休克病人的镇静镇痛治疗.ppt

休克患者的镇痛镇静,zhangwei7222,心源性休克的紧急处理,坐:端坐位氧：吸氧吗：吗啡肌注强：强心剂,降低休克患者的焦虑应激,EpidemiologyofanxietyforMVpatients,HeartVesselsBronchi,Systematicstressresponses,休克时的交感风暴,休克时大量的内源性儿茶酚胺的释放可诱发机体一系列行为、内分泌以及炎症介质的急剧变化。,紧张与恐惧发生在转运过程中,无机械通气病人更需要镇静,CPR时邻床清醒患者心律失常发生情况,李秦，马朋林中国危重病急救医学2008；20(4):193-196,HeartratechangesinnearbedconsciouspatientsduringCPR,SBPchangesinnearbedconsciouspatientsduringCPR,PlasmaepinephrinealterationsinnearbedconsciouspatientsduringCPR,CPR时邻床清醒患者心律失常发生情况,李秦，马朋林中国危重病急救医学2008；20(4):193-196,有害的应激反应,焦虑与躁动增加组织细胞的氧代谢加剧组织灌注障碍降低高级生命支持的有效性,镇痛和镇静能降低有害的应激反应,降低患者的焦虑应激改善组织灌注,1947onthejournalofFederationProceedings,对于早期失血性休克动物模型，恰当的镇静剂可能是有好处的,在失血性休克尚未变为不可逆前，给予小剂量苯巴比妥镇静，能起到有效改善循环、降低病死率等独特的作用,BACKGROUND:Anesthesiacanbecomeinadequateinadvertentlyorbymisjudgmentduringsurgeryoremergence,andthesurgicalstressandpainstimulationwillincreasewithoutadequatetreatment.Overtstimulationmayactivatethesympatheticnervoussystem,increasethebloodlevelofcatecholamines,andleadtosplanchnicarterialvasoconstriction.,Dexmedetomidinepreventsalterationsofintestinalmicrocirculationthatareinducedbysurgicalstressandpaininanovelratmodel.,YehYC,AnesthAnalg.2012Jul;115(1):46-53.Epub2012Apr13.,30Wistarratsdividedintothefollowing3groups:control,surgicalstressandpain(SSP),andsurgicalstressandpain+Dex(SSP+Dex).,YehYC,AnesthAnalg.2012Jul;115(1):46-53.Epub2012Apr13.,Usingthisratmodel(surgicalstressandpainstimulationontheintestinalmicrocirculation),wefoundthatdexmedetomidinecannormalizeglobalhemodynamicsandpreventthealterationofintestinalmicrocirculation.,Conclusion,YehYC,AnesthAnalg.2012Jul;115(1):46-53.Epub2012Apr13.,SedationattenuatedTNFproduction,.CritCare2009,13:R136,Sedationimprovesearlyoutcomeinseverelysepticrats,.CritCare2009,13:R136,恰当的镇痛镇静可改善组织灌注.有些我们看得见，有些看不见，但存在！,镇痛镇静对组织灌注的影响有多大,降低患者的焦虑应激改善组织灌注减少继发性损害,诱发严重低血压，导致器官损伤。,镇静/镇痛控制应激与血管张力,病例,男性，64岁，强体力劳动后发热1周，T:38.5-40C，伴咳嗽、咳黄痰、胸疼。接受抗感染治疗（用药不详）无效。加重伴气短、呼吸困难1天入急诊抢救室。既往体健,血压100/60mmHg、心率145次/分，呼吸38次/分,无哮鸣音，右下肺细湿啰音，左下肺呼吸音低，血气分析：pH7.48，PaCO231mmHg，PaO245mmHg（氧流量=4L/min），生化检查：Lac4.1mmol/L，余正常。,气管插管，机械通气。芬太尼0.05mg，propofol50mgIV。3min后血压65/45mmHg、心率105次/分，60min后生化检查：Lac6.5mmol/L。,镇静/镇痛深度与低血压的发生深镇静/镇痛易诱发严重低血压。,Ratswererandomlyreceivednormalsaline(1mL/h),1mg/kg/hror10mg/kg/hrpropofolafterhaemorrhagicshock.,(NS1mL/h),1mg/kg/hror,10mg/kg/hr,ClinExpPharmPhysiol(2008)35,766774,镇静/镇痛诱发严重低血压。严重影响组织灌注，继发器官损伤,10mg/kg/hr,ClinExpPharmPhysiol(2008)35,766774,ClinExpPharmPhysiol(2008)35,766774,镇静/镇痛诱发严重低血压。严重影响组织灌注，继发器官损伤诱发细胞代谢障碍,Casereportsbegantoappearinthepediatricliteraturelinkingunexplaineddeathswiththeprolongeduseofhigh-dosepropofolinfusions.ThisledtoanearlywarningissuedbytheDanishSideEffectCommitteein1990.NotitisFraBivirkningsnaenet.Propofol(Diprivan)bivirkninger.UgeskrrLaeger.1990;152:1176.,PRSI首例报道,ParkeTI,etal.Metabolicacidosisandfatalmyocardialfailureafterpropofolinfusioninchildren:fivecasereports.BMJ1992;305:61362,PropofolInfusionSyndrome,DrugSafety2008;31(4),诱发能量代谢障碍原因,长时间用药（72hr）大剂量给药（5mg/kg/hr）儿童（65mmHgSpO2:95%,SvO270%Hb10g/dl皮肤无花斑等灌注不良表现血乳酸异常增高（5mmol/l）,pH7.2,尿液颜色的显著变化,Guidelineforsedationinpatientswithshock,No,yet.,中越战场：氯胺酮万岁！,UseofKetamineContinuousInfusionforPediatricSedationinSepticShock,severelycompromisedpatient.Ketamineactstoincreaseheartrate,arterialpressure,andcardiacoutput.Furthermore,antiendotoxinandananti-tumornecrosisfactormechanismhavebeenreport