休克病人的镇静镇痛治疗

休克患者的镇痛镇静,,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,Epidemiology of anxiety for MV patients,HeartVesselsBronchi,Systematic stress responses,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,Heart rate changes in near bed conscious patients during CPR,SBP changes in near bed conscious patients during CPR,Plasma epinephrine alterations in near bed conscious patients during CPR,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,1947 on the journal of Federation Proceedings,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:Anesthesia can become inadequate inadvertently or by misjudgment during surgery or emergence, and the surgical stress and pain stimulation will increase without adequate treatment. Overt stimulation may activate the sympathetic nervous system, increase the blood level of catecholamines, and lead to splanchnic arterial vasoconstriction.,Dexmedetomidine prevents alterations of intestinal microcirculation that are induced by surgical stress and pain in a novel rat model.,Yeh YC, Anesth Analg. 2012 Jul;115(1):46-53. Epub 2012 Apr 13.,30 Wistar rats dividedinto the following 3 groups: control, surgical stress and pain (SSP), and surgical stress and pain + Dex (SSP + Dex).,Yeh YC, Anesth Analg. 2012 Jul;115(1):46-53. Epub 2012 Apr 13.,Using this rat model (surgical stress and pain stimulation on the intestinal microcirculation) , we found that dexmedetomidine can normalize global hemodynamics and prevent the alteration of intestinal microcirculation.,Conclusion,Yeh YC, Anesth Analg. 2012 Jul;115(1):46-53. Epub 2012 Apr 13.,Sedation attenuated TNF production,. Crit Care 2009, 13:R136,Sedation improves early outcome in severely septic rats,. Crit Care 2009, 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 -40 C，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 100/60 mm Hg、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：pH 7.48， PaCO2 31 mm Hg，PaO2 45 mm Hg（氧流量=4 L/min ），生化检查：Lac 4.1 mmol/L，余正常。,气管插管， 机械通气。 芬太尼0.05mg，propofol 50 mg IV。3min 后 血压 65/45 mm Hg、心率 105 次/分，60min 后生化检查：Lac 6.5 mmol/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。,Rats were randomly received normal saline (1 mL/h), 1 mg/kg/hr or 10 mg/kg/hr propofol after haemorrhagic shock.,(NS1 mL/h), 1 mg/kg/hr or,10 mg/kg/hr,Clin Exp Pharm Physiol (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,10 mg/kg/hr,Clin Exp Pharm Physiol (2008) 35, 766774,Clin Exp Pharm Physiol (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,Case reports began to appear in the pediatric literature linking unexplained deaths with the prolonged use of high-dose propofol infusions. This led to an early warning issued by the Danish Side Effect Committee in 1990. Notitis Fra Bivirkningsnaenet. Propofol (Diprivan) bivirkninger. Ugeskrr Laeger. 1990;152:1176.,PRSI 首例报道,Parke TI, et al . Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. BMJ 1992; 305: 61362,Propofol Infusion Syndrome,Drug Safety 2008; 31 (4),诱发能量代谢障碍原因,长时间用药（72 hr）大剂量给药（5mg/kg/ hr）儿童（65mmHg SpO2:95%, SvO270% Hb10 g/dl 皮肤无花斑等灌注不良表现 血乳酸异常增高（5 mmol/l）, pH7.2,尿液颜色的显著变化,Guideline for sedation in patients with shock,No, yet.,中越战场：氯胺酮万岁！,Use of Ketamine Continuous Infusion for Pediatric Sedation in Septic Shock,severely compromised patient. Ketamine acts to increase heart rate, arterial pressure, and cardiac output. Furthermore, antiendotoxin and an anti-tumor necrosis factor mechanism have been r