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- Symptoms Of obstetric shock, Early Symptoms And Signs Of obstetric shock
- Nursing Care Of obstetric shock-nursing Precautions-dietary Taboos
Knowledge of diagnosis and treatment of obstetric shock
Visiting department: treatment cost of obstetrics emergency department: the charging standards of different hospitals are inconsistent, and the cure rate of the top three hospitals in the city is about (5000-10000 yuan): treatment cycle: treatment method: western medicine treatment and blood transfusionGeneral treatment of obstetric shock
Western medicine treatment of obstetric shock
Stabilize the patient's mood, reduce the patient's pain and external bad mental stimulation. When the patient is irritable, pethidine 50 ~ 100mg or diazepam 10mg can be injected intramuscularly to reduce oxygen consumption.
2. Drug treatment
1) Replenish blood volume
Early compensatory shock, decreased blood volume, decreased tissue perfusion, vasoconstriction due to catecholamine secretion, and increased total peripheral resistance of blood vessels to keep blood pressure from falling (normal or slightly higher). In this period, the blood volume was replenished in time, the vasoconstriction was relieved, the effective circulation volume increased, and the patient improved. If the early shock is not recognized, the blood volume is not replenished, the treatment opportunity is lost, and the mechanism of maintaining blood pressure compensates, and the blood pressure drops to the inhibition shock, at this time, the blood vessels must not continue to contract due to the blood pressure drop, which will aggravate the shock. The blood vessels continue to contract, the true capillaries are ischemic for a long time, and the blood volume can not be replenished in time. If the disease continues to delay, the microcirculation will turn into congestion. Blood stasis and hypoxia in capillary network, It leads to metabolic acidosis, and then leads to vascular endothelial cell damage, platelet aggregation complicated with DIC or lysosome rupture into blood circulation, which can cause cell necrosis, produce tumor necrosis factor (TNF) and myocardial inhibitory factor (MDF) to enter shock failure stage, and even cause multiple organ damage, and develop into refractory severe shock, which was called irreversible shock in the past. Therefore, it is the key to replenish blood volume in the treatment of shock.
Types and indications of rehydration;
(1) Whole blood:
Blood loss is the main indication of blood transfusion. The total blood volume of human body is 7% ~ 8% of body weight. If the blood loss is less than 500ml or less than 10% of the total blood volume, interstitial fluid can enter the blood circulation and get compensation; Blood loss exceeds 10% and less than 20% of the total blood volume. Blood transfusion or colloidal fluid should be prepared at the same time of inputting normal saline or balanced liquid; Blood transfusion should be done in time for massive hemorrhage exceeding 1000ml, because severe shock can occur if blood loss is over 30% and shock index > 1 (pulse rate/systolic blood pressure). Whole blood is the most effective for hemorrhagic and traumatic shock. Besides volume expansion, it can also increase oxygen effect to supplement coagulation factors, and provide antibodies and complements for severe infection to enhance anti-infection ability.
The amount of blood transfusion depends on the amount of bleeding. In principle, the amount of supplement is equivalent to the amount of loss. For severe hemorrhagic shock, the amount of fluid rehydration should be twice that of blood loss. In recent years, it is considered that the extracellular fluid of hemorrhagic shock is reduced to a certain extent at the same time of blood loss. Therefore, it is better to infuse part of crystal fluid, especially balanced fluid, than to infuse whole blood alone, which makes the rate of acute renal failure decrease. In emergency, 500ml balanced fluid can be infused first to match blood, and blood can be saved.
(2) Blood transfusion components:
A lot of turbulent bleeding, Blood transfusion and infusion can't stop bleeding, but cause diluted coagulation disease. The reason is that the stored blood and red blood cell products lack factors V, VIII and XI, platelets and all soluble blood coagulation factors. Therefore, serious bleeding will lead to hypoproteinemia and prolonged prothrombin and thrombokinase time without infusion of necessary blood component hemostatic factors. It should be distinguished from consumptive coagulation disease, and the treatment methods of both are the same.
(3) Crystal liquid:
Self-made balance solution, commercial compound sodium lactate solution, suitable for early shock to supplement blood volume is the first choice. The chlorine content of normal saline is 50% higher than that of normal plasma, and a large amount of input can cause hyperchloremia to aggravate acidosis during shock. Alkaline solution and sodium bicarbonate are used for moderate and severe shock. When blood pressure is not measured or 80/50 mmHg (10.7/6.6 kPa) lasts for 2 hours or CO2 binding force is lower than normal, 5% NaHCO3 should be infused. If 250ml is infused, the volume can be expanded by 4 times to 1000ml.
(4) Colloidal fluid (plasma increment)
Glucose (dextran) and plasma substitute (706 plasma substitute) are commonly used.
① Dextran 70 (medium molecular dextran): The average molecular weight is 75,000, the colloid osmotic pressure is high, and it can absorb water from tissues and keep it in circulation, thus increasing blood volume. Long expansion time is suitable for hemorrhagic shock. The dosage should not exceed 1000 ~ 1500ml for 24h. When dextran 70 (medium molecular dextran) is infused, allergic reaction and even shock may occur occasionally, which should be paid attention to.
② Dextran 40 (low molecular weight dextran): The average molecular weight is about 4000, the volume expansion time is short, and the effect of increasing blood volume is only 1.5 hours. Dextran 40 (low molecular dextran) has osmotic diuretic effect, and 50% is excreted from kidney 3 hours after injection. Commonly used 6% solution, the main effect can reduce blood viscosity and red blood cell and platelet aggregation, so it can dredge microcirculation and improve microcirculation and tissue perfusion. But dextran 40 (low molecular dextran) can enter renal tubular cells to cause severe swelling and acute renal tubular occlusion, so the dosage of oliguria patients should be cautious.
3. Hydroxyethyl starch substitute plasma: It is made of corn starch. 6% hydroxyethyl starch is injected into the body, and the volume expansion time is long. The retention rate in blood is 80% at 4 hours and 60% at 24 hours. After 24 hours, the concentration in blood gradually decreases and is quickly excreted from stool. This starch has no toxicity, antigenicity and allergic reaction, and has no effect on blood coagulation. In the past, 6% hydroxyethyl starch isotonic NaCl solution was used, but in recent years, 6% hydroxyethyl starch electrolyte balance substitute plasma was widely used. Its electrolyte is similar to plasma, containing sodium, potassium, green and magnesium particles, and containing bicarbonate, which can provide alkali reserve and is a good plasma increment. It can not only supplement blood volume and maintain colloid osmotic pressure, but also supplement electrolyte components of functional extracellular fluid, prevent and correct massive blood loss and prevent acidosis, and its effect is better than that of hydroxystarch NaCl plasma substitute.
(5) Glucose solution:
It is not beneficial to infuse glucose solution in shock period. In compensatory period, catecholamine secretion increases, which can decompose liver glycogen and produce hyperglycemia. Under hypoxia condition, the oxidation energy of sugar decreases, and when a large amount of glucose solution is infused, sugar is not completely oxidized and ketone bodies are produced. Moreover, after sugar is used, only water is left without capacity expansion, so glucose solution is suitable for the later stage when blood volume has been supplemented and shock is rescued.
To sum up, anti-shock is based on the evolution of shock degree and the order of expansion: first infusion of balance solution, blood transfusion as soon as possible, then infusion of plasma increment and 5% NaHCO3 solution, and finally infusion of 10% glucose solution after microcirculation has improved. The patient's mind, complexion, skin temperature and color have obviously improved, blood pressure is normal, pulse pressure has increased, and urine volume ≥ 30 ml per hour can be considered as blood volume has been replenished.
2) Selection of vasoactive drugs
It mainly excites α receptor, but has weak effect on β receptor, which makes peripheral blood vessels constrict and increases the return blood volume. Increase the contractility of myocardium and increase arterial pressure. It is suitable for hemorrhagic shock, active hemorrhage has been controlled, blood volume has been replenished and blood pressure is too low to maintain blood supply to brain, heart, lung and kidney. Vasoconstrictors can be used to raise blood pressure and relieve low perfusion of important organs.
① Noradrenaline: Because it is a vasoconstrictor mainly excited α receptor and slightly excited β receptor, it is mainly used to raise hypertension clinically. Intravenous drip is used for various shock, but it is not suitable for active bleeding. In order to maintain blood supply to important organs, the time should not be too long, otherwise persistent contraction of blood vessels will aggravate tissue hypoxia.
Usage: Add 100ml of normal saline or 5% glucose solution to 1 ~ 2mg, and drip intravenously. The drip speed is adjusted according to the situation. When the blood pressure recovers, it gradually decelerates and maintains the blood pressure at a normal level. Prevent liquid medicine from leaking out of blood vessels to avoid tissue necrosis.
② Metaraminol or aramine: Indirect excitation of α and β receptors mainly excites α receptors. Instead of norepinephrine stored in nerve endings, norepinephrine is released and works. Compared with norepinephrine, the contraction effect of norepinephrine on resistance blood vessels is only 1/12 of that of norepinephrine, and the contraction effect on volume blood vessels is 1/24 of that of norepinephrine. The effect is slow and lasting, maintaining blood pressure more smoothly than norepinephrine, and can be injected intramuscularly and intravenously. It can increase cardiac output and peripheral vascular resistance at the same time.
Usage: Intramuscular injection with a dose of 2 ~ 10mg, the blood pressure increased after 5 minutes of injection, which can be maintained for 1.5 ~ 4 hours. The dose depends on the condition of the patient. Intravenous drip of 10 ~ 20mg plus 5% glucose or normal saline 100ml, the drip rate is 20 ~ 30 drops per minute, which can start from a small dose and take effect after drip for 1 ~ 2min. The drip rate and measurement depend on the increase of blood pressure, which is suitable for various shock and hypotension during operation.
③ Dopamine: It has β receptor excitation and α receptor excitation. It can enhance myocardial contractility, increase cardiac output, slightly accelerate heart rate, slightly contract peripheral blood vessels, increase arterial pressure, dilate visceral blood vessels, increase blood flow and increase. Glomerular filtration rate. It can improve microcirculation and increase urine output obviously. It is practical for all kinds of shock, especially for low-output and high-resistance shock with renal insufficiency. It can be used as the first choice for all kinds of shock.
Usage: 20mg is added with 5% glucose solution 200 ~ 300ml for intravenous drip, starting with about 20 drops per minute (equivalent to 75 ~ 100 μ g per minute), and then the speed or concentration can be accelerated according to the blood pressure. The maximum dose is 500 μ g per minute.
After supplementing blood volume, blood pressure still did not improve, and sympathetic nerve excitement signs appeared, such as pale skin, cold limbs, low pulse pressure and anuria. It is selected for severe septic shock with severe shock, microcirculation congestion, heart failure, low output and high resistance of pulmonary hypertension and severe cyanosis.
① Isopropyladrenaline: It is a β receptor stimulant, which acts on β 1 receptor, increases cardiac contractility, increases heart rate, accelerates conduction, and increases cardiac output and oxygen consumption. It acts on β 2 receptor of blood vessels and relaxes blood vessels.
Usage: 250 ~ 500ml of 5% glucose solution is added to 1 ~ 2mg each time for intravenous drip, initially 2 ~ 3 μ g per minute, with an equivalent drip rate of 15 ~ 30 drops. After that, the drip rate is adjusted according to blood pressure, and the heart rate should not exceed 120 beats/min. Intravenous or intracardiac injection, 0.2 ~ 1mg each time. Excess can cause tachycardia.
② Phentolamine (benzylaminazoline): It is an alpha receptor blocker with vasodilative effect. It is clinically used for vasospastic contraction diseases and can improve microcirculation. It is best used for severe arteriolar spastic contraction with obvious cyanosis and discoloration of fingers and toes and tachycardia.
Usage: Intravenous drip, 10mg dissolved in 5% grapesSugar solution is 100 ~ 250ml, initially 0.2 ~ 0.4 mg per minute, and then the dropping speed and concentration are adjusted according to the change of blood pressure.
③ Scopolamine: It has exciting effect on respiratory center and obvious inhibitory effect on cerebral cortex. It can dilate capillaries and improve microcirculation. It is used for rescuing severe shock, frequent convulsions and respiratory failure.
Usage: The common dose is 0.02 ~ 0.04 mg/kg, and 1ml injection containing 0.3 mg is directly injected intravenously or infused into Murphy tube. The medication time is generally 20 ~ 30min apart.
④ Anisodamine or 654-2: Anisodamine extracted from anisodamine, a unique plant in China, is an anticholinergic drug. It has the same effect as atropine, relaxing smooth muscle, relieving microvasospasm, and analgesic effect. It has obvious effect on rescuing toxic shock caused by infection combined with antibiotics.
Usage: Intravenous injection of 10 ~ 40mg each time, repeated administration every 10 ~ 30min when necessary, gradually prolonging the time when the situation improves, adding the amount if it does not improve, or adding 5% glucose solution for intra-meridian drip, 30 ~ 40mg/d.
⑤ Sodium nitroferricyanide: Intravenous injection takes effect quickly, and it fails to increase cardiac output and relieve symptoms of heart failure after 5 minutes of withdrawal.
Usage: The initial dripping speed should be slow, with the common dosage of 3 ~ 4 μ g/(kg min) and the maximum dosage of 10 μ g/(kg min). Usually, 50mg sodium nitroprusside is added into 500ml 5% glucose solution. 50 ~ 600 μ g maintenance dose was given intravenously away from light. This drug is metabolized by liver, and thiocyanate is formed by thiocyanase, which accumulates in fetal liver through placenta and poisons fetus, so it should be used briefly.
3) Correcting acidosis and electrolyte balance
During shock, pyruvate lactate is caused by ischemia and hypoxia of tissue cells and anaerobic metabolism; Hypoglycemia in the late stage of shock, the body catabolizes fat and protein, resulting in ketosis and amino acid, which contributes to metabolic acidosis during shock and aggravates the progress of shock. Therefore, acidosis should be actively corrected.
In order to correct acidosis, we should not only rely on capacity expansion, restore tissue perfusion and remove metabolites, but also apply alkaline buffer as appropriate. There are three kinds of alkaline solutions commonly used, and their input amounts are simply calculated by body weight and formula calculated as follows:
(1) 5% Sodium bicarbonate:
5ml/kg, one dose can increase bicarbonate 4 ~ 5mmol/L (carbon dioxide binding capacity 1vol% = 0.499 mmol/L).
Formula: 5% sodium bicarbonate ml= (normal bicarbonate value mmol/L-measured bicarbonate mmol/L) × body weight (kg) × 0.4
Input 1/2 ~ 1/3 of the amount obtained for the first time, and then decide whether to input part or all of it.
(2) 11.2% lactate:
3ml/kg, 1 dose increased bicarbonate 4 ~ 5mmol/l.
Formula: 1.2% sodium lactate ml= (normal bicarbonate value mmol/L-measured bicarbonate mmol/L) × body weight (kg) × 0.3
Liver dysfunction, should not use sodium lactate, because lactate is not easy to decompose, but increase acidosis.
(3) 0.6% trihydroxymethylaminomethane (tacrine) 5ml/kg:
Formula: 0.6% tacrine (ml) = (normal bicarbonate value mmol/L-measured bicarbonate mmol/L) × body weight (kg) × 0.6
Used to correct acute respiratory or metabolic acidosis.
We should pay attention to the imbalance of electrolyte balance while correcting acidosis, especially when septic shock is often complicated with hyponatremia, hypokalemia or hypernatremia. According to literature reports, 50% of septic shock is complicated with hyponatremia. Supplement sodium salt according to formula for correcting hyponatremia:
Formula: The amount of sodium salt supplementation (mmol/L) = (normal value of serum sodium 135mmol/L-measured blood sodium value) × body weight (kg) × 0.5
Although critically ill patients can adjust the acid-base and electrolyte balance according to the above formula. But in the course of treatment. It is still necessary to closely observe the changes of illness and adjust the infusion speed and measurement in time.
4) Application of glucocorticoid
Glucocorticoids are widely used in various kinds of shock, including hemorrhagic, infectious, traumatic, cardiogenic and anaphylactic shock, and their effects are as follows:
(1) It has specific anti-inflammatory and anti-allergic effects, improves the reaction ability of the body, inhibits the reaction of the body to inflammation, and has direct antagonistic effect on endotoxin, showing low toxicity.
(2) Protect cell membrane and lysosome, and prevent harmful metabolites such as bacterial endotoxin and acidosis from stimulating during shock. Lysosome rupture releases lysosomal enzyme and damages tissue cells to form myocardial inhibitory factor (MDF).
(3) Increase cardiac output, dilate peripheral blood vessels and reduce resistance, so as to improve microcirculation perfusion, increase blood pressure, increase urine output, reduce capillary permeability, reduce blood volume loss and relieve brain edema.
(4) Prevent platelet aggregation and leukocyte aggregation.
Usage: Any of the following three corticosteroids can be added into 5% glucose solution for one drop. If the effect is good, it should be given again within 36 hours, generally no more than 2 times within 24 hours. Cortisol (hydrocortisone) 10 ~ 20mg/kg, dexamethasone 1 ~ 3mg/kg, methylprednisolone (methylprednisolone) 30mg/kg. For short-term and large-scale administration, attention should be paid to infection spread and bleeding. It is forbidden for patients with active hemorrhage. Clinical experience proves that the best effect is within 4 ~ 6 hours after shock.
5) Application of antioxidants and purine oxidase inhibitors
It is reported in the literature that hemorrhagic irreversible shockThe reason may be that extreme hypoxia and repeated blood transfusion lead to the loss of adenine nucleotides and the formation of oxygen free radicals. Anti-purine oxidation inhibitor (xanthine oxidase inhibitor), alloparinol 50mg/(kg · d), and Augustine (superoxide dismutase) 15,000 U/(kg · d) were used. Helps save shock.
6) Application of antibiotics
Infection and hemorrhage in obstetrics and gynecology are mostly limited to pelvic cavity. Surgical removal of hemorrhagic lesions and infected lesions is an important measure to rescue shock.
Bleeding focus is a good culture medium for bacteria, and antibiotics should be used to prevent infection. The pathogenic bacteria of infectious and toxic shock are mostly gram-negative bacteria and anaerobic bacteria. Bacterial dissolution and destruction make bacterial endotoxin release, cause endotoxemia, directly destroy cell mitochondria, inhibit energy production and reduce cell oxygenation ability, and the damage caused by it is difficult to recover. Antibiotics, such as ampicillin (ampicillin) and cephalosporin, must be dripped quickly. According to the drug sensitivity test, 1 ~ 3 kinds of antibiotics with strong specificity were selected for combined application of pathogenic bacteria. In patients with renal insufficiency and renal failure, nephrotoxic antibiotics should be used with caution or avoided.
Usage: Ampicillin (ampicillin) is intravenously dripped, 1 ~ 2g each time is dissolved in 100ml solution, 3g can be used if necessary, 2 ~ 4 times/day, and once every 4 hours in severe cases. Intravenous drip of cefazolin can reach 6g per day in severe cases. If the renal function is normal, the daily dosage of kanamycin is 1.5 g/d [15mg/kg d], polymyxin is 200mg/d [2.5 mg/kg d], and gentamicin is 5mg/kg d.
7) Kidney monitoring and supportive treatment
Restoring renal function is one of the main goals of treating shock. Whether the urination volume reaches 30ml per hour is one of the indexes to judge whether the renal function is damaged. Oliguria and renal dysfunction occur after surgery, postpartum, trauma or septicemia. The most common causes are hypovolemia, hypotension and cardiac insufficiency. Therefore, proper rehydration and blood volume should be replenished. For patients with hypotension and hypovolemia, diuretics should be given to test whether renal function is damaged after rapid infusion, cardiac output and blood pressure have improved. After 200ml of 25% mannitol, intravenous drip within 30min or furosemide 0.2 ~ 0.4 mg, intravenous injection within 1 ~ 2min, the urination volume could not increase, which indicated that kidney damage might occur. At this time, we should limit the amount of liquid input and stop using osmotic diuretics to prevent pulmonary edema. If urine osmotic pressure is close to plasma osmotic pressure, urine sodium concentration is > 60mmol/L, alkaline urine or ratio of urine to plasma urea is ≤ 10/1, kidney damage is highly suspected. If the plasma urea nitrogen and serum creatinine values are increased, and the cell cast is found in urine test, it is an indication of acute kidney damage and renal insufficiency.
Treatment: The input of potassium and the excretion of potassium from extracellular fluid should be limited first.
(1) Penicillin G (penicillin potassium salt) and stored blood should be limited when hyperkalemia occurs, because it can release potassium salt.
(2) Sodium bicarbonate corrects acidosis and makes potassium ions flow back into cells. The blood potassium concentration decreased significantly.
(3) Calcium salt can antagonize the damage of hyperkalemia to heart.
(4) Giving ion exchange resin can make potassium permanently adsorbed and excreted, and 50 ~ 100g resin can also be dissolved in 200 ~ 300ml liquid for oral administration.
(5) If the above measures are ineffective, peritoneal and hemodialysis can be carried out to prevent potassium poisoning and endanger life.
3. Cardiac monitoring and supportive therapy
Critically ill patients often have abnormal heart rate and arrhythmia. Increasing myocardial contractility is an important measure to eliminate cardiac dysfunction. A large amount of fluid infusion is a method to increase cardiac stroke volume, cardiac output and myocardial contractility. However, it is necessary to pay close attention to whether jugular vein is irritated, whether lungs are wet rales, and whether urine volume increases after infusion, so as to avoid pulmonary edema caused by cardiac overload. Digitalis can increase myocardial contractility, slow down heart rate, increase cardiac output and decrease venous pressure.
The indications of digitalis in shock patients are: ① high central venous pressure and insufficient cardiac output; ② After infusion and vasoactive drugs, they can not achieve the desired curative effect; Shock complicated with heart failure or severe supraventricular arrhythmia. Cedilanid C (cedilanid-D) should be injected intravenously.
Usage: The first dose is 0.4 mg, diluted to 20ml with 5% glucose solution, and 0.2 ~ 0.4 mg can be injected again every 2 ~ 4 hours according to the situation. If the desired curative effect is achieved, it is not necessary to reach the saturated dose of 1 ~ 1.6 mg. For patients with myocardial damage, digitalis will lead to an increase in myocardial stress, and the dosage is 1/2 ~ 2/3 of the saturated amount.
4. Lung monitoring and supportive therapy
Despite hyperventilation and low partial pressure of carbon dioxide (PCCO) during shock, arterial blood gas measurements often show extremely significant hypoxemia. When the arterial partial pressure of oxygen (P02) drops to 10.6 kPa (80mmHg), oxygen should be supplied through nasal tube or mask, and the oxygen flow rate is 5 ~ 8L/min. This method can increase the oxygen concentration in alveoli by 40%. If the blood PO2 cannot be increased, a ventilator should be used to assist breathing, and its ventilation flow rate and speed must be increased above the normal range to achieve sufficient oxygenation. Auxiliary can often save lives, but it cannot further reduce the partial pressure of carbon dioxide. The tidal volume and velocity should be adjusted to make the arterial oxygen partial pressure reach 9.3 ~ 12kPa (70 ~ 90mmHg) and the carbon dioxide partial pressure reach 4.3 ~ 5.3 kPa (32 ~ 40mmHg).
Attention should be paid to the following treatments while assisting breathing: ① Keep the inhaled oxygen in sufficient humidity; 2. Reduce the viscosity of secretion to help dredge the blocked part of airway; ③ Control heart failure to reduce pulmonary edema; ④ Avoid excessive infusion and make heartDirty overload, if necessary, use diuretics to restore the alveoli filled with liquid to normal functional state; ⑤ Antibiotics should be used to reduce inflammatory exudate of alveoli.
5. Liver monitoring and supportive therapy
During shock, hepatocytes were ischemic or even necrotic, the permeability of hepatocyte membrane increased, and alanine aminotransferase and aspartate aminotransferase in blood increased. Jaundice is a bad phenomenon. Hypoxic hepatocytes can no longer bind glucuronide, and especially affect bilirubin unidirectional transporter enzyme. Jaundice is common in septic shock, because besides hypoxia, endotoxin damages liver cells.
Treatment: High carbohydrate, high vitamin diet, keep daily calories not less than 6280J (1500kcal). For those who can't eat, glucose solution is injected into stomach tube or intravenous infusion of glucose solution plus multivitamins (400g sugar is equivalent to 6700kJ calories), hypoproteinemia is adjusted, and 25% human albumin (albumin) and fresh frozen plasma are infused.
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