严重创伤患者的液体复苏FluidResuscitationinTraumaticCriticallyIllPatients.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,严重创伤患者的液体复苏FluidResuscitationinTraumaticCriticallyIllPatients,Patterns of Traumatic Injury,Penetrating injury ongoing significant blood loss is expected,Blunt injury blood loss may be occult or contained and significant or limited,Head injury maintenance of cerebral perfusion pressure,Others:pediatric and obstetric trauma,Shock,Definition,:a state of reduced organ perfusion resulting in tissue hypoxia and organ dysfunction,S/S:falling of BP,tachycardia,oligouria,decreased mental status,decreased peripheral pulses,diaphoresis,Main goal of therapy:rapid resuscitation with re-establishment of tissue perfusion using fluid therapy and vasoactive drugs,Hemorrhagic shock,Acute response:,Increased capillary permeability,Reduction in blood flow,Sympathetic compensation by peripheral vasoconstriction,Elevated IL-6 and TNF-alpha,Tissue hypoperfusion and anaerobic metabolism/acidosis,After systemic circulation is restored,reperfusion injury due to free oxygen radicals released during acute hypoxic stage may occur,Traumatic hemorrhagic shock,Acute stage:hemorrhagic shock,May be accompanied with:,Cardiogenic,shock,Neurogenic,shock,Obstructive shock,Septic shock,Hemorrhagic shock,Traumatic hemorrhagic shock,Trauma triad of death after hemorrhagic shock:,(1)Hypothermia,(2)Acidosis,(3)Coagulopathy,Traumatic hemorrhagic shock,Phase 1:The period from injury to definite surgical care and homeostasis,Phase 2:The period during and immediately after definite surgical procedure,Phase 3:The period in ICU following definitive care and characterized by established critical illness,Phase 1:pre-hospital/pre-operative fluid therapy,Traumatic hypotension without a head injury:no evidence suggest that pre-hospital fluids are beneficial,Delayed fluid resuscitation has better outcome than immediate resuscitation in penetrating torso injuries,The evidence supporting delayed or limited prehospital resuscitation in blunt trauma is less clear,Phase 2:perioperative fluid management,It is unclear whether targeting cardiac output or oxygen delivery to specific defined goals results in improved clinical outcomes,Maximized stroke volume using fluids titrated against a measure of blood flow is supported by limited available data,Phase 2:perioperative fluid management,The addition of inotropes to achieve specific blood flow or oxygen delivery goals may confer additional advantage but the available data is not conclusive,Phase 3:Critical care fluid management,Fluid strategies are directed at restoring organ function after the combined insult of hypovolemic hypoperfusion,surgery and trauma induced inflammatory response,Maintaining a normal circulating volume(cardiac output)is a priority,Targeting oxygen delivery goals has been demonstrated to be harmful in established critical illness,Trauma Fluid Resuscitation,Severity of hemorrhagic shock,Age,Co-morbid disorder,Injury types,Concurrent head or spinal injury,Pulmonary edema,Types of Fluid,Crystalloid solutions,Colloid solutions,Gelatins,Dextrans,Hydroxyethyl starches(HES),Albumin and plasma-protein fraction,Blood&blood substitutes,Crystalloids,Solutions in water of inorganic ions and small organic molecules,either glucose or sodium chloride based.,Colloids,A homogeneous,non-crystalline substance consisting of large molecules or ultramicroscopic particles of one substance dispersed through a second substance,Principal types of semisynthetic colloid molecules:gelatins;dextrans;and HES,Human plasma derivatives:albumin,FFP and immunoglobulin solutions,Colloids,Key characteristics of artificial colloids,Magnitude and duration of plasma volume expansion,Hemorreological characteristics,Hemostatic effects,Interaction with endothelial and inflammatory cells,Adverse drug reactions,Cost,Gelatins,Dextrans,HES,Gelatins:prepared by hydrolysisof bovine monly available preparation-succinylated gelatin(Gelofusin),Dextrans:high-MW D-glucose polymers joined largely into linear-branched macromolecules,HES:synthesized from amylopectin,a waxy starch derived from maize or sorghum,Albumin and plasma-protein fraction,Human albumin:a naturally occuring monodiperse colloid,FFP and plasma-protein fraction:a more polydisperse human-derived colloidal solution with significant amounts of higher-MW proteins-globulins,Blood Substitutes:hemoglobulin solutions,At an early stage of development and probably some way from routine clinical use,HBOC(Hemoglobic-based oxygen-carrying compounds),PBOC(Perflourocarbon-based oxygen-carrying compounds),Have a linear O,2,Hb dissociation profile and specific pharmacological effects,Thank you for your attention!,Hemorrhagic shock,Schematic diagram of capillary memebrane,Crystalloids,Colloids,HES solutions,HBOC,