20xx年醫(yī)學(xué)專(zhuān)題—兒科休克的診治-資料下載頁(yè)
2024-11-01 22:01本頁(yè)面
【正文】 t risk for adrenal insufficiency include children with severe septic shock and purpura,[318,319] children who have previously received steroid therapies for chronic illness, and children with pituitary or adrenal abnormalities. Children who have clear risk factors for adrenal insufficiency should be treated with stressdose steroids (hydrocortisone 50 mg/m2/24 hrs),第六十九頁(yè)，共八十頁(yè)。,Pediatric Considerations in Severe Sepsis,H. Protein C and Activated Protein C We recommend against the use rhAPC in children (grade 1B) I. DVT Prophylaxis We suggest the use of DVT prophylaxis in postpubertal children with severe sepsis (grade 2C) J. Stress Ulcer Prophylaxis No graded recommendations.,第七十頁(yè)，共八十頁(yè)。,Pediatric Considerations in Severe Sepsis,K. Renal Replacement Therapy No graded recommendations L. Glycemic Control No graded recommendations M. Sedation/Analgesia We recommend sedation protocols with a sedation goal when sedation of critically ill mechanically ventilated patients with sepsis is required (grade 1D),第七十一頁(yè)，共八十頁(yè)。,Pediatric Considerations in Severe Sepsis,N. Blood Products No graded recommendations O. Intravenous Immunoglobulin We suggest that immunoglobulin be considered in children with severe sepsis (grade 2C) P. Extracorporeal Membrane Oxygenation (ECMO) We suggest that use of ECMO be limited to refractory pediatric septic shock and/or respiratory failure that cannot be supported by conventional therapies (grade 2C),第七十二頁(yè)，共八十頁(yè)。,休克(xiūk232。)診治中應(yīng)注意的問(wèn)題,一、判斷失誤導(dǎo)致治療延遲或錯(cuò)誤： 休克誤診為心力衰竭(xīn l236。 shuāi ji233。)：強(qiáng)心、利尿、限液 休克誤診為顱內(nèi)感染：脫水、限液 炎性水腫誤判為液體超負(fù)荷：利尿、限液,第七十三頁(yè)，共八十頁(yè)。,液體復(fù)蘇應(yīng)注意(zh249。 y236。)的問(wèn)題,二、液體復(fù)蘇實(shí)施過(guò)程中的一些問(wèn)題： 復(fù)蘇液量不足，速度不夠(b249。g242。u) 血管活性藥物使用不當(dāng) 液體配置不當(dāng)：用糖稀釋高漲液，過(guò)多使用堿性液 血管通路 ：建立困難，通路本身不暢,第七十四頁(yè)，共八十頁(yè)。,休克診治(zhěnzh236。)中應(yīng)注意的問(wèn)題,三、復(fù)蘇時(shí)輸入(shūr249。)含糖液的危害 5％葡萄糖的含糖量 100ml含5g 20ml含1g 20ml/kg=1g/kg 高糖致高滲血癥 休克患兒多有應(yīng)激性高血糖 腦 滲透性利尿,第七十五頁(yè)，共八十頁(yè)。,液體復(fù)蘇(f249。 sū)應(yīng)注意的問(wèn)題,四、過(guò)多使用堿性液的危害 氧離曲線左移 增加CO細(xì)胞內(nèi)酸中毒 高鈉、低鉀、高滲 代堿 兩項(xiàng)研究：比較NS和等張?zhí)妓釟溻c(t224。n suān qīnɡ n224。)治療代酸，碳酸氫鈉(t224。n suān qīnɡ n224。)不能增加CO，也不能減少血管活性藥物應(yīng)用 Cooper, et al. Ann Intern Med 1990 Mathieu, et al. Crit Care Med 1991,第七十六頁(yè)，共八十頁(yè)。,Final Thoughts,Recognize compensated shock quickly have a high index of suspicion, remember tachycardia is first sign. Hypotension is late and ominous. Gain access quickly if necessary use an IO line. Administer adequate amounts of fluid rapidly. Remember ongoing losses. Correct electrloytes and glucose problems quickly. If the patient is not responding the way you think he should, broaden your differential, think about different types of shock.,第七十七頁(yè)，共八十頁(yè)。,第七十八頁(yè)，共八十頁(yè)。,謝謝(xi232。 xie)！,第七十九頁(yè)，共八十頁(yè)。,內(nèi)容(n232。ir243。ng)總結(jié),兒科休克的診治?！蠓繅骸蚊?xì)血管楔壓↑→肺淤血。由于血液重新分布和毛細(xì)血管滲漏液體丟失, 持續(xù)低血容量可能持續(xù)數(shù)日。收縮壓該年齡組第5百分位或該年齡組正常值2個(gè)標(biāo)準(zhǔn)差。1~10歲70mmHg+[2年齡（歲）]。反復(fù)評(píng)估(p237。nɡ ɡū)循環(huán)及灌注、肺部羅音及肝大小。繼續(xù)輸液和維持輸液。液體配置不當(dāng)：用糖稀釋高漲液，過(guò)多使用堿性液。謝謝,第八十頁(yè)，共八十
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