如何理解创伤患者允许性低血压与休克复苏的辩证关系课件

如何理解创伤患者允许性低血压与休克复苏的辩证关系,福建省立医院 SICU 于荣国,2019/3/22,permissive hypotension,2,前言,推荐意见11：应迅速利用包括超声和手段在内的各种必要方法，检查与评估出血部位不明确、存在活动性失血的休克病人，（推荐级别：D级）。,低血容量休克的病因治疗：,低血容量休克复苏指南 (中华医学会重症医学分会2007),2019/3/22,permissive hypotension,3,前言,未控制出血的失血性休克是低血容量休克一种特殊类型，临床处理有特殊性！,早期限制性液体复苏是否适合各类失血性休克，需维持多高的血压，可持续多长时 间尚未有明确结论,2019/3/22,permissive hypotension,4,前言,临床研究表明未控制出血的失血性休克患者现场就地早期复苏病死率明显高于到达医院延迟复苏患者,允许性低血压的概念形成？ Permissive Hypotension,2019/3/22,permissive hypotension,5,允许性低血压的概念,允许性低血压 Permissive Hypotension,多少？ 时限？,2019/3/22,permissive hypotension,6,允许性低血压 Permissive Hypotension -几个概念的区别,控制性低血压 （Controlled Hypotension，deliberate hypotension） 手术中麻醉期间 延迟性液体复苏 （delayed fluid resuscitation）hypotensive period is intentionally prolonged until operative intervention 低血压延至手术干预 允许性低血压 （Permissive Hypotension）restrictive fluid treatment increases systemic pressure without reaching normotension 液体治疗只维持较低水平血压 restrictive fluid therapy 限制性液体复苏 Hypotensive resuscitation primary resuscitation small volume resuscitation,2019/3/22,permissive hypotension,7,Up to 50% of early deaths are due to massive hemorrhage,Shock 2006, 26: 322-331. Rossaint R, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Gordini G, Stahel PF, Hunt BJ, Neugebauer E, Spahn DR: Key issues in advanced bleeding care in trauma.,Critical Care 2008, 12:218 (doi:10.1186/cc6919),2019/3/22,permissive hypotension,8,出血性休克病理生理 pathophysiology of hemorrhagic shock,2019/3/22,permissive hypotension,9,Blood loss leads hemodynamic instability, coagulopathy, decreased oxygen delivery, decreased tissue perfusion, cellular hypoxia,出血性休克病理生理 pathophysiology of hemorrhagic shock,2019/3/22,permissive hypotension,10,低血容量造成的继发性器官损害？,实验室和临床资料都提示： 移位的细菌内毒素和缺氧/再氧合刺激产生的大量白细胞，特别是巨噬细胞 ，炎性细胞因子，NO等都参入了出血性休克的发生机制,The pathogenesis of organ injury secondary to hypovolemic insult is still incompletely understood,Chaudry IH, Zellweger R, Ayala A: The role of bacterial translocation on Kupffer cell immune function following hemorrhage. Prog Clin Biol Res 1995, 392:209-218. Harbrecht BG, Billiar TR: The role of nitric oxide in Kupffer cellhepatocyte interactions. Shock 1995, 3:79-87,2019/3/22,permissive hypotension,11,低血容量造成的继发性器官损害？,实验室和临床资料都提示： 移位的细菌内毒素和缺氧/再氧合刺激产生的大量 白细胞，特别是巨噬细胞 ，炎性细胞因子，NO等都参入了出血性休克的发生机制,The pathogenesis of organ injury secondary to hypovolemic insult is still incompletely understood,Chaudry IH, Zellweger R, Ayala A: The role of bacterial translocation on Kupffer cell immune function following hemorrhage. Prog Clin Biol Res 1995, 392:209-218. Harbrecht BG, Billiar TR: The role of nitric oxide in Kupffer cellhepatocyte interactions. Shock 1995, 3:79-87,临床资料循证不足,2019/3/22,permissive hypotension,12,创伤性休克的液体复苏开始的最佳时机-不是越早越好,“以往强调”： 创伤失血性休克要快速输血和输液来维持足够的循环容量和组织灌注 Bickell等研究发现， 穿透性躯干伤合并低血压的病人在未控制出血前给予积极的液体复苏会出现严重不良后果。,2019/3/22,permissive hypotension,13,收缩压90mmHg ? 研究比较了即刻复苏和延迟复苏对躯体贯通伤的创伤低血压患者死亡率和并发症的影响，即刻复苏组死亡率显著增高，急性呼吸窘迫综合征、急性肾衰、凝血障碍、严重感染等的发生率也明显增高,创伤性休克的液体复苏开始的最佳时机-不是越早越好,2019/3/22,permissive hypotension,14,失血性休克的救治关键在于及时予以容量复苏,存在矛盾?,2019/3/22,permissive hypotension,15,紧急手术止血,2019/3/22,permissive hypotension,16,目标血压是多少 维持多少时间?,适量的液体复苏, 多少？ 循环血压能够维持基本的组织灌流 （收缩压8090mmHg）？ 血管活性药？ 对机体具有保护作用 ？,2019/3/22,permissive hypotension,17,应该认为 -出血性休克,快速扩容使血压升到正常不是第一选择 大量液体（晶体/胶体）+大量血管活性药 允许性低血压（ Permissive Hypotension ）也可以适当输液和使用血管活性药,2019/3/22,permissive hypotension,18,模型：猪腹主动脉出血 MAP=30mmHg,Kowalenko et al.,2019/3/22,permissive hypotension,19,model of uncontrolled intraabdominal bleeding in pigs,Stern and coworkers,2019/3/22,permissive hypotension,20,96例严重创伤合并未控制出血性休克,结论: 创伤性休克术前在未控制出血情况下,限制性液体复苏可明显降低患者的出血量,并发症和死亡率.,郑世成 第四军医大学学报(J FourthMilMed Univ) 2009, 30 (7),2019/3/22,permissive hypotension,21,DIC的消耗性低凝期 是否在补充凝血因子,新鲜冰冻血浆基础上用小剂量肝素治疗? 与允许性低血压有矛盾吗？,2019/3/22,permissive hypotension,22,When “permissive hypotension” should best be avoided,Hypertensive patients Cardiovascular disease/angina pectoris Myocardial infarction with compromised cardiac function Cerebrovascular disease and carotid artery stenosis Compromised renal function renalis stenosis; intermittent claudication stage III/IV, where low blood pressure may induce sludge and lead to occlusion of the vessel lumen.,2019/3/22,permissive hypotension,23,When “permissive hypotension” should best be avoided,Hypertensive patients Cardiovascular disease/angina pectoris Myocardial infarction with compromised cardiac function Cerebrovascular disease and carotid artery stenosis Compromised renal function renalis stenosis; intermittent claudication stage III/IV, where low blood pressure may induce sludge and lead to occlusion of the vessel lumen.,创伤性失血性休克患者？,2019/3/22,permissive hypotension,24,多发性创伤（脑外伤） polytraumatised patients also the brain is affected,Systolic blood pressure 90 mm Hg PaO2 60 mm Hg mortality ,Traumatic Coma Data Bank,2019/3/22,permissive hypotension,25,由于创伤后脑内自身调节功能（cerebral autoregulation）受损，低血容量性低血压可能导致大脑血流减少，发生脑缺氧性改变 以脑部为主要的多发性创伤与大出血性多发伤在病理生理上有所不同,多发性创伤（脑外伤） polytraumatised patients also the brain is affected,2019/3/22,permissive hypotension,26,颅内压（ICP）的增高，要求更多的液体复苏，维持一定的血压，满足脑灌注 对于低血容量休克合并颅脑损伤患者，合适的灌注压是保证中枢神经组织氧供的关键,多发性创伤（脑外伤） polytraumatised patients also the brain is affected,2019/3/22,permissive hypotension,27,颅脑损伤后颅内压增高，此时若机体血压降低,则会因脑血流灌注不足而继发脑组织缺血性损害,进一步加重颅脑损伤 一般认为对于合并颅脑损伤的严重失血性休克患者，宜早期输液以维持血压，必要时合用血管活性药物，将收缩压维持在正常水平，以保证颅内灌注压，而不宜延迟复苏,多发性创伤（脑外伤） polytraumatised patients also the brain is affected,2019/3/22,permissive hypotension,28,多发性创伤（脑外伤） polytraumatised patients also the brain is affected,脊髓损伤 维持正常体循环MAP，可以保证脊髓血供，减少由于缺血缺氧导致的继发性脊髓损伤 通过扩容使MAP维持在 85 mmHg以上，结合血管活性药的应用、脊柱制动、激素应用等，可以明显改善神经系统功能恢复。,Vale FL, Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the meri