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Shock Diagnosis & Treatment

Shock Diagnosis & Treatment. 台大醫院 外科加護病房 柯文哲 醫師. Three Tasks in SICU. Shock ?  resuscitation 2 underlying problems ?  treatment 3 nutrition ?  support (metabolic support vs nutritional support). Shock or Not?. Shock. Inadequate tissue perfusion.

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Shock Diagnosis & Treatment

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  1. Shock Diagnosis & Treatment 台大醫院 外科加護病房 柯文哲 醫師

  2. Three Tasks in SICU • Shock ?  resuscitation 2 underlying problems ?  treatment 3 nutrition ?  support (metabolic support vs nutritional support)

  3. Shock or Not?

  4. Shock Inadequate tissue perfusion

  5. 1. What is the adequate tissue perfusion? 2. What is the optimal cardiac output for a patient at a specific time? For example: A patient with acute nercotizing pancreatitis?

  6. Definition of Shock Shock is a state of inadequate tissue perfusion 1 decreased tissue perfusion 2 inadequate tissue metabolism

  7. Diagnosis of Shock • symptom & sign • vital sign (BP, HR, RR) • ABG • urine output • cardiac output • SvO2 (mixed venous oxygen saturation) • serum lactate • tonometry

  8. Symptom & Sign Clinical finding: color, temp., pulse, capillary refilling conscious level mental status: clear even in very low C.O. state but maybe confused in early sepsis

  9. Vital organs: brain, heart, lung棄車保帥:divert blood flow to vital organsvessels in vital organs: no -receptorssympathetic tone   blood vessel constriction except in vital organs

  10. Symptom & Sign Concept of vital organs: brain, heart, lung Concept of compensation: sympathetic tone   perfusion to vita organs skin  cool, pale GI  paralysis, bleeding, “translocation” kidney  oliguria

  11. Symptom & sign • Disadvantages: • Too late to be effective • Subjective • Not quantified • Unreliable in modern ICU

  12. Vital Signs HR, BP, RR Disadvantages: • large overlap between normal & abnormal • when obvious (too late)

  13. BP = CO × SVRV = I × R 相信血壓 一定會倒楣

  14. 阿婆的故事

  15. Vital Sign • Advantages: • Quantified, objective number • Automatic, computerized • Continuous --> trend analysis, not single value

  16. Blood Gas Analysis pH, BE • intermittent measurement • pH.: A real vital sign change only in decompensated state

  17. Basic Model in Critical Care survive success stress => compensation failure death PH in ABG

  18. Urine Output • Advantages: • No instrument required (one Forley tube) • Simple and easy • Real time ( rapid reflection of renal perfusion) • Allow trend analysis

  19. Urine Output NTUH SICU routine: U/O record q1h

  20. Urine Output Normal heart, kidney, endocrine, volume status  normal urine output ( p  q  q  p ) • too many interfering factors: renal diseases, diuretics, mannitol, glycerol, hyperglycemia, DI, ATN diuretic phases • awkward in children e.g. 3 cc/hr • labor-intensive

  21. Cardiac Output Method: • Thermodilution (intermittent, continuous) • Pulse contour (PiCCO) • Bioimpedance • Indicator-thermodilution (COLD)

  22. - T time CO = Indicator - thermodilution

  23. a b c d e a b c d Noise, random, summation

  24. Cardiac output

  25. Cardiac Output • Intermittent: cold water injection • continuous: heating wire pulse contour impedance

  26. Tissue Perfusion demand supply

  27. SvO2(mixed venous oxygen saturation)

  28. SaO2 VO2 C.O. SvO2 Hb

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