Hemodynamika, šok. doc. MUDr. Jozef Firment, PhD. I. klinika anestéziológie a intenzívnej medicíny UPJŠ LF a UNLP, Košice
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1 Hemodynamika, šok doc. MUDr. Jozef Firment, PhD. I. klinika anestéziológie a intenzívnej medicíny UPJŠ LF a UNLP, Košice
2 KRVNÝ OBEH EKG (arytmie, tvary krivky), arteriálny TK syst. diast, stredný, neinvazívny, invazívny. Monitorovanie hemodynamiky (S-G katéter, termodilučný): CVP, AP, PA, PCWP, LAP, CO, SV, LVSW, SVR, PVR, indexy... Monitorovanie arytmií, Holter, telemetria. Palpácia pulzu (miesta a kvalita). S a O 2, S v O 2, S p O 2, p tc O 2, 2
3 Soni-OHMEDA Firment STREDNÝ ARTÉRIOVÝ TLAK TKm = TKd + 1/3 (TKs-TKd) 4
4 POLOHA S-G KATÉTRA Soni-OHMEDA Firment 5
5 Soni-OHMEDA Firment PRELOAD = CVP, PAWP 9
6 Soni-OHMEDA Firment AFTERLOAD = PVR, SVR 10
7
8 Stroke Volume Variation
9 Hodnotenie odpovede na objem u septických pacientov Marik et al. Annals of Intensive Care 2011, 1:1
10 Teboul J-L: AboutSepsis.com Teboul J-L: Colours of Sepsis Ostrava
11 Teboul J-L: Colours of Sepsis Ostrava 2014 Teboul J-L: AboutSepsis.com 15
12 Volume Responsive Algorithm
13 Rampal T, Jhanji S, Pearse R: Using oxygen delivery targets to optimize resuscitation in critically ill patients. Current Opinion in Critical Care 2010, 16: Application of Starling s law of the heart to identify a fluid responsive patient A fluid challenge results in an increase in venous return (straight line). When plasma volume is low, this increase will be associated with an increase in stroke volume and hence cardiac output. The absence of a stroke volume response suggests euvolaemia and fluid challenges should be discontinued. 17
14 Jansen JRC, Maas JJ, Pinsky MR: Bedside assessment of mean systemic filling pressure. Current Opinion in Critical Care 2010, 16: Effects of an inspiratory hold maneuver on arterial pressure (Pa), central venous pressure (Pcv), airway pressure (Pvent) and beat-to-beat cardiac output (COmf) 18
15 DEFINÍCIA ŠOKU Komplexný syndróm vyvolaný nedostatočným prekrvením nutričného kapilárneho riečiska tkanív. Vedie k nedostatku kyslíka a energetických zdrojov v tkanivách, k patologickému metabolizmu a ku kumulácii toxických produktov. 19
16 NÁSLEDKY ŠOKU Orgány a systémy sa v dôsledku poruchy cirkulácie poškodia spočiatku funkčne, neskôr aj štrukturálne. Vzniknú šokové orgány (MODS) šokové pľúca s ARDS, šokové obličky, šokové zmeny na sliznici tráviacej rúry šokové porucha hemokoagulácie (DIC) atď. MSOF... smrť 20
17 EWS 21
18 Dodávka O 2 22
19 OXYGEN DELIVERY - CONSUMPTION Relationship between oxygen uptake (VO 2 ) and oxygen delivery (DO 2 ) in cardiogenic, hypovolaemic and septic shock. 23 Oh s Intensive care manual, Bersten, 6th, 2009
20 The oxygen delivery cascade indicating the potential role of current and future therapies to optimize oxygen delivery to the tissues Rampal T, Jhanji S, Pearse R: Using oxygen delivery targets to optimize resuscitation in critically ill patients. Current Opinion in Critical Care 2010, 16:
21 PATOFYZIOLOGICKÉ DELENIE ŠOKU Hypovolemický (dehydratácia, hemorágia) Distribučný (lézia miechy, vysoká spinálna anestézia, anafylaktický, septický) Obštrukčný (pľúcna embólia, hydroperikard, PNO) Kardiogénny (AIM, chlopňové chyby, arytmie) 25
22 Príznaky šoku HYPOTENZIA Šokový index = počet pulzov systolický TK Vyhodnotenie: pod 0,5 = normálny nález nad 1,0 = vyžaduje okamžitý zásah Pozor! Digitalis, betablokátory, kardiostimulátory... 26
23 Príznaky šoku OLIGÚRIA Diuréza < 0,5 ml/kg/hod LABORATÓRNE PREJAVY MLAC > 2 (4) mmol/l S CV O 2 < 65% 27
24 Trzeciak S. et al: Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med (2007) 33:
25 Values obtained from the pulmonary artery catheter in the four major types of shock Oh s Intensive care manual, Bersten, 6th,
26 DELENIE ŠOKU PODĽA KLINICKÝCH PRÍČIN anafylaktický šok (alergia na liek, na jed...) neurogénny šok spinálny šok (lézia miechy, vysoká spinálna anestézia...) hemoragický šok traumatický šok popáleninový šok toxický šok (pankreatitída...) septický šok (sepsa...) kardiogénny šok (AIM...) 30
27 Terapeutické postupy pri šoku ÚVODNÉ VŠEOBECNÉ PROTIŠOKOVÉ OPATRENIA Kyslík Zastavenie krvácania Zabezpečenie dýchania (UVP?) Protišoková poloha Analgézia, tranquilizácia Neutrálne teplotné prostredie Šetrný transport 31
28 Terapeutické postupy pri šoku HYPOVOLEMICKÝ ŠOK Zastavovanie krvácania Autotransfúzna protišoková poloha Rýchly i.v. prívod tekutín - koloidy (HOHO, resp. izovolemický roztok) Inhalácia kyslíka, resp. UPV. Zlepšenie perfúzneho tlaku pomocou dopamínu v R1/1 (RL1/1) 32
29 33
30 34
31 Strata objemu krvi v % HTK < 25% Bielkoviny < 50 g/l Quick < 35% POSTUPNOSŤ NAHRADZOVANIA KRVNÝCH STRÁT KryKol Ery Alb, MrPlaz Tr Tr < 50 tis/mm 3 5 3,5 3 1,5 1 Objem krvi v litroch 35
32 URČIŤ ROZSAH KRVÁCANIA ZÁVAŽNOSŤ KRVÁCANIA Stupeň I Stupeň II Stupeň III Stupeň IV Strata krvi (ml) < >2 000 Počet pulzov (/min) <100 >100 >120 >140 Krvný tlak Normálny Normálny Znížený Znížený Plnosť pulzu Normálna Znížený Znížený Znížený Frekvencia dýchania (/min) >40 Diuréza (ml/hod) > Nepatrná CNS (mentálny stav) Nepatrná úzkosť Mierna úzkosť Zmätenosť Malátnosť Odhad pre 70 kg dospelého. 36
33 37
34 Terapeutické postupy pri šoku ANAFYLAKTICKÝ ŠOK Prerušiť prívod alergénu (infúzia, blokovať jeho ďalšie vstrebávania - obstrek vpichu hmyzom trimecain c. adren, chladenie miesta alergénu...) Zlepšenie perfúzneho tlaku pomocou Inhalácia kyslíka, resp. UPV. Autotransfúzna poloha Rýchly i.v. prívod tekutín - koloidy (HOHO, resp. izovolemický roztok) Adrenalin titračne 1,0 mg i.v. v infúzii Glukokortikoid (Hydrocortison) 300 mg i.v. dopamínu v R1/1 38
35 39
36 SEPTICKÉ SYNDRÓMY SIRS = horúčka + leukocytóza... Sepsa = SIRS + infekcia Ťažká sepsa = sepsa + MODS (MSOF) Septický šok = ťažká sepsa + refraktérna hypotenzia Kerr G. E.: Some current concepts and strategies in critical care. PGA55 Singh S., Evans T.W.: Organ dysfunction during sepsis. Intensive Care Medicine, 2006, 32,
37 Terapeutické postupy pri šoku CAVH CVVH CAVHD CVVHD 45
38 Terapeutické postupy pri šoku KARDIOGÉNNY ŠOK Inhalácia kyslíka, resp. UPV Analgézia (Fentanyl, Morfin) MgSO 4 20% 10 ml, Cardilan 20 ml, Skorá podpora dýchania Kombinácia vazoaktívnych látok (nitroglycerín + dobutamin) Trombolýza event. PCI Intraaortálna kontrapulzácia (IABP) 46
39 BALÓNIKOVÁ KONTRAPULZÁCIA Continuing Education in Anaesthesia, Critical Care & Pain Volume 9 Number , IABP 47
40 Hypotéza: Črevo ako ŠTARTÉR multiorgánového zlyhania Vyvolávajúca príčina Neuroendokrinná odpoveď Prietoku krvi splanchnikom Ischémia čreva Reperfúzia PLA 2 MSOF Kirton, Civetta, Critical Care 1997 Systémové vplyvy PMN PAF Aktivácia PMN 48
41 APACHE II Scoring System APACHE I was developed in 1981 APACHE II was introduced in 1985 APACHE III in
42 SYNDRÓM MULTIORGÁNOVEJ DYSFUNKCIE (ZLYHANIA) MODS MSOF (Kerr, PGA55) Orgán systém 1. Pľúca 2. Obličky 3. Kardiovask. systém 4. CNS 5. Perif. NS 6. Koagulačný systém 7. Gastrointest. trakt 8. Pečeň 9. Nadobličky 10. Kostrové svalstvo Klin. syndróm 1. ARDS 2. Akút. tubul. nekróza 3. Hyperdyn. hypotenzia 4. Metab. encefalopátia 5. Polyneuropátia 6. DIK 7. Gastroparéza, ileus 8. Neinfekčná hepatitis 9. Akútna insuf. nadobl. 10. Rabdomyolýza 50
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