The challenge in management of hemorrhagic shock in trauma

Transfusion and resuscitation practices in trauma have undergone a sea change over the past decade. New understanding of transfusion physiology and experiences in military trauma over the last decade has identified key factors taken as challenges in trauma. The most important challenge remains acute traumatic coagulopathy (ATC) which sets in early after a trauma and spirals the patient into shock and continued bleeding. World wide trauma is the leading cause of mortality. More than 6 million deaths occur due to trauma out of which 20% are due to uncontrollable bleeding. Out of the hospital admissions in trauma 20% develop coagulopathy. Mortality is three to four times higher in a patient with coagulopathy and thus prevention and correction of coagulopathy is the central goal of the management of hemorrhagic shock in trauma. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy, This article looks at the importance of acute traumatic coagulopathy, its etiology, diagnosis, effects and resuscitation strategies to prevent it and to see the background behind this shift.     

Fluid management of shock in critically-ill patients

This article summarizes the theoretical basis and practical applications of the fluid management of shock in critically-ill patients. It also draws attention to the differences in the aetiology and management of fluid disturbances in adult and paediatric practice. Some evidence suggests that colloidal solutions alone may be superior to crystalloid solutions alone in the resuscitation of patients with shock, but in most situations a combination of both types of fluid is more logical.     

感染性休克患者的麻醉处理分析

目的:对感染性休克患者的麻醉处理方法进行探讨。方法:对进行感染性休克手术治疗的62例患者临床资料进行回顾性分析。结果:62例患者经麻醉处理后效果显著。结论:良好的麻醉处理服务是保障医患关系和谐的基础,将优质服务融入到感染性休克患者的麻醉处理工作中,对于保证患者的治愈以及建立良好的医患关系起到积极地推动作用。     

Vasopressin for the management of catecholamine-resistant anaphylactic shock

Severe anaesthetic anaphylaxis is relatively uncommon. Oxygen, fluids and epinephrine are considered to be the mainstay for treatment of cardiovascular collapse and current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of a cardiovascular collapse. Recently, evidence has emerged in the support of the use of vasopressin in cardiopulmonary resuscitation; it is also recommended for the treatment of ventricular fibrillation, septic shock and post-cardiopulmonary bypass distribution shock. Currently, there is no algorithm or guideline for the management of anaphylaxis that include the use of vasopressin. We report a 24-year-old woman who developed severe anaphylactic shock at induction of anaesthesia while undergoing laparoscopic cholecystectomy. Circulation shock was refractory to epinephrine and high doses of pure alpha-agonist phenylephrine and norepinephrine. Single intravenous dose of two units of vasopressin re-established normal circulation and blood pressure.     

Evaluation and management of patients after implantable cardioverter-defibrillator shock

Context  There has been a tremendous increase in the use of implantable cardioverter-defibrillators (ICDs) after several large clinical trials demonstrated their ability to effectively reduce mortality in selected populations of patients with cardiac disease. Thus, the nonelectrophysiologist will often encounter patients who have received an ICD shock. Objective  To assess options for the evaluation and management of patients who have received an ICD shock. Evidence Acquisition  Literature search using the PubMed and MEDLINE databases to identify articles published from January 1990 to September 2006, using the Medical Subject Headings defibrillators, implantable; defibrillators, implantable/adverse effects; anti-arrhythmic agents; electric countershock; quality of life; tachycardia therapy; algorithm; ventricular tachycardia/diagnosis; and supraventricular tachycardia/diagnosis. Case reports were excluded and articles were limited to those published in English. Scientific statements and guidelines from the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society were also reviewed, as were the reference lists of retrieved articles, to identify any additional articles for inclusion. Evidence Synthesis  There are multiple causes of both appropriate and inappropriate ICD shocks. Irrespective of appropriateness, receiving ICD shocks substantially impairs a patient's quality of life. A variety of techniques are available using ICD programming to reliably limit the occurrence of appropriate or inappropriate ICD shocks. Antiarrhythmic medications can also effectively reduce the occurrence of shocks. Conclusions  Through the use of effective ICD programming and antiarrhythmic medications, the occurrence of ICD shocks can be reduced while maintaining the lifesaving ability of the ICD. A basic understanding of the range of available options is fundamental for evaluation and management of the patient who has received an ICD shock.      

The pathophysiology of shock

Shock describes a group of circulatory syndromes, all of which result in generalized cellular hypoxia. This leads to the depletion of adenosine triphosphate, the failure of the sodium-potassium pump, mitochondrial dysfunction, and ultimately, the release of a variety of toxic substances. Eventually these given rise to irreversible cardiovascular collapse because of their effects on the microcirculation. Shock may arise due to a failure of preload (hypovolaemic shock), myocardial contractility (cardiogenic shock), afterload (septic shock) or combinations of these (for example, anaphylactic shock, traumatic shock and neurogenic shock). During shock, important physiological changes occur in the nervous, respiratory, renal and gastrointestinal systems, as well as in intermediary metabolism. Hypotension is not synonymous with shock, and emphasis should be placed on the detection of more subtle, early signs. Management requires a systematic approach in which diagnostic and therapeutic processes take place in parallel. Particular attention must be paid to ventilation, oxygenation, fluid and electrolyte therapy, haemodynamic monitoring and, where appropriate, inotropic drugs. Corticosteroid and opioid antagonist agents probably do not have a role, but other agents, such as thyroid hormones, are under investigation.     

中暑休克抢救的实验研究

为了探讨中暑休克的抢救方法,将家兔热暴露至休克发生,然后将其置于室温下。用不同方法抢救后,观察动物中心体温的变化和存活时间。（1）对照组（n=7）,在室温下自然冷却,直肠温度（Tr）和食道温度（Te）不降或略升,全部动物在几分钟内死亡,平均存活（7.57±3.11）min;（2）冷水浸泡组（n=6）,Tr和Te下降缓慢,平均存活（14.00±23.27）min;（3）腹腔冷液灌洗组（n=8）,平均存活（83.00±65.68）min;（4）药物腹腔灌洗组（n=9）,在腹腔灌洗液中加入山莨菪碱,平均存活（89.89±35.78）min。两个腹腔灌洗组都使Tr和 Te下降迅速,血压回升,比对照组和冷水浸泡组存活时间显著延长,30min存活率显著提高,但药物灌洗组与单纯腹腔泠液灌洗组尚无统计学差异。结果提示,腹腔冷液灌洗是抢救中暑休克有效的方法,为进一步救治赢得了时间。     

严重多发伤及休克病人的围手术期处理

本文报告了经手术证实以肝、脾、胰为主的严重多发伤112例，其中车祸伤51例，坠落伤32例，压伤20例，其它伤9例．112例中总伤337处，脾破裂占70．5％，肝破裂占57．1％，胰腺破裂占10．7％。治愈98例（87．5％），死亡14例（12．5％）。文中重点就围手术期中术前准备、术中抢救及术后处理有关问题进行如下讨论。     

如何确定感染性休克的血流动力学的治疗指标

感染性休克是重症监护病房(ICU)患者死亡的首要原因.近年来,感染性休克的治疗取得了长足进展.2004年,美国危重病医学会(SCCM)、欧洲危重病医学会(ESICM)以及国际全身性感染论坛(ISF)根据多项前瞻临床试验结果,制定了拯救全身性感染行动指南(surviving sepsis campaign guideline).     

The microcirculation in shock

Some aspects of blood fluidity in hypoperfusion with particular reference to the important role of the red cell are discussed. Changes in different organ beds and the internal fluidity of the red cell, which is of obvious importance in capillary flow are not considered.     

高龄脓毒症休克患者行胆道手术围术期麻醉管理

老年女性患者,85岁,主因“上腹部疼痛1d余,加重10h”入院.患者既往高血压病史30余年,糖尿病史20余年,冠心病、陈旧性心肌梗死病史30余年,陈旧性脑梗死病史10余年.入院诊断为急性化脓性梗阻性胆管炎、脓毒性休克、胆总管结石等.患者高龄,病情危重,手术麻醉风险极高危.采用快速顺序麻醉诱导,持续输注丙泊酚、瑞芬太尼、右美托咪定及顺式阿曲库铵维持麻醉,连续监测心电图、心率、有创动脉压、血氧饱和度(SpO2)、脑电双频谱指数、体温、心输出量、心指数、每搏量变异度.术中采用目标导向液体治疗及输注去甲肾上腺素抗休克,应用甲泼尼龙及乌司他丁减轻炎症反应,并积极纠正低钙血症及低钾血症.术毕患者带气管插管返回重症监护病房,继续接受支持治疗.术后第9天拔除气管导管,术后25 d好转出院.