休克病人的镇静镇痛治疗.

休克患者的镇痛镇静[e-mail]心源性休克的紧急处理1.坐:端坐位2.氧：吸氧3.吗：吗啡肌注4.强：强心剂5.…降低休克患者的焦虑应激EpidemiologyofanxietyforMVpatientsAuthorCitedfromPatientTypeAnxietyJonesCCCM2001ICU33/45(73%)RotondiCCM2002ICU,MV100/150(67%)SwaissMEJA2004ICU,MV37/55(68%)SharonAJCC200431ICUs73/106(69%)LeurCrtCare04ICU,MV66/123(54%)HsiaoAATW2006ICU,MVSerioussympatheticNerveMedullaAdrenalineNon-adrHeartVesselsBronchiSystematicstressresponsesBeneficialHarmful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病例数N=87CPR时处理措施对照组26用软布帘隔离心理组33专职护士对其进行心理护理镇静组28给予咪唑安定0.1mg/kg静脉注射。李秦，马朋林中国危重病急救医学2008；20(4):193-196HeartratechangesinnearbedconsciouspatientsduringCPR020406080100120140基础值10min4hr24hr图5心率变化(beats/min)对照组N=26心理护理组N=33镇静组N=28SBPchangesinnearbedconsciouspatientsduringCPR020406080100120140160180200基础值１０分钟４小时２４小时图6.收缩压改变(mmHg)对照组N=26心理护理组N=33镇静组N=28PlasmaepinephrinealterationsinnearbedconsciouspatientsduringCPR00.511.522.50分钟10分钟4小时24小时图2血浆肾上腺素浓度变化(ng/ml)对照组N=13心理护理组N=13镇静组N=14CPR时邻床清醒患者心律失常发生情况病例数心律失常例数（百分率）总例数室上速房性早搏室性早搏短阵室速对照组2622（84.6）22（84.6）5（19.2）7（26.9）0（0）心理组3318（54.5）16（48.5）6（18.1）4（12.1）1（3.0）镇静组286（21.4）6（21.4）0（0）2（7.1）0（0）P值0.050.010.010.050.05-----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.ConclusionYehYC,AnesthAnalg.2012Jul;115(1):46-53.Epub2012Apr13.SedationattenuatedTNFαproduction.CritCare2009,13:R136Sedationimprovesearlyoutcomeinseverelysepticrats.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/hror10mg/kg/hrClinExpPharmPhysiol(2008)35,766–774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/hrClinExpPharmPhysiol(2008)35,766–774ClinExpPharmPhysiol(2008)35,766–774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;305:613–62PropofolInfusionSyndromeDrugSafety2008;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（16yr）异质性群体严重全身感染（细胞代谢障碍）临床预警特征突发不可解释的严重酸中毒MAP: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-tumornecrosisfactormechanismhavebeenreportedinanimalmodels.PediatricEmergencyCare26,Number9,2010氯胺酮的作用不仅仅是镇静Anaesthesist2006・55:883–891总结：真的重要！恰当的浅镇静，有效镇痛监测镇静相关的呼吸循环影响推荐：休克早期复苏时选择氯胺酮+咪唑安定Thankyouforyourattention