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Samenvatting - Shock en orgaanfalen
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Samenvatting van het vak 'Shock & Orgaanfalen' gegeven door prof. Jorens in de 2e Bachelor Geneeskunde aan de UA. Samenvatting van slides én lesnotities.
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InhoudstafelZuurstofradicalen...........................................................................................................................................8
Reactive Oxygen Species (ROS)...............................................................................................................8
Stikstofoxide (NO)...................................................................................................................................... 9
Ischemie-reperfusie..................................................................................................................................10
Eliminatie van ROS.................................................................................................................................. 10
Necrose vs. apoptose.................................................................................................................................. 11
Necrose.................................................................................................................................................... 11
Apoptose.................................................................................................................................................. 12
Necrose vs. apoptose.............................................................................................................................. 12
Inflammatie................................................................................................................................................... 13
Acute inflammatie.....................................................................................................................................13
LPS / superantigen...................................................................................................................................13
Mediatoren van sepsis............................................................................................................................. 14
Acute fase respons.................................................................................................................................. 15
Werking van NO....................................................................................................................................... 16
Prostaglandines....................................................................................................................................... 17
Ischemie reperfusie..................................................................................................................................... 17
Stikstofmonoxide (NO)............................................................................................................................. 18
Endotheline.............................................................................................................................................. 18
Eicosanoïden........................................................................................................................................... 19
Cytokines – chemokines.......................................................................................................................... 19
Reperfusieschade.................................................................................................................................... 19
Biochemische aspecten.............................................................................................................................. 19
Celbeschadiging.......................................................................................................................................19
Lactaatvorming.........................................................................................................................................20
Metabole respons bij shock......................................................................................................................20
Zuur-base......................................................................................................................................................21
Bufferes.................................................................................................................................................... 21
Anion gap................................................................................................................................................. 22
H+ excretie............................................................................................................................................... 22
Beoordeling van zuur-base status............................................................................................................22
Bloedstolling................................................................................................................................................ 23
Bloedstolling.............................................................................................................................................23
Stollingscascade...................................................................................................................................... 23
Disseminated intravascular coagulation (DIC)......................................................................................... 24
Hemoglobine en zuurstoftransport............................................................................................................ 24
Gastransport............................................................................................................................................ 24
Zuurstofdissociatiecurve.......................................................................................................................... 25
Cellulaire hypoxie en weefselhypoxie........................................................................................................27
Celdood....................................................................................................................................................27
Hypoxie.................................................................................................................................................... 27
Zuurstoftransport......................................................................................................................................28
Zuurstofaanbod........................................................................................................................................ 28
Zuurstofverbruik....................................................................................................................................... 28
Zuurstofextractie...................................................................................................................................... 28
Weefselhypoxie........................................................................................................................................ 28
, Arteriële hypoxie...................................................................................................................................... 29
Anemische hypoxie.................................................................................................................................. 29
Hypokinetische hypoxie........................................................................................................................... 29
Oorzaken van weefselhypoxie................................................................................................................. 29
Gevolgen..................................................................................................................................................30
Autonoom zenuwstelsel.............................................................................................................................. 30
Neurotransmissie..................................................................................................................................... 30
Sympathisch zenuwstelsel....................................................................................................................... 30
Adrenerge receptoren.............................................................................................................................. 31
Parasympathisch zenuwstelsel................................................................................................................ 31
Neurotransmitters.....................................................................................................................................31
Circulatie.......................................................................................................................................................32
Nerveuze controle van de circulatie......................................................................................................... 32
Hartdebiet.................................................................................................................................................32
Shock............................................................................................................................................................ 33
Klinische vormen......................................................................................................................................... 33
Multiple Orgaan Falen (MOF) = Multiple Organ Disfunction Syndrome (MODS).....................................33
Stadia van shock......................................................................................................................................34
Algemene symptomatologie....................................................................................................................... 34
Cyanose................................................................................................................................................... 34
Diagnose, labo, hemodynamisch profiel................................................................................................... 35
Arteriële bloeddruk................................................................................................................................... 35
Afwijkende polsdrukken........................................................................................................................... 35
Centraal veneuze druk............................................................................................................................. 36
Capillaire refill...........................................................................................................................................36
Cardiac output..........................................................................................................................................36
Swan-Ganz katheterisatie........................................................................................................................ 37
Tekens van cellulaire schade................................................................................................................... 37
Labo......................................................................................................................................................... 37
Weefselhypoxie meten............................................................................................................................. 38
Lactaat..................................................................................................................................................... 38
Gemengd veneuze zuurstofsaturatie....................................................................................................... 38
Toekomst.................................................................................................................................................. 39
Conclusie................................................................................................................................................. 39
Cardiogene shock........................................................................................................................................ 39
Fysiopathologie........................................................................................................................................ 40
Risicofactoren.......................................................................................................................................... 40
Klinische presentatie................................................................................................................................ 40
Dyspnoe................................................................................................................................................... 41
Oedeem................................................................................................................................................... 41
Hemodynamische parameters................................................................................................................. 41
Hemodynamische subsets....................................................................................................................... 42
Hemodynamische profielen......................................................................................................................42
Hypovolemische shock............................................................................................................................... 43
Stadia van shock......................................................................................................................................43
Hemodynamische profielen......................................................................................................................43
Oorzaken..................................................................................................................................................43
Klinische presentatie................................................................................................................................ 44
1
,Septische shock...........................................................................................................................................44
Systemic inflammatory response syndrome (SIRS).................................................................................44
Sepsis...................................................................................................................................................... 44
Ernstige sepsis.........................................................................................................................................45
Septische shock....................................................................................................................................... 45
Definities.................................................................................................................................................. 45
Verband tussen zuurstofaanbod en zuurstofverbruik...............................................................................45
Lactaat..................................................................................................................................................... 46
Klinische presentatie................................................................................................................................ 46
Sequentie van pathogenetische stappen................................................................................................. 46
Verstoring van bloedstolling..................................................................................................................... 47
Hemodynamische veranderingen............................................................................................................ 47
Tekens ter hoogte van de huid................................................................................................................... 48
Darmen..........................................................................................................................................................48
Anatomie.................................................................................................................................................. 48
Fysiologie................................................................................................................................................. 49
Splanchnische circulatie...........................................................................................................................49
Oxygen countercurrent exchange............................................................................................................ 50
Pathofysiologie van ischemische enteritis................................................................................................50
Hypoperfusie van de darm....................................................................................................................... 51
Hypovolemische shock............................................................................................................................ 51
ischemie en infarct................................................................................................................................... 51
necrose en sepsis.................................................................................................................................... 52
Klinisch beeld - dikke darm...................................................................................................................... 52
Diagnose.................................................................................................................................................. 52
Klinisch beeld - dunne darm.....................................................................................................................53
Bacteriële translocatie..............................................................................................................................53
Behandeling............................................................................................................................................. 53
Bij acute intestinale ischemie................................................................................................................... 54
Lever..............................................................................................................................................................54
Anatomie.................................................................................................................................................. 54
Ischemische hepatitis (levershock).......................................................................................................... 54
Evolutie naar acuut leverfalen..................................................................................................................55
Behandeling............................................................................................................................................. 55
Onthouden.................................................................................................................................................... 55
Shock............................................................................................................................................................ 55
Regulatie van bloeddruk bij shock.............................................................................................................56
Acute regulatie van arteriële druk............................................................................................................ 56
Baroreceptorreflex....................................................................................................................................56
Chemoreceptorreflex................................................................................................................................57
CZS ischemische respons....................................................................................................................... 57
Verloop van reflexmechanismen.............................................................................................................. 57
Renine-angiotensine vasoconstrictor mechanisme..................................................................................58
Vloeistofshift doorheen de capillaire wand...............................................................................................58
Conclusie................................................................................................................................................. 59
Effecten van shock op het cardiovasculair systeem................................................................................59
Sepsis-geïnduceerde cardiomyopathie....................................................................................................59
Microcirculatoire disfunctie.......................................................................................................................59
2
, Cardiogene shock........................................................................................................................................ 60
Oorzaken..................................................................................................................................................60
Ruptuur van papillairspiertjes...................................................................................................................60
Ventriculair septum ruptuur...................................................................................................................... 61
Vrije wand ruptuur.................................................................................................................................... 61
Mechanische complicaties....................................................................................................................... 61
Behandeling............................................................................................................................................. 61
Intra-aortic balloon pump (IABP)..............................................................................................................62
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO).......................................................... 62
ARDS............................................................................................................................................................. 63
ARDS vs. acute longbeschadiging...........................................................................................................63
Risicofactoren.......................................................................................................................................... 63
De spelers................................................................................................................................................ 64
Verschillende stappen.............................................................................................................................. 64
3 stadia.....................................................................................................................................................64
Fysiopathogenese: 4 basisconcepten......................................................................................................64
Radiografie...............................................................................................................................................65
Verwikkelingen......................................................................................................................................... 65
Fysiologische principes.............................................................................................................................. 66
Cerebrale bloedflow (CBF).......................................................................................................................66
Cerebrale perfusiedruk (CPP)..................................................................................................................66
Cerebrale autoregulatie............................................................................................................................66
Monroe-Kelly principe.............................................................................................................................. 67
Cerebrale bloedvolume............................................................................................................................ 68
Effect van PCO2.......................................................................................................................................68
Bloed-hersenbarrière............................................................................................................................... 68
Encephalopathie.......................................................................................................................................... 68
Septische encephalopathie...................................................................................................................... 69
Rol van endotheel bij pathogenese
NIET......................................................................................................................................................... 70
Rol van astrocyten bij pathogenese
NIET......................................................................................................................................................... 70
Rol van neuronen bij pathogenese
NIET......................................................................................................................................................... 70
Cushing-respons...................................................................................................................................... 70
Neurogeen longoedeem...........................................................................................................................70
Invloed van hersenpatholgoie op de hemodynamiek...............................................................................71
Shock............................................................................................................................................................ 71
Acute Kidney Injury (AKI)............................................................................................................................71
Diagnose.................................................................................................................................................. 71
AKI + shock vs. AKI - shock..................................................................................................................... 72
Pathofysiologie: AKI etiologische diagnose............................................................................................ 72
Renale hypoperfusie................................................................................................................................ 73
Renale veneuze congestie.......................................................................................................................73
Microcirculatoire disfunctie.......................................................................................................................73
Endotheliale disfunctie............................................................................................................................. 74
Microvasculaire trombose........................................................................................................................ 74
Inflammatie...............................................................................................................................................74
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