版權(quán)說明:本文檔由用戶提供并上傳,收益歸屬內(nèi)容提供方,若內(nèi)容存在侵權(quán),請(qǐng)進(jìn)行舉報(bào)或認(rèn)領(lǐng)
文檔簡(jiǎn)介
Denominationvariation1973secondarysystemfunctionfailure---Tilney
Summarydataof18casesARFpatientsafterabdominalaorticaneurysmoperation,and17patientsdiedfromorganfailureduringdialysis.1975-1977
MOFS,multipleorganfailuresyndrome-----Baue,1975
(Yetthetreatmentdidnotsavethelives.)
MOF,multipleorganfailure-----Eiseman,1977
1980‘s
MSOF,multiplesystemorganfailure-----Fry38/533
pointouttherelationshipbetweenMSOFandsevereinfection
1990‘s※MODS,multipleorgandysfunctionsyndrome※1第一頁,共61頁。Case1Male26yPost-subtotalexcisionofcolonIleocolonicstomaleakageMultipleintestinalfistula2第二頁,共61頁。Abdominalabscess3第三頁,共61頁。Long-termapplicationofhighcaloriaparenteralnutrition(fatemulsion)
livertumefaction
liverdysfunction
SGPT36SGOT144TB167.9
DB102.8
4第四頁,共61頁。HR170RR55PaCO223.8WBC18700Positivebloodcultivation5第五頁,共61頁。Jan16th
septicshockJan17thRenalfunction
BUN20.5Cr337needinhalationofoxygenwithmask
continuoushemofiltrationJan19th
tracheotomy
ventilatorapplication6第六頁,共61頁。Case2male59yExtensiveanteriorwallMyocardialinfarction20daysafteronset(2002/3/6)
continuousventriculartachycardia→ventricularfibrillation
electricdefibrillation5times
antiarrhythmicdrugs
countershockdrugs
ventilatorapplication7第七頁,共61頁。HR120RR28PaCO226.8WBC126008第八頁,共61頁。Repeatedlyventriculartachycardiaandfibrillation,totally21timeselectricdefibrillationContinuoushyperpyrexia、highWBC、HR≥90、RR≥22Cultivationnegative,antibioticsnoeffectivenessOrgandysfunctioncameincrowdsshockRespiratorydysfunctionDeteriorationofliverfunctionCastinurineroutinetest→BUN、Cr↑
→oliguria、anuriaCoagulationabnormalitydeath9第九頁,共61頁。AcuteonsetManifestatinofexcessiveinflammationDeteriotationofpts’conditionsdespiteactivetherapyMultipleorgandysfunctionDifferentpts,SameprogressCase1:infectiousCase2:noninfectious10第十頁,共61頁。clinicalbehaviorAccumulativeSubstanceirreversibleMultipleorganlowfunctioncausedbyinteractionbetweenorgansChronicdiseaseMultipleorganlowfunction11第十一頁,共61頁。MODSfollowedbyprimaryemergencydiseasein24hoursClinicalmanifestationburstoutSimultaneousdiequicklyprimaryMODSIschemiaischemiaandreperfusionphysicalandchemicalinjuryfactor12第十二頁,共61頁。Sequentialorgandysfunctionafteremergencydisease,MODSClinicalbehaviorDelayedSequentialReversibleMODSExcessiveinflammatorymediators13第十三頁,共61頁。1.DirectinjuryofischemiaOxygen&nutrientinsufficiencyIntegrityofcellmembrane↓organelleinsult↓ATP↓
Extracellularfluidin-flowHydrolaseactivationNatriumin-flowcalciumin-flow
14第十四頁,共61頁。1.DirectinjuryofischemiaHypersensibitityinheartandbrainSelectiveischemiaEndothelialcellinjuryleadstohighvascularpermeabilityandlowvolume15第十五頁,共61頁。permeabilityofcellmembrane↑Na+Ca++H2OADPAMPIMPadenosinexanthinehypoxanthinehypoxanthineribosideUricAcidoxygen-derivedfreeradidicalsxanthineoxidasexanthineoxidaseXanthinedehydrogenaseIntracellularacidosisLowerproteinsynthesisInjuryofischemiaandreperfusion16第十六頁,共61頁。Vesselpermeability↑+WBCchemotaxis
monocyte/macrophage
neutrophil
elastinasePLA2ODFR
TNFIL-8etal
IL-1IL-6
liver:acute
phasereactionRemoteorganinjuryTissuedamageetiologicalfactor
neutrophilAdherentmolecule2.ExcessiveinflammationSIRSMODSVascularendothelialcellSIRSMODS17第十七頁,共61頁。ClinicalprogressuncontrolledstressSIRSCapillaryleakagesyndromeMODSMSOF18第十八頁,共61頁。ImportantmoleculeinMODS
Pro-inflammatorycytokines:TNF-αβ,IL-1、2、6etcStimulatesynthesisandreleaseofothercytokinesActivateneutrophiles,eosinophilsandmonocytes;activateTandBcell;chemotaxisIncreasetheexpressionofadherentmoleculeActivatecomplementandcoagulationsystemIncreasepermeabilityofvessels,decreaseBPCausefeverandcatabolismofmuscle19第十九頁,共61頁。ImportantmoleculeinMODS
Anti-inflammatorycytokines:IL-4、10
etcMaintainandenhancethefunctionofactivatedNKcells,monocytes,BandTcells,InhibitproliferationofT,BcellInhibitpro-inflammatorycytokinesproduction,receptorexpressionandcytotoxicityofmonocytesInhibitadherentmoleculeexpressionofvascularendothelialcells(VECs)InhibitH2O2、NOproductionofmacrophageInhibitantigenpresentationandotherassistantfunctionsofmonocytesandmacrophage20第二十頁,共61頁。ImportantcellsinMODSPolymorphonuclearleucocyte(PMN):Effectorcellofinflammatoryresponse.CouldreleaseseveralproteinenzymesandODFRtodestroyVECsandstromaVECs:Whenactivated,VECsexpresshigheradherencetoPMNandhigherclottingcompetence;alsotheyproducepro-inflammatorycytokinesandvasodilatingagenttomagnifyinflammatoryresponse;finally,capillaryleakagesyndromecomesifVECsweredestroyed.21第二十一頁,共61頁。ImportantorganinMODSIntestinesBecauseofstress,fastingandcatabolism,theblood-mucosabarrierofintestinescouldbedestructed,thebacteriaandtoxintranlocatetobloodcirculationandthelattercouldenhanceinflammatoryresponsetoformviciouscycle.Sointestinesarecalled“motor”ofinflammatoryresponse,andaresourcesoflatestageinfectonsofMODSpts.22第二十二頁,共61頁。uncontrolledstresscarbohydratemetabolismdysfunction,Insulintolerance,withoutKetonemiahyperkineticcirculatorystate,Hyperpyrexia,HighStrokevolume,HighoxygenconsumptionProteinmetabolismdysfunction,highkatabolism,acutephaseprotein23第二十三頁,共61頁。T>38℃or<36℃HR>90beat/minRR>20/minorPaCO2<32mmHgWBC>12000mm3or<4000mm3orprematurecells>10%SepsisSystemicInflammatoryResponseSyndrome(SIRS)(SIR+PositiveCulture)(SIRwithoutinfection)SystemicInflammatoryResponsesyndrome
SIRS24第二十四頁,共61頁。ChaoticinternalmilieuduringacutephaseDisturbanceofelectrolytesandacid-basebalanceFeverCatabolism:emaciated,anemiaAcutedisseminatedintravascularcoagulationArrhythmiaHyperglycemia,noketonemia25第二十五頁,共61頁。Secondaryaldosteronism---highdensityurinewithoutProteinuria,oliguria
---prerenalazotemia---swollenPlasmaproteinleakage---Interstitialedema
---Hypoproteinemia
---bloodinspissasion---HypovolemiaCapillaryleakagesyndrome,CLS26第二十六頁,共61頁。DiagnosisofCLSPositivebodyfluidbalanceBloodvolumedeficiencyHypoproteinemiaOrganandtotalbodyInterstitialedemalungInterstitialedemacerebralInterstitialedema27第二十七頁,共61頁。OrgansdysfunctionorfailureOrganorsystemdysfunctionfailurelungLiverkidneyintestineBloodHypoxemia,respiratoratlist3-5daysARDS,PEEP>10cmH2O,FiO2>0.5Bilirubin>2-3mg/dL,Liverfunction>2normalvalueBilirubin>2-3mg/dL,icterusoliguriadialysisUntoleranceofenteralnutrition>5daysCurlingl'sulcerneedsbloodtransfusion,AcalculouscholecystitisPTorPTTelongation,platelet<50-80thousand,HypercoagulablestateDICcentralnervoussystemcardiovascularsystemInsanity,lightorientationdisorderProgressivedeepencoma
EjectionFraction
↓,capillaryleakageIrresponsivitytomusclestrengthdrugs28第二十八頁,共61頁。GlasgowScore29第二十九頁,共61頁。InfluencedorganLung——ARDS>95%Kidney——ARF
onlyafew30第三十頁,共61頁。AcuteRespiratoryDistressSyndrome,ARDSPathologyoflungHighcapillarypermeability——InterstitialedemaVasoconstriction,microthrombosis——communicatingbranchopeningAlveolarandsmallbronchus——AtelectasisDecreasedalveolarsurfactantEdemaItypeepithelialcellsinsteadbyIItypecellSymptomTachypnea,respiratorydistresscannotbeeasedbyoxygeninhalationNoralesNolungx-rayabnormality1.Theearlystage31第三十一頁,共61頁。PathologyDeterioratedlungInterstitialinflammation,usuallycomplicatedwithSEPSISSymptomObviouslydyspnoeaandcyanosis——needsventilatorIncreasedrespiratorytractsecretion,ralesLungx-ray——infiltratesDisturbanceofconsciousnessFebrileorhighleucocyte↑.Thesecondstage32第三十二頁,共61頁。3.Telophase
PathologyLungparenchymafibrosisMicrovascularocclusionIncreasedpreload,hypoxiaSymptomDeepcomaArrhythmia—bradycardia—cardiacarrest33第三十三頁,共61頁。Diagnosis34第三十四頁,共61頁。AcuteRenalFailure,ARFEtiologyPrerenalHemorrhage,shock,fluidlosingwithoutappropriatefluidresuscitationpostrenalbothsideureterorurinaryflowblockedrenalkidney
ischemia(hematorrhea,sepsis,allergicreaction)intoxication(aminoglycosideantibiotic,biotictoxin,chemical)35第三十五頁,共61頁。1.HistoryandphysicalexaminationEtiologyprerenalpathogenpostrenalpathogenDiagnosisofARF36第三十六頁,共61頁。2.DifferentiationDiagnosiswithprerenalARF37第三十七頁,共61頁。3.DifferentiationDiagnosiswithPostrenalARFBtypeultrasound(renalenlargement,ureter)Abdominalx-rays(calcification,calculusorObstruction)38第三十八頁,共61頁。4.LaboratoryUrinetestUrinarycathetertorecordurinevolumeUrineacidity/density(1.010-1.014)UrinemicroscopicexaminationRBCandrenaltubuleepithelia(renalcortexandrenalmedullanecrosis)LargeBrowncasts(renalfailurecasts)Eosinophil↑(interstitialnephritis)Redcellcast(glomerulonephritis)Normal(prerenalorpostrenalfailureearlierperiod)39第三十九頁,共61頁。5.renalfunctionexaminationUrineureanitrogen↓
(<180mmol/24)UrineNa↑(>175mmol/24h)Fractionalexcretionoffiltratedsodium>1
FENa(%)=(UNa/PNa)×(PCr/UCr)×100osmoticpressureofurine
*ARF------<400mOsm/L
*prerenalARForglomerulonephritis------>400mOsm/LBUN(morethan
3.8-9.4mmol/Lperday),Cr↑Urine/PlasmaCr------<20renalfailureindex,RFIRFI=Una×(PCr/UCr)
*>1------ARF*<1------prerenal40第四十頁,共61頁。IntensivecareOrganandsystemfunctionMonitoringandsupportObjectameliorateoxygenmetabolismamelioratenutrienstateTherapyaimedatstressandinflammatoryMediatorsTreatmentofcapillaryleakageTreatmentofprimarydisease41第四十一頁,共61頁。OxygenmetabolismMonitoringCriticalDO2Assayofplasmalacticacid/pyruvicacid42第四十二頁,共61頁。OxygenassociatedindexDO2OxygenDelivery---OxygenofferedtothebodyinacertainperiodbycirculatorysystemDO2=CO×(1.38×SaO2+0.003×PaO2)VO2OxygenConsumption---Oxygenconsumptedbyallcellsinacertainperiod.VO2=Ca-vDO2×CO×1043第四十三頁,共61頁。CriticalDO2VO2DO2SepsisARDSMODSNormalCriticaldeliveryoxygen44第四十四頁,共61頁。LacticAcidandcellshypoxiaLacticAcid↑--latentcellshypoxia
lacticacidosis--tissueperfusiondeficiencyandcellshypoxia
LacticAcidnormalvalue---0.5-1.5mmol/L
>4-5mmol/L→SBandPH↓→lacticacidosisL/Prate↑--cellshypoxia
L/Prate
normalvalue---10:145第四十五頁,共61頁。Strategyofameliorateoxygenmetabolism
Improvementofoxygendeliveryrespiratorysupport---toimprovearterialbloodoxygencontenthigherinhalatedoxygenconcentration,ventilatorincreasecardiacoutput
Heartrate,cardiacrhythm,cardiaccontractility,preload/afterloadBloodsystemrisehemoglobinconcentration46第四十六頁,共61頁。StrategyofameliorateoxygenmetabolismIncrease
oxygenextractionratioAmeliorateinterstitialedemaReducebloodcapilarypermeabilityAmeliorateoxygenextractionofcells47第四十七頁,共61頁。TreatmenofCLSLimitationofwater-intakepremise:nevergetCOdownInfusionvolumedecidedbyurinevolumeperhourwhenlungandbraininterstitialedemahappen.RisecolloidosmoticpressureUsepowerfuldiureticUseglucocorticoid48第四十八頁,共61頁。NutritionalsupportMetabolismsupportOffernutritionalsubstratebutneverincreaseorganloading.MetabolismmodulationInhibitionofcatabolismhormonesPromoteproteinsynthesis,easenegativenitrogenbalance49第四十九頁,共61頁。NutritionalsupportAddaccessoriesPromoteproteinsynthesisandcellgrowthModulateimmunologicresponse
EnteralnutritionProtectbowelblood-mucosabarrier(preventfrominfection)50第五十頁,共61頁。DiscussionoftherapyforstressandinflammatorymediatorsAntagonismandclearanceAimatexcessivecytokines---post-translationlevelsReductionofsynthesis
keepthebalancebetweenpro-andanti-cytokines---intranscriptionlevels
---intranslationlevel51第五十一頁,共61頁。CytokinesmodulationIntranscriptionlevelAnti-mRNAexpression
(NF-κBisinchargeofmanykindsofcytokineexpression.)TranslationlevelReducecytokinessynthesisPosttranslationlevelAnti-cytokines(antibodyorsolublereceptor)BlockreceptorofcytokinesClearanceofcytokines(plasmapheresis)52第五十二頁,共61頁。TreatmenofARDSCorrecthypoxemiaquicklyuseventilatorassoonaspossibleappropriatePEEP(regainalveolarfunctionandfunctionalresidualcapacity)53第五十三頁,共61頁。TreatmenofARDSMaintainCirculationandlunginterstitialedemaPropercrystal/colloidrateDiureticNegativewaterbalance(accordingtoCVP/PAWP,urineoutputandlungauscultation)54第五十四頁,共61頁。TreatmenofARDSPreventandtreatinfectionBlockSIRScorticoidintheinitialstagemediatorsinhibitor(Ibuprofen,Dentoxifylline,TNFantibody)55第五十五頁,共61頁。TreatmentofARFOliguriaoranuriastage
(7-10days,average5-6andmax.morethan1month)confinewaterintakeEqualwaterintakeandoutputfluidintakeperday=(dominantwaterlosing)+(nondominantwaterlosing)-(endogeneouswater)or0.5kgnutrientLowprotein,highcalorie,highVitaminproteinsynthesishormones56第五十六頁,共61頁。TreatmentofARFcorrectelectrolytesimbalaHyperkalemiaHyponatremia
溫馨提示
- 1. 本站所有資源如無特殊說明,都需要本地電腦安裝OFFICE2007和PDF閱讀器。圖紙軟件為CAD,CAXA,PROE,UG,SolidWorks等.壓縮文件請(qǐng)下載最新的WinRAR軟件解壓。
- 2. 本站的文檔不包含任何第三方提供的附件圖紙等,如果需要附件,請(qǐng)聯(lián)系上傳者。文件的所有權(quán)益歸上傳用戶所有。
- 3. 本站RAR壓縮包中若帶圖紙,網(wǎng)頁內(nèi)容里面會(huì)有圖紙預(yù)覽,若沒有圖紙預(yù)覽就沒有圖紙。
- 4. 未經(jīng)權(quán)益所有人同意不得將文件中的內(nèi)容挪作商業(yè)或盈利用途。
- 5. 人人文庫(kù)網(wǎng)僅提供信息存儲(chǔ)空間,僅對(duì)用戶上傳內(nèi)容的表現(xiàn)方式做保護(hù)處理,對(duì)用戶上傳分享的文檔內(nèi)容本身不做任何修改或編輯,并不能對(duì)任何下載內(nèi)容負(fù)責(zé)。
- 6. 下載文件中如有侵權(quán)或不適當(dāng)內(nèi)容,請(qǐng)與我們聯(lián)系,我們立即糾正。
- 7. 本站不保證下載資源的準(zhǔn)確性、安全性和完整性, 同時(shí)也不承擔(dān)用戶因使用這些下載資源對(duì)自己和他人造成任何形式的傷害或損失。
最新文檔
- 畫印章購(gòu)買合同模板
- 網(wǎng)上閱卷服務(wù)費(fèi)合同模板
- 借款附加資產(chǎn)合同模板
- 購(gòu)銷辦公文具合同模板
- 冷凍設(shè)備采購(gòu)合同模板
- 法人借款合同模板
- 自由閑置轉(zhuǎn)讓合同模板
- 職工餐廳采購(gòu)合同模板
- 聘用簡(jiǎn)易合同模板
- 跟別人合作買車合同模板
- 建設(shè)工程施工合同
- 康復(fù)治療技術(shù)專業(yè)實(shí)訓(xùn)室設(shè)計(jì)方案
- 初三數(shù)學(xué)第一單元測(cè)試卷(共4頁)
- 突出“五個(gè)把握” 做實(shí)鄉(xiāng)鎮(zhèn)人大監(jiān)督工作
- 中央廣播電視大學(xué)畢業(yè)生登記表(樣本)
- 潔凈室監(jiān)測(cè)記錄表
- 復(fù)習(xí)酒水投標(biāo)書
- (完整版)工字鋼懸挑腳手架施工方案
- 瑞慈健康體檢 體檢報(bào)告書
- 冷庫(kù)工程質(zhì)量驗(yàn)收標(biāo)準(zhǔn)
- 工程預(yù)算編制準(zhǔn)確性的控制措施
評(píng)論
0/150
提交評(píng)論