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Final srb post resuscitation care 2010v1 ii

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Lecture
Post Reanimaciona Nega
Learning outcomes
Razumeti:
Potreba za nastavkom reanimacionih postupaka
nakon uspostavljanja spontane cirkulacije
Kako lečiti sindrom nakon srčanog zastoja
Kako bezbedno transportovati pacijenta
Uloga i ograničenja procene prognoze nakon
srčanog zastoja
Lanac preživljavanja
Post Reanimaciona Nega
Cilj je postići:
Normalnu cerebralnu funkciju
Stabilan srčani ritam
Adekvatnu perfuziju organa
Obnovu kvaliteta života
Post cardiac arrest syndrome
Oštećenje mozga nakon srčanog zastoja:
– Coma, senzorijum, mioklonus
Miokardna disfunkcija nakon srčanog zastoja
Sistemski odgovor ishemija-reperfuzija:
– ‘Sepsis-like’ syndrome
Perzistiranje uzročne patologije
Disajni put i disanje
Obezbediti slobodan vazdušni put, adekvatnu
oksigenaciju i ventilaciju
Razmotriti trahealnu intubaciju, sedaciju i
kontrolisanu ventilaciju
Pulsna oksimetrija:
– Cilj je SpO2 94 – 98%
Kapnografija:
– Cilj je normokapnia
– Izbeći hiperventilaciju

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Final srb post resuscitation care 2010v1 ii

  • 2. Learning outcomes Razumeti: Potreba za nastavkom reanimacionih postupaka nakon uspostavljanja spontane cirkulacije Kako lečiti sindrom nakon srčanog zastoja Kako bezbedno transportovati pacijenta Uloga i ograničenja procene prognoze nakon srčanog zastoja
  • 4. Post Reanimaciona Nega Cilj je postići: Normalnu cerebralnu funkciju Stabilan srčani ritam Adekvatnu perfuziju organa Obnovu kvaliteta života
  • 5. Post cardiac arrest syndrome Oštećenje mozga nakon srčanog zastoja: – Coma, senzorijum, mioklonus Miokardna disfunkcija nakon srčanog zastoja Sistemski odgovor ishemija-reperfuzija: – ‘Sepsis-like’ syndrome Perzistiranje uzročne patologije
  • 6. Disajni put i disanje Obezbediti slobodan vazdušni put, adekvatnu oksigenaciju i ventilaciju Razmotriti trahealnu intubaciju, sedaciju i kontrolisanu ventilaciju Pulsna oksimetrija: – Cilj je SpO2 94 – 98% Kapnografija: – Cilj je normokapnia – Izbeći hiperventilaciju
  • 7. Disajni put i disanje Gledaj,slušaj i oseti Razmotriti: – običan / tenzioni pneumotoraks – kolaps / konsolidacija – bronhijalna intubacija – plućni edem – Aspiracija – prelom rebara-fluktulentni segment
  • 8. Disajni put i disanje Postaviti gastrični tubus radi dekompresije želuca i poboljšanja plućne komplijanse Osigurati disajni put za transfer Razmotriti hitnu ekstubaciju ukoliko se disanje i nivo svesti pacijenta brzo poboljšavaju nakon povratka spontane cirkulacije;
  • 9. Cirkulacija Puls i krvni pritisak Periferna perfuzija npr. vreme kapilarnog punjenja Popuštanje desne komore - Proširene vene vrata Popuštanje leve komore – Plućni edem EKG monitoring i 12-kanalni EKG
  • 10. Disability – Neurološki status Neurološka procena: Glasgow Coma Scale skor Zenice Tonus ekstremiteta i pokreti Postura (Držanje tela)
  • 12. Dalji postupci - Istorija Istorija Zdravstveno stanje pre srčanog zastoja Proteklo vreme do započetih mera KPR Trajanje reanimacije Uzrok srčanog zastoja Porodična istorija bolesti
  • 13. Dalji postupci - Monitoring Dalji postupci - Monitoring Vitalni znaci EKG Pulsna oksimetrija Krvni pritisak npr. Arterijski pritisak Kapnografija Diureza Temperatura
  • 14. Dalji postupci - Pretrage: Dalji postupci - Pretrage: Gasne analize krvi Kompletna krvna slika Biohemijske pretrage i ŠUK Troponin Ponoviti 12-kanalni EKG RTG grudnog koša Ehokardiografija
  • 16. Transfer pacijenta Razgovor sa timom pri preuzimanju Obezbediti kanile, drenove, sonde Sukcija Kiseonička terapija Monitoring Dokumentacija Ponovna procena pacijenta pre predavanja Razgovor sa porodicom
  • 17. Vanbolnički VF srčani zastoj uzrokovan sa AMI Pacing Cooling IABP Defibrillator Inotropes Ventilation Enteral nutrition Insulin
  • 18. Optimalizacija funkcija organa - Srce Post cardiac arrest syndrom Ishemijsko-reperfuziono oštećenje: – Reverzibilna miokardna disfunkcija tokom 2-3 dana – Aritmije
  • 19. Optimalizacija funkcija organa - Srce Slaba miokardijalna funkcija uprkos optimalnom punjenju: - Echokardiografija – Cardiac output monitoring – Inotropi i/ili balon pumpa Srednjim arterijskim pritiskom postižemo: - Diureza od 1 ml kg-1 hour-1 - Normalizacija koncentracije laktata
  • 20. Optimalizacija funkcija organa - Mozak Nema cerebralne autoregulacije – održavati “normalan” krvni pritisak Sedacija Kontrola senzorijuma Glukoza (4-10 mmol l-1 ) Normokapnia Izbegavanje/lečenje hipertermije Razmotriti terapijsku hipotermiju
  • 21. Terapijska hipotermija: efekti Rezultati eksperimentalnih istraživanja pokazuju da je neuroprotektivni efekt hipotermije multifaktorijalni: Redukcija neuralne apoptoze, inhibicija ekscitatornih procesa uzrokovanih ishemijom i reperfuzijom, promena koncentracije intracelularnih katjona, supresija inflamatornih citokina, smanjenje produkcije slobodnih radikala redukcija cerebralnog edema.
  • 22. Terapijska hipotermija – Koga hladiti? Odrasle pacijente bez svesti sa ROSC nakon VF srčanog zastoja treba rashladiti na 32-34o C Korisna za pacijente nakon srčanog zastoja kada nije indikovana defibrilacija/srčani zastoj u bolnici Isključiti: tešku sepsu, ranije koagulopatije Započeti što ranije i kontinuirano tokom 24 h Zagrevati sporo 0.25o C h-1
  • 23. Terapijska hipotermija – Kako hladiti? Dati - 30 ml kg-1 4o C IV rastvora i/ili spoljašnje hlađenje Način – spoljašnje hlađenje: – Pakovanja leda, prekrivači – Pločice ili papučice za hlađenje – Pločice obložene gelom Način – unutrašnje hlađenje – Intravaskularni izmenjivač toplote – Kardiopulmonalni bypass
  • 24. Terapijska hipotermija Fiziološki efekti i komplikacije Drhtavica: sedacija +/- paraliza/lekovi za neuromuskularnu blokadu Bradikardija i kardiovaskularna nestabilnost Infekcije Hiperglikemija Elektrolitski poremećaji Povećava vrednost amilaze Smanjuje klirens lekova
  • 25. Prognoza oporavka Nema kliničkih neuroloških znakova koji predviđaju ishod < 24 h nakon ROSC Loš ishod se može predvideti nakon 3 dana putem: – Odsutnog refleksa zenica na svetlost i kornealnog refleksa – Smanjenog ili odsutnog motornog odgovora na bol Ali imamo ograničenu pouzdanost podataka vezanih za prognozu nakon terapijske hipotermije
  • 26. Donacija organa Pacijent koji nije preživeo srčani zastoj može biti donor : – Donor srca (moždana smrt) – Donor ostalih organa
  • 27. Sažetak Post cardiac arrest sindrom je složen Kvalitet lečenja nakon oživljavanja utiče na krajnji ishod Adekvatan monitoring, bezbedan transfer i trajna podrška vitalnim organima Prognozu oporavka je teško precizno predvideti

Editor's Notes

  1. Chest X-ray shows: tracheal tube; right internal jugular central line, defibrillation patch, collapse of the right upper lobe with loss of lung volume on the right