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Сепсис. д-р Господин ДИМОВ, дм. Основни задачи на лекцията. Определени я на основните понятия Патофизиология на септичния шок и свързаните с него синдроми Диагноза и диференциална диагноза на септичния шок Терапевтичен подход при пациент със септичен шок.

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Сепсис

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3826774

- ,


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,

Sir Isaac Newton, 1687


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, ,


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- :

  • 360 38.30

  • 90 /min

  • 20/min PaCO2< 32 mmHg

  • 4.109/l 12.109/l / 10%


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  • - 7.7 mmol/l

  • 2 mmol/l

  • 2 s


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SIRS


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+


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SIRS

12


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SIRS>CARS

SIRS

CARS

MARS

SIRS>CARS

S

SIRS<CARS

SIRS = CARS


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:

  • :

    • - 2/Fi2<300

    • < 0.5 ml/kg/h 45 ml 2 h

    • 2mmol/l


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:

  • :

    • > 200 mcmol/l

    • 35 mmol/l

    • :

      • INR>1.5 aPTT > 60 s

    • 100 000 /mcl

    • 2mmol/l


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+, :

  • 20 -40 ml/kgRinger lactate

  • 40 ml/kg Ringer lactate


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+ , 1 ( 500 ml 0.9% NaCl) /


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  • Hageman

  • ,


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  • -

  • I

  • TNF

  • -


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  • PAI-1

  • F-1a


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-


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  • PIRO:

    • Predisposition: Genetics, Chronic illness

    • Insult: Infection, Injury, Ischemia

    • Response: Physiologic, Mediators, Markers

    • Organ Dysfunction: Outcome, Organ dysfunction


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  • :

    • ,

    • ,


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  • ( )

  • ( )


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  • ,

  • - ARDS


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  • - ,


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  • :


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, ,


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, ,


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  • :

  • :


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  • DO2 = CO x CaCO2 x 10=6401200 ml O2/min

  • VO2 = CO x (CaO2 CvO2)x10=180 280 ml O2/min

  • CI = HR x SV / m2=2.8 4.2 l/min/m2

  • CaO2 = (1.34xHbxSaO2) + (PaO2 x 0.0031) = 19 vol%

  • CvO2 = (1.34xHbxSvO2) + (PvO2 x 0.0031) = 14 vol%

  • AvDO2 = CaO2 CvO2= 3 5 vol %

  • O2ER = VO2 / DO2= 22 30 %


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  • ,

  • :

    • ?


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  • :

    • -/

  • :

  • -


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  • :


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  • :


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  • :

    • , , ,

    • : , ,


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  • :

    • ,

    • , ,

    • , D-

    • ST, , , ,


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  • 2 :

    • +

    • AC


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  • - 8.3 mmol/l


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  • :

    • - 12-15 mm Hg

  • () > 3-4 l/min/m2

  • (SvO2) 65-70%

  • 60 mmHg

  • 0.5 ml/kg/h


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- I

  • :

    • 20 min - 500 ml 20-40ml/kg

  • :

  • Dopamine -10-20 mcg/kg/min 2-5 mcg/kg/min 10 min


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- II

  • :

    • Swan-Ganz

    • , , S/G

  • :

    • < 2.5 l/min/m2

    • > 14 mmHg

    • > 1100 dynes.s.cm-5/m2

    • Dobutamine 20 mcg/kg/min


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- II

  • :

    • > 4 l/min/m2

    • 12 mmHg < < 14 mmHg

    • < 1100 dynes.s.cm-5/m2

    • Nordarenaline - 0.5-5 mcg/kg/min

    • Dobutamine - 20 mcg/kg/min

    • Vasopressine - 0.01-0.04 U/h


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- , - HCHS 7 300 mg/


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:

  • .


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  • -Xigris

  • Naloxone

  • Fibronectin?

  • NSAID?

  • ?


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<70 mmHg

>30/min

PaO2<55 mmHg


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( 6 h)

  • :

    • 3

    • 1


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( 6 h)

  • / > 4 mmol/l:

    • 20 ml/kg e

    • ( 65 mmHg)


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( 6 h)

  • , ( ) / 4 mmol/l :

    • 8 mm Hg

    • (ScvO2) 70%, (SvO2) 65%


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24

  • C

  • , 8.3 mmol/l

  • 30 cm H2O


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