外科學(xué)總論 MODS多器官衰竭

MultipleorgandysfunctionSyndrome外科教研室大綱多器官功能障礙的定義和特點(diǎn)掌握多器官功能障礙的臨床演進(jìn)熟悉多器官功能障礙的診斷熟悉急性腎功能衰竭的病因熟悉急性腎功能衰竭的定義和病因熟悉腎功能衰竭的臨床表現(xiàn)、診斷和防治方法熟悉急性呼吸窘迫綜合征的定義和病因熟悉急性呼吸窘迫綜合征的臨床表現(xiàn)、診斷和治療熟悉2CascliniqueM.26years,whohashadacolectomywithananastomosisFeverat40degree,abdominaltendernessHemoculture:Escherichiacoli3T40℃HR170RR55PaCO223.8Whitecell18700Hemoc+41stday

chocSeconddya

anuriaetdyspnea (BUN20.5Crea337)

Thirddaymechanicalventilation5He+patomegalybecauseoflongtermparenteralnutrition

SGPT36SGOT144TB167.9DB102.8

6MODS7Name1973sequentialdysfunction1977Remoteorgandysfunction1986post-traumaticmultipleorgandysfunction1991Multipleorgandysfunctionsyndrome8Definition

sequentialorsimultaneous>2organsdysfunctioncausedbyprimitiveillnessoragression(inflammation)9EtiologySepsisetsepticshockTraumaandburnsMajorbleedingIschemiaandreperfusionIntra-abdominalinfectionAcutepancreatitis10DifferentfromdeathTerminalstage：StressabsentNaturalorgandegradationIrreversibleMODS：AcutestressInflammatorydamageReversible11ExempleRespiratoryandcirculatoryfailureleadingfromsepticshockheptorenalsyndromepulmonary

heart

diseasePulmonaryedema12PhysiopathologyPolytraumaSepticshock?MODS13?=SIRS

SystemicInflammatoryResponseSyndromeMorethan2pointsHRmorethan90RRmorethan20/minorPaCO2lessthan32mmHgBodytemperaturemorethan38℃orlessthan36℃；Whitecell>12000/mm3

or<4000/mm3,orprematureratiomorethan10%14inflammationBodydefenseresponsetobacteria,foreignbodyanddamageProandanti-inflammatorybalanceDolor,calor,rubor,tumor,functiolaesa15Cytokinendotheliumneutrophilemono-macrophageTNF-aIL-1、2、6v.sIL-10Amplifiedinflammation--SIRSDamageintroducedbyneutrophilandcytokinviolentstress16resultendotheliumdamageEndothéliumcontractionCapillaryleakhemodynamicinstabilitycoagulationminithrombosismicrocirculationfailureIschemiareperfusion17organinvolvedLungCardiovascularsystemkidneyliverdigestiveImmunologyhematologyneurology

18PreventionEtiologictreatmentEarlyidentificationTachypneashockOliguriaAntibiotic19Abdominalabces

20Intestinalfistula21AcutekidneyinjurySyndromeofazotemia,hydro-electroliticdisturbancecausedbyfunctionalororganicrenaldysfunction22etiologypre-renalhypovolemiaandhypoperfusionshockBleedingExtracellulardehydrationabdominalcompartmentsyndrome23etiologyrenalAcutetubularnecrosisGlomerulonephritisRhabdomyolysisMedicinepost-renalobstruction24mechanismeischemieTubularnecrosisObstructionischemiareperfusioninfection,medicine,endotoxine2526ClinicalManifestationoliguricSeveraldaysto3weekshydro-electrolticetacido-basicdisturbanceazotemiableeding:subcutaneous,gums,post-operative27Manifestationpolyuric（14

days）RecoverstylerapidprogressiveslowHomeostasisdisturbance28Diagnostic

historydehydrationVomiting,diarrhea,sweatbleedingCapillaryleakIatrogenicfactorHeartfailureSeveresepsis,septicshock29DiagnosticPre-renalTachycardiashockCVPdecreaseSkinmarbleandcoldMoistralesAbdominalhypertension30DiagnosticRenalemedicineHistoryofrenaldiseaseInsuffisancecardiaqueouhépatiquechroniqueSepsisProlongedischemia

31DiagnosticDifferentialIRfonctionnelleIRorganiqueetiology HypoperfusionInfectionConcentrationBaruriaIsosthenuriaNatriuriadecreased>40mmol/LbunIncreasealoneIncreasewithcreatininHydratationrecoverOliguriaLasilixeffectivenoneeffective32LaboratoryUrinaryUrinevolumepH,pycnometerMicroscopieBiochemistryazotemiaCreatinineclearanceratedecrease33LaboratoryHyperkaliemiaHypermagnesemiaHyperphosphoremiaHyponatremiaHypochloremiaHypocalcemiaAcidosisWaterIntoxication34PreventionresuscitationAlkalinizationofbloodDecompressionInotropic35TreatmentOliguriaLiquidrestrictionAvoidhypoperfusionAdequatecalorieProteinatleast1g/kg/d36TreatmentHomeostasisHyperkaliemiaacidosisAntibiotherapyAvoidnephortoxicmedicine37TreatmentContinuousrenalreplacetreatmentHemodialysisHemofiltrationHemodiafiltrationPeritonealDialysis383940TreatmentPolyuriaAvoidhypovolemiaMaintainelectrolyticbalanceProteinAntibiotherapy41AcuterespiratorydistresssyndromeARDSAcuterespiratoryfailurewithprogressivehypoxia,bilateralinfiltration,pulmonarycompliancedecreasecausedfromtrauma,sepsis,pancreatitis.42EtiologydirectedamageaspirationPulmonarycontusionInhalation:hotortoxicgasdrowning43EtiologyIndirectedamageSepsisorsepticshock

AcutepancreatitisVasttransfusionofbloodproductsTrauma

Polyfracture44mechanismeSIRSCapillaryleakAlveolarandinterstitialdestructionbyneutrophiloxygenationdysfunctionPulmonarycompliancedecreasePulmonaryhypertension45mechanismeshuntingAlveolarcollapseDeadspacevasoconstrictionandminithrombosisPneumocytedestructionsurfactantdecreaseHyalinemembraneFunctionalresidualcapacitydecrease4647ManifestationHypoxemiaprogressiveAcutestageTachypnea

l’oxygenotherapynotworkAuscultation:normalChestradio:normal48ProgressivestageSevererespiratoryfailure:mechanicalventilationRespiratorysecretion:raleandwheezeRadio─bilateralopacityObnubilationFeverandhyperleucocytosisTerminalstageComaArrhythmia→bradycardia→cardiacarrest4950DiagnosticBloodgasHypoxemiaPaO2decreasePaO2/FiO2decreaseHypercapniaMorecriticalHemodynamicSwan-Ganz,echocardiography51TreatmentetiologyInterstitialedemaCristalloidetcolloidDiuresisLiquidrestriction52TreatmentOxygenotherapyCannulaMaskVentilatio