儿科休克的诊治医学PPT.ppt

儿科休克的诊治,.,主要内容,休克的定义氧运输及心血管功能复习休克分类和病因不同休克的特点低灌注的临床判断和休克早期诊断休克的治疗休克诊治中应注意的问题,ImprovedOutcomesAssociatedWithEarlyResuscitationinSepticShock:DoWeNeedtoResuscitatethePatientorthePhysician?AileenKirbyandBrahmGoldsteinPediatrics2003;112;976-977,EarlyReversalshockandoutcom,Retrospectiveclinicalstudy(from19932001)91infantsandchildrenwithsepticshockfromlocalcommunityhospitalsandtransporttoChildrenshospitalShockreversal(definedbyreturnofnormalSBPandCRT)ResuscitationpracticeconcurrencewithACCMPALSGuidelinesHospitalmortality,Han,etal.Pediatrics2003;112;793-799,EarlyReversalshockandoutcom,Han,etal.Pediatrics2003;112;793-799,EarlyReversalshockandoutcom,Unfortunately,resuscitationpracticewasconsistentwithACCM-PALSGuidelinesinonly27(30%)patientsHan,etal.Pediatrics2003;112;793-799,EarlyReversalshockandoutcom,Comparedwithsurvivors,nonsurvivorstreatedwithmoreinotropictherapies,notincreasedfluidtherapy:dopamine/dobutamine:42%vs20%epinephrine/norepinephrine:42%vs6%fluid:32.9mL/kgvs20.0mL/kg,Han,etal.Pediatrics2003;112;793-799,休克的定义,休克（Shock)系因循环功能不全或衰竭导致组织灌注不良，脑及全身重要器官缺氧核心问题：氧运输(oxygendelivery)不能满足代谢需要（DO23秒（需除外环境温度影响）5、尿量10岁90mmHg,中华儿科杂志,2006;44(8):15,休克的处理基本原则,永远都要遵循ABC原则！气道不能维持通畅时及时插管呼吸开始给予100%氧气氧饱和度监测呼吸支持循环快速建立静脉通道心肺监测，反复测血压,休克的治疗基本原则,目标:增加氧运输，减少氧消耗氧气液体控制体温抗生素纠正代谢异常正性肌力,休克的治疗基本原则,实验室:血气血糖电解质血常规凝血功能,血交叉试验血培养胸片心脏超声其他辅助检查,休克的治疗液体复苏,第1小时：国外指南：首剂20ml/kg等张晶体或胶体510minIV输入国内方案：首剂NS1520minIV输入评估组织灌注，再给第二、第三剂每剂1020ml/kg，每剂后均再评估第1h4060ml/kg，甚至更多根据临床体征及相关检查鉴别心源性休克,中华儿科杂志,2006;44(8):15,休克的治疗液体复苏,继续和维持输液：1/21/3张液体，根据电解质调节根据血气纠酸，致PH7.25即可6h内速度510ml/kg.h,24h内24ml/kg.hHCT100g/L纠正低血糖，GS0.5g/kg,中华儿科杂志,2006;44(8):15,液体复苏成功的指标,复苏成功的临床指标：心率增快好转组织灌注改善：中心和外周脉搏无差异,神志精神好转，四肢转暖，肤色好转，CRT2s尿量1mL/（kg.h）混合静脉血氧饱和度（SVO2）0.70血乳酸4mEq/L或碱缺失正常有创血流动力学监测指标,液体复苏成功的指标,有创血流动力学监测：CVP（612cmH2O）心指数3.3和6.0L.min-1.m-2肺动脉楔压（812mmHg）获得相应年龄的正常灌注压（平均动脉压/中心静脉压）紫绀心脏病或严重肺疾病用动-静脉氧含量差代替混合静脉氧饱和度,Fluidinearlysepticshock,Retrospectivereviewof34pediatricpatientswithculture+septicshock,from1982-1989.HypovolemiadeterminedbyPCWP,u.oandhypotension.Overall,patientsreceived33cc/kgat1hourand95cc/kgat6hours.Threegroups:1:receivedupto20cc/kgin1st1hour2:received20-40cc/kgin1sthour3:receivedgreaterthan40cc/kgin1sthourNodifferenceinARDSbetweenthe3groupsCarcillo,etal,JAMA,1991;266(9):1242-5.,Fluidinearlysepticshock,Carcillo,etal,JAMA,1991;266(9):1242-5.,目前对液体选择的看法（1）,只要液体量达到相同的充盈压（CVP）水平时，都能恢复相同水平的组织灌注。因此，确定应给予的液体量比选择液体的种类更重要无循证医学证据证实晶体液或胶体液复苏对存活率有不同影响或哪一种液体较其他好，但有报道乳酸盐LR治疗者恢复较慢欧洲喜欢用胶体，北美更常用晶体液，国内推荐首选NS,目前对液体选择的看法（2）,若脉压小，胶体可能对恢复脉压更有效晶体复苏效果不佳可适当补充胶体，如血浆白蛋白问题：无文献报道白蛋白可改善预后和降低病死率，故不推荐常规使用白蛋白，只用于低蛋白血症患儿其他血制品不做推荐，以避免相关的危险性，但失血性休克首选输血,如何正确液体复苏？,快速识别组织低灌注状态，早期诊断休克建立有保障的静脉通道，紧急时骨髓输液掌握液体复苏方法反复评估循环及灌注、肺部罗音及肝大小鉴别诊断及时调整,骨髓输液,首次19世纪20年代80年代重新重视1988年美国心脏病学会（AHA）主张6岁乃至成人均可用2000年AHA规定90”3次静脉穿刺失败即作骨髓输液只用于危重婴幼儿作为暂时性措施,骨髓输液的并发症,并发症1并发症包括：胫骨骨折腔隙综合征皮肤坏死骨髓炎,休克的治疗血管活性药物（1）,充分液体复苏仍有低血压低灌注首选多巴胺：510ug/kg.min20ug,IV泵维冷休克、多巴胺抵抗首选肾上腺素0.052ug/kg.min,IV泵维暖休克、多巴胺抵抗首选去甲肾上腺素0.050.3ug/kg.min，IV泵维去甲肾上腺素抵抗试用血管紧张素和精氨酸血管加压素,中华儿科杂志,2006;44(8):15,休克的治疗血管活性药物(2),莨菪类可选用(国内方案)心功能障碍时儿茶酚胺类药物取代洋地黄类多巴酚丁胺510ug/kg.min,20ug/kg.min多巴酚丁胺抵抗者用肾上腺素若儿茶酚胺抵抗可用磷酸二酯酶（PDE）抑制剂高外周阻力时，在液体复苏和正性肌力药物基础上用扩管药如：硝普钠0.58ug/kg.min,中华儿科杂志,2006;44(8):15,液体配制“乘6原则”,液体配置“乘6原则”,休克的治疗激素应用,用药指征重症感染性休克疑有肾上腺皮质功能低下(如流脑)、ARDS、长期使用激素或出现儿茶酚胺抵抗性休克剂量和疗程目前主张小剂量、中疗程氢化可的松35mg/(kgd)或甲基强的松龙23mg/(kgd),分23次给予,中华儿科杂志,2006;44(8):15,休克的治疗DIC防治,早期可给予小剂量肝素510U/kg,皮下注射或静脉输注(注意肝素钠不能皮下注射),每6小时1次已明确有DIC,则应按DIC常规治疗,中华儿科杂志,2006;44(8):15,各型休克处理重点过敏性,立即终止过敏原肾上腺素液体复苏激素抗过敏药物,各型休克处理重点心源性,增加心输出量纠正心律失常适合的前负荷增强心肌收缩力降低后负荷,维持心肌最小做功维持正常的体温镇静气管插管、机械通气纠正贫血,各型休克处理重点低血容量性,第一小时快速液体复苏失血性休克首选输血补充继续丢失和生理需要纠正酸碱、电解质紊乱注意隐匿失血治疗原发病,各型休克处理重点感染性,第一小时快速液体复苏继续输液和维持输液第一个24小时常需入量远远大于出量血管活性药尽早应用有效抗生素，1小时内及早心肺支持防治DIC清除感染灶,SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2008,InternationalSurvivingSepsisCampaignGuidelinesCommitteePediatricConsiderationsinSevereSepsisCritCareMed.2008;36(1):296-327,PediatricConsiderationsinSevereSepsis,A.AntibioticsWerecommendthatantibioticsbeadministeredwithin1hroftheidentificationofseveresepsis,afterappropriatecultureshavebeenobtained(grade1D).Earlyantibiotictherapyisascriticalforchildrenwithseveresepsisasitisforadults.B.MechanicalVentilationNogradedrecommendations.Duetolowfunctionalresidualcapacity,younginfantsandneonateswithseveresepsismayrequireearlyintubation,PediatricConsiderationsinSevereSepsis,C.FluidResuscitationWesuggestthatinitialresuscitationbeginwithinfusionofcrystalloidswithbolusesof20mL/kgover5-10mins,titratedtoclinicalmonitorsofcardiacoutput,includingheartrate,urineoutput,capillaryrefill,andlevelofconsciousness(grade2C)D.Vasopressors/Inotropes(ShouldBeUsedinVolume-LoadedPatientsWithFluidRefractoryShock)Wesuggestdopamineasthefirstchoiceofsupportforthepediatricpatientwithhypotensionrefractorytofluidresuscitation(grade2C).,PediatricConsiderationsinSevereSepsis,Dopamine-refractoryshockmayreversewithepinephrineornorepinephrineinfusion.309Wesuggestthatpatientswithlowcardiacoutputandelevatedsystemicvascularresistancestates(coolextremities,prolongedcapillaryrefill,decreasedurineoutputbutnormalbloodpressurefollowingfluidresuscitation)begivendobutamine(grade2C).,PediatricConsiderationsinSevereSepsis,E.TherapeuticEndPointsWesuggestthatthetherapeuticendpointsofresuscitationofsepticshockbenormalizationoftheheartrate,capillaryrefillof1mLkg-1hr-1,andnormalmentalstatus290(grade2C).,PediatricConsiderationsinSevereSepsis,F.ApproachtoPediatricSepticShock（略）G.SteroidsWesuggestthathydrocortisonetherapybereservedforuseinchildrenwithcatecholamineresistanceandsuspectedorprovenadrenalinsufficiency(grade2C).Patientsatriskforadrenalinsufficiencyincludechildrenwithseveresepticshockandpurpura,318,319childrenwhohavepreviouslyreceivedsteroidtherapiesforchronicillness,andchildrenwithpituitaryoradrenalabnormalities.Childrenwhohaveclearriskfactorsforadrenalinsufficiencyshouldbetreatedwithstress-dosesteroids(hydrocortisone50mg/m2/24hrs),PediatricConsiderationsinSevereSepsis,H.ProteinCandActivatedProteinCWerecommendagainsttheuserhAPCinchildren(grade1B)I.DVTProphylaxisWesuggesttheuseofDVTprophylaxisinpostpubertalchildrenwithseveresepsis(grade2C)J.StressUlcerProphylaxisNogradedrecommendations.,PediatricConsiderationsinSevereSepsis,K.RenalReplacementTherapyNogradedrecommendationsL.GlycemicControlNogradedrecommendationsM.Sedation/AnalgesiaWerecommendsedationprotocolswithasedationgoalwhensedationofcriticallyillmechanicallyventilatedpatientswithsepsisisrequired(grade1D),PediatricConsiderationsinSevereSepsis,N.BloodProductsNogradedrecommendationsO.IntravenousImmunoglobulinWesuggestthatimmunoglobulinbeconsideredinchildrenwithseveresepsis(grade2C)P.ExtracorporealMembraneOxygenation(ECMO)WesuggestthatuseofECMObelimitedtorefractorypediatricsepticshockand/orrespiratoryfailurethatcannotbesupportedbyconventionaltherapies(grade2C),休克诊治中应注意的问题,一、判断失误导致治疗延迟或错误：休克误诊为心力衰竭：强心、利