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

1、 副主任醫(yī)師休 克Shock Syndrome1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)胞受損的病理過程Shock is a condition in which the cardiovascular system fails to perfuse tissues adequately. Inadequate tissue perfusion can result in:generalized cellular hypoxia (starvation)widespread impairment of cellul

2、ar metabolismtissue damage organ failuredeath維持有效循環(huán)血量的必要因素: 充足的血容量 Sufficient blood volume有效的心排出量 Effective cardiac pump 良好的周圍血管張力 Upstanding peripheral angiotasisEffective circulating blood volume2休克的分類（Types of Shock） 分類 疾病舉例低血容量性休克 創(chuàng)傷出血、上消化道出血 （hypovolemic shock ） 燒傷、腸梗阻 感染性休克 膽道感染等（Septic Shock）

3、心源性休克 心梗（Cardiogenic Shock ）過敏性休克 青霉素過敏、血清過敏 （Anaphylactic shock） 神經(jīng)源性休克 疼痛刺激、脊髓損傷（ Neurogenic Shock） hemorrhage shock and traumatic shock.3PATHOPHYSIOLOGY OF SHOCK SYNDROME微循環(huán)改變 Microcirculation Change代謝變化 Metabolism Change內(nèi)臟器官的繼發(fā)性損害 Secondary damage on internal organs4Microcirculation ChangeDecomp

4、ensated phaseCompensated phaseIrreversible phaseDeath5Sympathetic nervous system activatesCardiac effects Increased force of contractions Increased heart rate Increased cardiac outputPeripheral effects Arteriolar constriction Pre-/post-capillary sphincter contraction Increased peripheral resistance

5、Shunting of blood to core organsDecreased renal blood flowRenin released from kidney arterioleRenin & Angiotensinogen combineConverts to Angiotensin IAngiotensin I converts to Angiotensin IIPeripheral vasoconstrictionIncreased aldosterone release (adrenal cortex)Peripheral capillaries contain minima

6、l bloodStagnationAerobic metabolism changes to anaerobicCompensatory Mechanisms6休克的病理生理過程-微循環(huán)的變化微循環(huán)收縮期(休克代償期)的特點(diǎn): 心跳中樞、血管舒縮中樞、交感神經(jīng)興奮心跳加快，心排出量增加，兒茶酚胺大量釋放兒茶酚胺的作用： 促使外周和內(nèi)臟小、微血管和毛細(xì)血管前括約肌強(qiáng)烈收縮，動(dòng)靜脈短路和直捷通道開放收縮期結(jié)果: 外周血管阻力增加和回心血量增加；低灌注、缺氧狀態(tài)。7Continued anaerobic metabolismRelaxation of precapillary sphinctersC

7、ontinued contraction of postcapillary sphinctersPeripheral pooling of bloodDecreased blood flow to the tissues causes cellular hypoxiaDecreased coronary blood flowMyocardial ischemiaDecreased force of contractionDecreased blood pressureDecompensated Shock8休克的病理生理過程-微循環(huán)的變化微循環(huán)擴(kuò)張期(休克抑制期)的特點(diǎn): 組織灌流不足，乏氧代

8、謝，酸性物質(zhì)增多，微動(dòng)脈和毛細(xì)血管前括約肌擴(kuò)張，但毛細(xì)血管后靜脈仍收縮 肥大細(xì)胞釋放組胺,緩激肽,毛細(xì)血管擴(kuò)張范圍增加擴(kuò)張期結(jié)果： 毛細(xì)血管多灌少流，容積增加，血液濃縮，回心血大減，心排血量減少，血壓下降，心腦灌注不足，休克加重。 9If Low Perfusion States persists:IRREVERSIBLE DEATH IMMINENT!10Decreased perfusion causes tissue damage/necrosisTissue necrosis triggers diffuse clottingDiffuse clotting consumes clot

9、ting factorsFibrinolysis beginsSevere, uncontrolled systemic hemorrhage occursDisseminated Intravascular Coagulation (DIC)11休克的病理生理過程-微循環(huán)的變化微循環(huán)衰竭期（DIC期）的特點(diǎn)： 毛細(xì)血管內(nèi)形成微血栓，DIC，細(xì)胞缺氧，組織自溶，由于凝血因子消耗，纖維蛋白溶解系統(tǒng)激活，出現(xiàn)嚴(yán)重的出血傾向12休克的病理生理變化體液代謝的改變能量不足(Energy deficiency)乏氧代謝(Anonic metabolism)致乳酸(Lactic acid)和丙酮酸(Pyru

10、vic acid)積聚，造成酸中毒(Metabolic acidosis) 鈉泵(Sodium-pump)和鈣泵(Calcium pump)功能異常，致細(xì)胞腫脹 ，甚至死亡13休克的病理生理變化內(nèi)臟器官的繼發(fā)性損害多器官衰竭 (Multiple Organ Systems Failure, MOSF):幾個(gè)臟器相繼或同時(shí)受損：呼吸窘迫綜合征, （ ARDS: Adult respiratory distress syndrome ）腎衰 (Renal failure):腎皮質(zhì)內(nèi)腎小管上皮變性壞死3. 心：心肌受損，局灶性壞死4. 肝功能衰竭 (Hepatic failure)：小葉中央壞死5.

11、 胃腸道：粘膜糜爛、出血6. 腦：腦水腫(cerebral edema) 、腦疝(cerebral hernia) 14Stages of ShockInitial stage - tissues are under perfused, decreased CO, increased anaerobic metabolism, lactic acid is building Compensatory stage - Reversible. SNS activated by low CO, attempting to compensate for the decrease tissue perf

12、usion. Progressive stage - Failing compensatory mechanisms: profound vasoconstriction from the SNS ISCHEMIA Lactic acid production is high anaerobic metabolic acidosisIrreversible or refractory stage - Cellular necrosis and Multiple Organ Dysfunction Syndrome may occur DEATH IS IMMINENT!15Hypotensio

13、n 90 mmHg (may be normal level or increase due to compensatory mechanism) Mean arterial pressure (MAP) 60 mmHgTachycardia: weak and thready pulseTachypnea: blow off CO2 respiratory alkalosisDecreased urine outputGenerally Clinical Presentation16休克的臨床表現(xiàn)休克代償期： 喪失血容量20%1. 神志淡漠 (Disturbance of conscious

14、ness) 昏迷 (Coma) 2. 口唇 (Oral lip)、肢端 (Limb)發(fā)紺 (Cyanosis) ，出冷汗 (Cold sweat) 3. 脈細(xì)速 (Rapid rate and thread / weak pulse) ，血壓下降 (Falling BP) ，脈壓差 (Pulse pressure difference)明顯縮小 4. 5. 尿量減少或無尿 (Anuria) 休克的臨床表現(xiàn)18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. 無尿 (Anuria) 5. 器官功能衰竭

15、的表現(xiàn)休克的臨床表現(xiàn)19休克的診斷Diagnosis of Shock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，尿少或無尿20 神志狀態(tài) (Mental status) 肢體溫度、色澤 (Limb temperature and color) 血壓 (Blood pressure) 脈率 (Pulse) 尿量 (Urine output) 休克的監(jiān)測(cè)一般監(jiān)測(cè)General Monitor 21休克的監(jiān)測(cè)特殊監(jiān)測(cè)Sp

16、ecial Monitor 中心靜脈壓(Central Venous Pressure ,CVP): 血容量和心功能正常值：0.49-0.98 kPa (5-10cmH2O) CVP，血容量不足 CVP，心功能不全或過度收縮（1.47 kPa) 充血性心力衰竭 (Congestive Heart Failure) (1.96 kPa)22休克的監(jiān)測(cè)特殊監(jiān)測(cè) Special Monitor 肺動(dòng)脈楔壓 (Pulmonary Capillary Wedge Pressure, 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：0.8-2.0 kPa ,低于正常值，提示血

17、容量不足， 4.0 kPa，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?(Arterial Blood Gas Analysis )： 可了解呼吸功能和酸堿平衡的變化。 PaO2 80-100mmHg, PaCO2 36-44mmHg, PaCO260mmHg, PaO28 mmol/L, 死亡率100%。DIC的實(shí)驗(yàn)室檢查確診依據(jù)： Plat 80109/L; 纖維蛋白原3, 副凝實(shí)驗(yàn)(+);3P試驗(yàn)陽性；血涂片中破碎紅細(xì)胞超過2%。24休克的治療Treatment of Shock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

18、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25休克的治療 Treatment of Shock補(bǔ)充血容量 (Restore circulating volume and tissue perfusion) ：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 (Treat Reversible Causes) ：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)26Shock treatment“A rude unhinging of

19、 the machinery of life”“A brief pause in the act of dying”27休克的治療Treatment of Shock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 (Circulatory Support ) 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28In summary, Treatment of ShockIdentif

20、y the patient at high risk for shockControl or eliminate the causeImplement measures to enhance tissue perfusionCorrect acid base imbalanceTreat cardiac dysrhythmias29失血性休克的治療(Treatment of Hemorrhagic Shock)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

21、止血 要處理好休克和止血手術(shù)間的辨證關(guān)系30中心靜脈壓和補(bǔ)液的關(guān)系CVP BP 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)過多 舒血管 高 正常 容量血管過度收縮 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 31損傷性休克的治療 (Treatment of Traumatic Shock)補(bǔ)充血容量：應(yīng)根據(jù)監(jiān)測(cè)指標(biāo)的變化來決定補(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32Hypovolemic S

22、hockManagement goal: Restore circulating volume and tissue perfusion:Control hemorrhageRestore circulating volumeOptimize oxygen deliveryVasoconstrictor if BP still low after volume loading33Aimed at improvement tissue hypoperfusion Insert Foley catheter to monitor the urine flow;Augment systolic bp

23、 to 100mmHg: 1. Place in reverse Trendelenburg position; 2. IV volume infusion (500-1000ml bolus), unless cardiogenic shock suspected (begin with normal saline, then whole blood, dextran, or packed RBCs, if anemic), continue volume replacement as needed to restore vascular volume;Add vasoactive drug

24、s after intrvascular volume is opmtimized; administer vasopressors if systemic vascular resistance is decreased. If severe metabolic acidosis is presented (pH7.15), administer NaHCO3;Identify and treat the underlying cause of shock.34感染性休克的特點(diǎn)Characteristics of Septic Shock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

25、內(nèi)臟損害比較嚴(yán)重全身炎癥反應(yīng)綜合征35感染性休克的類型Types of Septic Shock高排低阻型（高動(dòng)力型）： “Warm” shock hyperdynamic response, 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” shock hypodynamic response 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36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

26、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)) 30ml37Septic ShockTreatment:Prevention Find and kill the source of the infection Fluid resuscitationVasoconstrictorsInotropic drugsMaximize O2 delivery SupportNutritional Support38Treatment of Septic ShockAntibiotic treatment;Removal or

27、 drainage of a focal source of infection: Remove indwelling intravascular catheters and send tips for quantitative culture; replace Foley and other drainage catheters;Hemodynamic, respiratory, and metabolic support: . Maintain intravascular volume with IV fluids. Initiate treatment with 1-2L of norm

28、al saline administered over 1-2 h, keeping pulmonary capillary wedge pressure at 12-16 mmHg or central venous pressure at 8-12 cmH2O, urine output at30ml per hour, mean arterial blood pressure at 65mmHg. 39 Add inotropic and vasopressor therapy if needed. Maintain central venous oxygen saturation at

29、 70%. . Maintain oxygenation with ventilator support as indicated. Other treatments: Antiendotoxin, anti-inflammatory, and anticoagulant drugs are being studied in severe sepsis treatment.Anticoagulant recombinant activated protein C (aPC): constant infusion of 24ug/kg per hour for 96 h.Treatment of

30、 Septic Shock40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41THE END42Clinical examples-1An 82-year-old man was brought to the emergency room by his grandson, who report

31、ed that the man had been eating poorly for 2 days and had been difficult to arouse that morning. The patient had no specific complaints. On exam, the patient would open his eyes and mumble incoherently in response to pain. His temperature was 38.6, BP 75/40, HR 124 regular, respirations 26. His lung

32、s were clear. No murmurs or extra sounds were appreciated on cardiac exam. 43Clinical examples-1His skin was warm, with bounding peripheral pulses. His chest radiograph and EKG were normal. Laboratory data: white blood cell count 19500 (normal less than 10000). A bladder catheter was inserted (with

33、difficulty) and yielded cloudy urine, which was noted to contain many white cells and bacteria. Urine was sent for culture.44Clinical examples-2An 35-year-old woman presented to an emergency room complaining of a headache present since a myelogram which had been performed 4 days before. Her past med

34、ical history was unremarkable and her physical examination was normal. She was given an injection of meperidine for her pain. After the injection she began to complain of numbness and tingling in her fingertips, lightheadedness, shortness of breath and diffuse itching. 45Clinical examples-2Her pulse

35、 was noted to be 140 and blood pressure was palpable at 70/0 mmHg. Faint wheezes were noted throughout the lungs. Although she had initially denied drug allergies, she now remembered similar symptoms which had followed an injection of pain medicine” 2 years before.46Clinical examples-3An 67-year-old female arrived in the emergency room compl