燒傷、腸梗阻感染性休克膽道感染等（SepticShock）心源性休克心梗（CardiogenicShock）過(guò)敏性休克青霉素過(guò)敏、血清過(guò)敏（Anaphylacticshock）神經(jīng)源性休克疼痛刺激、脊髓損傷（NeurogenicShock）,hemorrhageshockandtraumaticshock.,PATHOPHYSIOLOGYOFSHOCKSYNDROME,微循環(huán)改變MicrocirculationChange代謝變化MetabolismChange內(nèi)臟器官的繼發(fā)性損害Secondarydamageoninternalorgans,MicrocirculationChange,Decompensatedphase,Compensatedphase,Irreversiblephase,Death,Sympatheticnervoussystemactivates,CardiaceffectsIncreasedforceofcontractionsIncreasedheartrateIncreasedcardiacoutput,PeripheraleffectsArteriolarconstrictionPre-/post-capillarysphinctercontractionIncreasedperipheralresistanceShuntingofbloodtocoreorgans,DecreasedrenalbloodflowReninreleasedfromkidneyarterioleRenin交感神經(jīng)活動(dòng)增強(qiáng)1.神清(consciousness)，但煩躁(restlessness)，呼吸加快(quickenrespiration)2.皮膚蒼白(Paleskin)，手足厥冷(Coldhandsandfeet)3.心率快(Rapidrate)，血壓正常(NormalBP)或稍升高(IncreasingBP)，舒張壓(diastolicbloodpressure)升高，脈壓縮小(narrowpulsepressure)4.尿量(urineoutput)正常或減少,休克抑制期：?jiǎn)适а萘?0%1.神志淡漠(Disturbanceofconsciousness)昏迷(Coma)2.口唇(Orallip)、肢端(Limb)發(fā)紺(Cyanosis)，出冷汗(Coldsweat)3.脈細(xì)速(Rapidrateandthread/weakpulse)，血壓下降(FallingBP)，脈壓差(Pulsepressuredifference)明顯縮小4.5.尿量減少或無(wú)尿(Anuria),休克的臨床表現(xiàn),重度休克：血容量喪失40%1.昏迷(Coma)2.全身皮膚粘膜紫紺(Cyanosis)，四肢冰冷3.脈搏摸不到，血壓測(cè)不出4.無(wú)尿(Anuria)5.器官功能衰竭的表現(xiàn),休克的臨床表現(xiàn),休克的診斷DiagnosisofShock,早期診斷:病史：失血、失液、創(chuàng)傷等臨床表現(xiàn)：興奮或煩躁，出冷汗，心率快，脈壓縮小，尿少抑制期診斷：依靠典型表現(xiàn)神志淡漠，反應(yīng)遲鈍，皮膚蒼白或紫紺，四肢濕冷，脈細(xì)速，呼吸淺快，收縮壓下降至12kPa（90mmHg）以下，尿少或無(wú)尿,神志狀態(tài)(Mentalstatus)肢體溫度、色澤(Limbtemperatureandcolor)血壓(Bloodpressure)脈率(Pulse)尿量(Urineoutput),休克的監(jiān)測(cè)一般監(jiān)測(cè)GeneralMonitor,休克的監(jiān)測(cè)特殊監(jiān)測(cè)SpecialMonitor,中心靜脈壓(CentralVenousPressure,CVP):血容量和心功能正常值：0.49-0.98kPa(5-10cmH2O)CVP，血容量不足CVP，心功能不全或過(guò)度收縮（1.47kPa)充血性心力衰竭(CongestiveHeartFailure)(1.96kPa),休克的監(jiān)測(cè)特殊監(jiān)測(cè)SpecialMonitor,肺動(dòng)脈楔壓(PulmonaryCapillaryWedgePressure,PCWP)：可直接反映肺靜脈、左心房和左心室的壓力，了解肺循環(huán)阻力正常值：0.8-2.0kPa,低于正常值，提示血容量不足，4.0kPa，表示肺水腫心排出量和心臟指數(shù)：心排出量難以準(zhǔn)確測(cè)定，臨床應(yīng)用少動(dòng)脈血?dú)夥治?ArterialBloodGasAnalysis)：可了解呼吸功能和酸堿平衡的變化。PaO280-100mmHg,PaCO236-44mmHg,PaCO260mmHg,PaO2<60mmHg,休克的監(jiān)測(cè)特殊監(jiān)測(cè)SpecialMonitor,動(dòng)脈血乳酸鹽測(cè)定：反映細(xì)胞血液灌流情況。正常值：1-2mmol/L，濃度越高，休克越嚴(yán)重。8mmol/L,死亡率100%。DIC的實(shí)驗(yàn)室檢查確診依據(jù)：Plat3,副凝實(shí)驗(yàn)(+);3P試驗(yàn)陽(yáng)性；血涂片中破碎紅細(xì)胞超過(guò)2%。,休克的治療TreatmentofShock,一般緊急措施控制活動(dòng)性大出血休克體位:頭和軀干抬高20-30度,下肢抬高5-20度吸氧，6-8L/min；保持呼吸道通暢保持安靜，避免搬動(dòng)保暖，可用休克服,休克的治療TreatmentofShock,補(bǔ)充血容量(Restorecirculatingvolumeandtissueperfusion)：是抗休克的根本措施補(bǔ)充量：可根據(jù)CVP調(diào)節(jié)，應(yīng)補(bǔ)充喪失量和已擴(kuò)大的毛細(xì)血管床容量積極處理原發(fā)病(TreatReversibleCauses)：在恢復(fù)有效血容量后積極手術(shù)處理外科原發(fā)病。在原發(fā)病不除，休克不能糾正時(shí)，應(yīng)抗休克的同時(shí)，積極手術(shù)處理，以免喪失搶救時(shí)機(jī),Shocktreatment,“Arudeunhingingofthemachineryoflife”,“Abriefpauseintheactofdying”,休克的治療TreatmentofShock,糾正酸堿平衡失調(diào)：主要是酸中毒酸中毒的糾正有賴于休克的根本好轉(zhuǎn)補(bǔ)充血容量，改善組織灌流，休克嚴(yán)重者，應(yīng)給予堿性藥物如碳酸氫鈉心血管藥物的應(yīng)用(CirculatorySupport)Vasoconstrictor：去甲腎上腺素；間羥胺；苯腎上腺素；苯芐胺；芐胺唑啉；多巴胺；異丙腎上腺素；西地蘭等治療DIC改善微循環(huán)皮質(zhì)類固醇和其他藥物的應(yīng)用,Insummary,TreatmentofShock,IdentifythepatientathighriskforshockControloreliminatethecauseImplementmeasurestoenhancetissueperfusionCorrectacidbaseimbalanceTreatcardiacdysrhythmias,失血性休克的治療(TreatmentofHemorrhagicShock),補(bǔ)充血容量：根據(jù)情況輸入晶體或/和膠體溶液出血量少，無(wú)活動(dòng)性出血者，輸入晶體液出血量大，有活動(dòng)性出血者，先輸晶體液，后輸血根據(jù)中心靜脈壓調(diào)整輸液量和速度止血：在補(bǔ)充血容量的同時(shí)積極止血要處理好休克和止血手術(shù)間的辨證關(guān)系,中心靜脈壓和補(bǔ)液的關(guān)系,CVPBP原因處理原則低低血容量嚴(yán)重不足充分補(bǔ)液低正常血容量不足適當(dāng)補(bǔ)液高低心功能不全強(qiáng)心藥，糾酸，或血容量相對(duì)過(guò)多舒血管高正常容量血管過(guò)度收縮舒張血管正常低心功能不全補(bǔ)液實(shí)驗(yàn)或血容量不足,損傷性休克的治療(TreatmentofTraumaticShock),補(bǔ)充血容量：應(yīng)根據(jù)監(jiān)測(cè)指標(biāo)的變化來(lái)決定補(bǔ)液量糾正酸堿平衡失調(diào)：堿中毒酸中毒適當(dāng)應(yīng)用堿性藥物手術(shù)治療：應(yīng)根據(jù)病情判斷是否需要手術(shù)以及手術(shù)時(shí)機(jī)的選擇藥物治療：大量抗生素，復(fù)合維生素等,HypovolemicShock,Managementgoal:Restorecirculatingvolumeandtissueperfusion:ControlhemorrhageRestorecirculatingvolumeOptimizeoxygendeliveryVasoconstrictorifBPstilllowaftervolumeloading,Aimedatimprovementtissuehypoperfusion,InsertFoleycathetertomonitortheurineflow;Augmentsystolicbpto100mmHg:1.PlaceinreverseTrendelenburgposition;2.IVvolumeinfusion(500-1000mlbolus),unlesscardiogenicshocksuspected(beginwithnormalsaline,thenwholeblood,dextran,orpackedRBCs,ifanemic),continuevolumereplacementasneededtorestorevascularvolume;Addvasoactivedrugsafterintrvascularvolumeisopmtimized;administervasopressorsifsystemicvascularresistanceisdecreased.Ifseveremetabolicacidosisispresented(pH<7.15),administerNaHCO3;Identifyandtreattheunderlyingcauseofshock.,感染性休克的特點(diǎn)CharacteristicsofSepticShock,內(nèi)毒素性休克微循環(huán)變化的不同階段常同時(shí)存在微循環(huán)變化和內(nèi)臟損害比較嚴(yán)重全身炎癥反應(yīng)綜合征,感染性休克的類型TypesofSepticShock,高排低阻型（高動(dòng)力型）：“Warm”shockhyperdynamicresponse,原因：感染灶釋放擴(kuò)血管物質(zhì)特點(diǎn)：周圍血管阻力降低，心排出量增加低排高阻型（低動(dòng)力型）“Cold”shockhypodynamicresponse原因：血容量減少+繼發(fā)感染活性因子：兒茶酚胺、5-羥色胺、組織胺、緩激肽特點(diǎn)：周圍血管阻力增加，心排出量降低,感染性休克的兩種臨床表現(xiàn),臨床表現(xiàn)冷休克(高阻力型)暖休克(低阻力型)神志躁動(dòng)、淡漠或嗜睡清醒皮膚色澤蒼白、紫紺或花斑樣紫紺淡紅或潮紅皮膚溫度濕冷或冷汗溫暖、干燥毛細(xì)血管充盈時(shí)間延長(zhǎng)1-2秒脈搏細(xì)速慢、有力脈壓（kPa）4尿量(每小時(shí))30ml,SepticShock,Treatment:PreventionFindandkillthesourceoftheinfectionFluidresuscitationVasoconstrictorsInotropicdrugsMaximizeO2deliverySupportNutritionalSupport,TreatmentofSepticShock,Antibiotictreatment;Removalordrainageofafocalsourceofinfection:Removeindwellingintravascularcathetersandsendtipsforquantitativeculture;replaceFoleyandotherdrainagecatheters;Hemodynamic,respiratory,andmetabolicsupport:.MaintainintravascularvolumewithIVfluids.Initiatetreatmentwith1-2Lofnormalsalineadministeredover1-2h,keepingpulmonarycapillarywedgepressureat12-16mmHgorcentralvenouspressureat8-12cmH2O,urineoutputat30mlperhour,meanarterialbloodpressureat65mmHg.,Addinotropicandvasopressortherapyifneeded.Maintaincentralvenousoxygensaturationat70%.Maintainoxygenationwithventilatorsupportasindicated.Othertreatments:Antiendotoxin,anti-inflammatory,andanticoagulantdrugsarebeingstudiedinseveresepsistreatment.AnticoagulantrecombinantactivatedproteinC(aPC):constantinfusionof24ug/kgperhourfor96h.,TreatmentofSepticShock,感染性休克的治療,補(bǔ)充血容量：以平衡鹽溶液為主，配合適量的血漿和全血；并根據(jù)CVP調(diào)節(jié)輸液量和速度控制感染：處理原發(fā)感染灶；應(yīng)用抗菌藥物；改善病人的一般狀況；維持呼吸功能等糾正酸中毒：酸中毒發(fā)生早，嚴(yán)重，及早應(yīng)用堿性藥物心血管藥物應(yīng)用：西地蘭；B-受體興奮劑和a受體抑制劑聯(lián)合應(yīng)用減輕細(xì)胞損害：皮質(zhì)類固醇，大劑量應(yīng)用；SOD，抑肽酶，PGI2，試用中,THEEND,Clinicalexamples-1,An82-year-oldmanwasbroughttotheemergencyroombyhisgrandson,whoreportedthatthemanhadbeeneatingpoorlyfor2daysandhadbeendifficulttoarousethatmorning.Thepatienthadnospecificcomplaints.Onexam,thepatientwouldopenhiseyesandmumbleincoherentlyinresponsetopain.Histemperaturewas38.6,BP75/40,HR124regular,respirations26.Hislungswereclear.Nomurmursorextrasoundswereappreciatedoncardiacexam.,Clinicalexamples-1,Hisskinwaswarm,withboundingperipheralpulses.HischestradiographandEKGwerenormal.Laboratorydata:whitebloodcellcount19500(normallessthan10000).Abladdercatheterwasinserted(withdifficulty)andyieldedcloudyurine,whichwasnotedtocontainmanywhitecellsandbacteria.Urinewassentforculture.,Clinicalexamples-2,An35-year-oldwomanpresentedtoanemergencyroomcomplainingofaheadachepresentsinceamyelogramwhichhadbeenperformed4daysbefore.Herpastmedicalhistorywasunremarkableandherphysicalexaminationwasnormal.Shewasgivenaninjectionofmeperidineforherpain.Aftertheinjectionshebegantocomplainofnumbnessandtinglinginherfingertips,lightheadedness,shortnessofbreathanddiffuseitching.,Clinicalexamples-2,Herpulsewasnotedtobe140andbloodpressurewaspalpableat70/0mmHg.Faintwheezeswerenotedthroughoutthelungs.Althoughshehadinitiallydenieddrugallergies,shenowrememberedsimilarsymptomswhichhadfollowedaninjectionofpainmedicine”2yearsbefore.,Clinicalexamples-3,An67-year-oldfemalearrivedintheemergencyroomcomplainingofchestpainandsevereweaknessfor12hours.Thesesymptomshadbeenprecededbyseveraldaysofnauseaandvomiting,poorappetite,andsubjectivefever.Onexamination,shehadapulserateof110andBP85/50.Therewasnojugularvenousdistension.Herlungswereclearandnomurmurorgallopwereheardonauscultationoftheheart.Therewasnoextremityedema.,Clinicalexamples-3,EKGshowednewSTelevationintheinferiorleads,suggestinganevolvinginferiormyocardialinfarction.RightprecordialleadsdidnotshowevidenceofRVinfarctionatthattime.Thepatientwasgivensublingualnitroglycerinandwithinminutesbecameconfusedandunabletoresponsetoquestions.Systolicbloodpressuredroppedto60andpulseslowedto70.herlegswereelevatedandrapidinfusionofintravenousfluidswasbegun.,Clinicalexamples-3,Hermentalstatusimprovedbutsheremainedhypotensive.Thedecisionwasmadetoplaceapulmonaryarterycathetertohelpwithmanagementofcardiogenicshock.InitialHemodynamicData:BP:80/50,mean60RA:4mmHg,RV22/3,PA22/10,PAOP6Cardiacoutput:1.9liters/minSVR:2350dynes-cm-5-sec(normal400-1900),