外科休克

过氧化物oxidants
• 在缺血再灌注时产生 引起缺血再灌注损伤
Oxidants are produced in ischemia-reperfusion injury
• 现代观点：休克是一序惯性事件 是一个 从亚临床阶段的组织灌注不足到多器官 功能障碍的病理过程
• Current interpretation:a continuum ,ranging from subclinical deficits in perfusion to MODS
休克分类classification
• 内毒素endotoxin G的胞壁成分 脂多糖 感染性休克的强 效介质
A cell wall component of gram-negative bacteria and a potent mediator in the development of septic shock as well as a lipopolysaccharide molecule
• 巨噬细胞激活同时释放细胞因子是感染性 休克生理紊乱的关键
The activation of macrophages by endotoxin with subsequent release of cytokines appears to be a key factor in the physiologic derangement of septic shock
休克的定义
definition
• 有效循环血量↓↓ • 组织灌注不足 • 细胞代谢紊乱及功能障碍 的病理过程
• Valid circulation blood volume↓insufficient perfusion of tissues derangement in cellular metabolism and dysfunction released inflammatory mediators oxygen demand exceeds the oxygen supply
• 皮肤 皮下 胃肠道 → 交感传出↑
Sympathetic neurat output↑ ↓ CA Ang-Ⅱ VP ET TXA2
心脑
Skin subcutaneous gastrointestinal tract →heart brain
• ↓ • HR ↑ • 心肌收缩力↑ • 组织间液重吸收 •
•集落刺激因子 colony stimulating factors 刺激中性粒细胞 巨噬细胞生长
Stimulates growth of granulocytes macrophages
• 干扰素（IFN）Interferone
促进巨噬细胞功能 加强TNF的作用
Promotes macrophages function potentiates the TNF
一氧化氮NO nitric oxide
由精氨酸代谢产生 又称内皮细胞源性舒因子 具强力血管扩张 抑制血小板集聚 可引起难 治性低血压 NO is produced from the metabolism of L-arginine
formerly called endothelium-derived relaxing factor a potent vasodilator and inhibitor of platelet agg-regation refractory hypotension
IL-6→
• 肿瘤坏死因子（TNF-a) Tumor necrosis factors
↓
低血压 hypotension 乳酸酸中毒 lactic acidosis DIC disseminated intravascular coagulation 血管通透性增加vascular permeability increase 过氧化物释放oxidants released
Keith. 1919年 用染料稀释法确定血容量 休克的另 一重要机制是低血容量
Keith in 1919
used dye-dilution method to determine blood volume provided another mechanism namely hypovolemia was an important determinant of shock
微循环改变
• 微循环收缩期
Microcirculation contraction stage
微循环血流受毛细血管前括约肌舒缩效应 控制
Control of flow through capillaries is effected by contraction and relaxation of precapillary sphincters
• Wiggers:
不可逆性休克: 进行性系统循环失代偿 氧供减少 氧债 组织损伤
in the early 1940s defined for first time the concept of irreversible shock ,a state characterized as progressive systemic circulatory decompensation impaired DO2 oxygen debt tissue injury or death
Leabharlann Baidu
细胞因子 cytokines
• 白介素interleukins (IL) IL-1→ TNF-a IL-6 PAF PG fever acute-phase protein 内皮细胞促凝活性↑
endothelial procoagulant activity↑
IL-2→
hypotension
TNF-a IFN-gamma T 细胞增殖 T cell proliferation 急性相蛋白合成 acute-phase protein synthesis 中性粒细胞 活性↑ neutrophil activation
休克：冲击 打击 震荡
shock referred to a violent impact or blow
1815年George james
首次shock描述创伤后生理紊乱
in 1815 George James first used the word shock connote physiologic instability after impact
• 1960年 微循环障碍
• 近年 分子生物学发展 炎性介质 ：细胞因子 白三烯 前列腺素等
Recent work spurred on ,by rapid advances in molecular biology inflammatory mediators ,such as Cytokines Leukotrienes PG
•
↓ 胃肠道低灌注 不可逆休克 SIRS
Irreversible shock SIRS
微循环扩张期
microcirculation dilation stage
• • • • •
缺氧 hypoxia 无氧代谢 anaerobic metabolism 乳酸堆积 lactate accumulation 酸中毒 acidosis 血管舒张介质
• 毛细血管血流淤滞 Capillary sludging • 酸中毒 acidosis • 高凝 hypercoagulation
• 红细胞 血小板聚集 red cell platelet aggregation • DIC • 水解酶释放 细胞溶解
代谢改变
metabolism derangement
糖异生 gluconeogenesis (Adr NE) 蛋白质 脂肪分解 急性相蛋白合成(ACTH) proteolysis lipolysis acute-phase protein
• 生命膜功能障碍vital membrane dysfunction
炎症介质及缺血再灌注损伤
inflammatory mediators and ischemia reperfusion injury
• 无氧代谢
Anaerobic metabolism supervenes
丙酮酸(P) → 乳酸(L)+2ATP Pyruvate lactate +2ATP
高乳酸血症hyperlactatemia 代谢性酸中毒acidosis
L/P>15-20 细胞缺氧 cellular hypoxia
• 能量代谢障碍Bioenergetic failure
• 低血容量休克 ： 出血 血浆容量丢失
Hypovolemic shock Hemorrhage losses or plasma volume losses
• 血管源性休克 内外源性血管活性介质起 作用
Vasogenic shock endogenous exogenous vasoactive mediators play a major role
• →imminent death
• 赖得朗 ：1743年 首次将shock 翻译成英语 而不用法语choc
• Le Dran: first medical use of the term ―shock ‖in 1743 ,he translated ―shock‖ • into English ,did not use the French word ―choc‖
• 缺氧 无氧代谢 酸中毒
Hypoxia anaerobic metabolism and acidosis
伤害性组织灌注不足 导致氧供不能满 足氧耗 休克的主要病理机制
Impaired tissue hypoperfusion the primary pathophisiologic mechanism in shock lead to decreased oxygen delivery relative to needs
外科休克 surgery shock
什么是休克？ Historical aspects
希波克拉底的思考
• 创伤 出血→止血→希波克拉底面容→死 亡
• Traumatic wounds hemorrhage→tourniquet to arrest hemorrhage→ Hippocratic
facies
宿主对内毒素的反应
host responses to endotoxin
• 激活巨噬细胞 补体 凝血系统
Activation of macrophages complement and coagulation systems and release of numerous mediators including TNF-a IL-I,6 PAF NO oxidants
NO PGE2 PGI2 IL-2 BK
• 血管通透性↑ • 血粘度↑
permeability ↑
viscosity ↑
• 静脉回流减少venous return ↓CO ↓ • 心 脑缺血 cardiac cerebral ischemia
微循环衰竭期 microcirculation failure stage
感染性休克
Septic
创伤性休克
traumatic shock
• 心源性休克 cardiogenic shock • 神经源性休克neurogenic shock
病理生理
pathophysioligy
• 休克的共同特点：有效血容量锐减 组织灌注不足 炎症介质释放
• Common feature :valid circulation volume decreased dramatic hypoperfusion elaboration of inflammatory mediators
• 组织低灌注Hypoperfusion:
微循环改变 分布异常 alteration on microcirculation maldistribution 组织缺氧 Tissue hypoxia 代谢改变 Anaerobic metabolisms 酸中毒 acidosis 炎症介质释放 elaboration of inflammatory mediators