Shock en orgaanfalen
Inleiding en fysiopathologie van shock ................................................................................................. 15
Zuurstofradicalen .............................................................................................................................. 15
Reactive Oxygen Species (ROS) ................................................................................................. 16
“ROS” beschadigen de belangrijkste klassen van macromoleculen ......................................... 17
Vrije zuurstofradicalen .............................................................................................................. 17
Ischemie-reperfusie ................................................................................................................... 18
Reperfusie schade: bv. na de ischemie bij een acuut myocardinfarct .................................. 18
Eliminatie van “ROS” ................................................................................................................. 19
Vitamine C is een goed antioxidant ....................................................................................... 19
Antioxidant enzymen ............................................................................................................ 19
Herstel van beschadigde moleculen.......................................................................................... 19
Lipide peroxiden .................................................................................................................... 19
Te onthouden ............................................................................................................................ 20
Necrose-apoptose ............................................................................................................................. 20
Necrose...................................................................................................................................... 20
Apoptose ................................................................................................................................... 20
Wanneer zie je apoptose? ..................................................................................................... 20
Apoptose necrose................................................................................................................. 21
Apoptose ................................................................................................................................... 22
Histologie ................................................................................................................................... 23
Te onthouden ............................................................................................................................ 23
Inflammatie ....................................................................................................................................... 23
Inflammatoir proces .................................................................................................................. 23
Acute inflammatie – big picture ................................................................................................ 23
Lipide A ...................................................................................................................................... 24
Superantigen ............................................................................................................................. 24
Wat is sepsis? ............................................................................................................................ 24
Mediatoren van sepsis .............................................................................................................. 25
Sepsis cascade ........................................................................................................................... 25
Geactiveerde cascades .............................................................................................................. 25
Acute fase respons ‼ ................................................................................................................. 26
1
, Fibrinogeen................................................................................................................................ 26
Acute fase eiwitten.................................................................................................................... 26
Positieve acute fase reagents ................................................................................................ 27
Endotheliale schade .................................................................................................................. 27
iNO ............................................................................................................................................. 27
Bij ischemie, sepsis… veranderingen thv darm ......................................................................... 28
Bacteriële translocatie............................................................................................................... 28
3 HIT hypothese..................................................................................................................... 29
Maag-lymfe theorie ................................................................................................................... 29
Te onthouden… ......................................................................................................................... 29
Ischemie reperfusie ........................................................................................................................... 30
Inflammatie ............................................................................................................................... 30
Ischemie..................................................................................................................................... 30
Reperfusie.................................................................................................................................. 30
Reperfusie schade ..................................................................................................................... 30
Oxidatieve stress ....................................................................................................................... 31
Stikstofoxide (NO) ..................................................................................................................... 31
Synthese ................................................................................................................................ 31
Positieve acties ...................................................................................................................... 31
Negatieve acties .................................................................................................................... 31
Endotheline – een vasoactieve peptide .................................................................................... 31
Eicosanoïden bij I/R injury ......................................................................................................... 32
Cytokines ................................................................................................................................... 32
Chemokines ........................................................................................................................... 32
Tumor Necrose Factor (TNF) ................................................................................................. 32
Platelet activating factor (PAF) .................................................................................................. 32
Reperfusie schade ..................................................................................................................... 33
Te onthouden ............................................................................................................................ 33
Biochemische aspecten ..................................................................................................................... 34
Celschade................................................................................................................................... 34
Manifestaties van celschade: cellulaire accumulaties van ........................................................ 34
Metabole respons bij shock ...................................................................................................... 34
Te onthouden ............................................................................................................................ 35
2
,Zuur-base ........................................................................................................................................... 35
Zuur base evenwicht ................................................................................................................. 35
Normale H+ concentraties......................................................................................................... 35
H+ units...................................................................................................................................... 35
CO2: de majeure bron van zuur in het lichaam......................................................................... 36
Dagelijkse H+ turnover (mmol/24h) .......................................................................................... 36
Bufferen ..................................................................................................................................... 36
Zuur base controle................................................................................................................. 37
Andere buffers: haemoglobine CO2 van weefsel respiratie ................................................. 37
Andere buffers: fosfaat ......................................................................................................... 37
Anion gap................................................................................................................................... 37
H+ ‘excretie’............................................................................................................................... 38
Beoordeling van zuur base status ............................................................................................. 38
Metabole respons bij shock ...................................................................................................... 39
Te onthouden ............................................................................................................................ 39
Bloed: stolling .................................................................................................................................... 39
Functies van bloed..................................................................................................................... 39
Bloedstolling .............................................................................................................................. 39
Overzicht van stollingscascade .................................................................................................. 40
Extrinsieke pathway .............................................................................................................. 40
Finale common pathway ....................................................................................................... 40
Intrinsieke pathway ............................................................................................................... 40
DIC = disseminated intravasculaire coagulatie.......................................................................... 41
Te onthouden ............................................................................................................................ 41
Hemoglobine en zuurstoftransport ................................................................................................... 42
O2 diffusie doorheen de alveolocapillaire membraan .............................................................. 42
Zuurstoftransport ...................................................................................................................... 42
Hemoglobine ............................................................................................................................. 42
Functie van hemoglobine .......................................................................................................... 42
Recyclage van hemoglobine componenten .............................................................................. 42
Binding van O2 aan heem.......................................................................................................... 43
CO vergiftiging ........................................................................................................................... 43
Hemogobine O2 binding curve (zuurstofdissociatie curve) ...................................................... 43
3
, Coöperativiteit bij binden O2 .................................................................................................... 43
Hemoglobine en de perifere weefsels ...................................................................................... 44
O2 flow ...................................................................................................................................... 44
Het Bohr effect .......................................................................................................................... 45
Te onthouden ............................................................................................................................ 45
Cellulaire hypoxie en weefselhypoxie ............................................................................................... 45
Celhypoxie ................................................................................................................................. 45
Celdood ..................................................................................................................................... 46
Chemie gasuitwisseling ............................................................................................................. 46
Bohr vs Haldane effect .............................................................................................................. 46
Hypoxie ...................................................................................................................................... 47
Oorzaken ............................................................................................................................... 47
Zuurstofaanbod ......................................................................................................................... 47
Zuurstofverbruik ........................................................................................................................ 47
Zuurstoftransport ...................................................................................................................... 48
VO2 en DO2 ............................................................................................................................... 48
Weefselhypoxie ......................................................................................................................... 48
Definitie ................................................................................................................................. 48
Oorzaken ............................................................................................................................... 48
Oorzaken van arteriële hypoxie ........................................................................................ 49
Oorzaken van anemische hypoxie ..................................................................................... 49
Oorzaken van hypokinetische hypoxie .............................................................................. 49
Oorzaken van weefselhypoxie............................................................................................... 49
Gevolgen................................................................................................................................ 50
Te onthouden ............................................................................................................................ 50
Autonoom zenuwstelsel .................................................................................................................... 51
Neurotransmitters ..................................................................................................................... 51
Sympathische stimulatie ........................................................................................................... 51
Adrenerge receptoren ‼ ............................................................................................................ 51
Parasympathisch zenuwstelsel .................................................................................................. 52
Adrenaline ................................................................................................................................. 52
Te onthouden ............................................................................................................................ 52
Circulatie............................................................................................................................................ 52
4
, Componenten van circulatie ..................................................................................................... 52
Distributie bloedvolume en rol veneus systeem in vulling hart ................................................ 53
Nerveuze, humorale en locale regulatie van het cardiovasculaire systeem ............................. 53
Sympathicus-activatie ............................................................................................................... 53
Nerveuze controle circulatie → snelle controle BD ................................................................. 53
Hartdebiet ................................................................................................................................. 54
Positieve feedback shock ....................................................................................................... 54
Te onthouden ............................................................................................................................ 54
Kliniek en fysiopathologie geïntegreerd................................................................................................ 55
Definitie shock ................................................................................................................................... 55
Klinische vormen ............................................................................................................................... 55
MOF (MODS) ............................................................................................................................. 55
Vormen van shock ..................................................................................................................... 55
Algemene symptomatologie ............................................................................................................. 56
Kliniek van shock ....................................................................................................................... 56
Cyanose ..................................................................................................................................... 56
Multipel Orgaan Falen (MOF – MODS)...................................................................................... 57
Diagnose, labo, hemodynamisch profiel ........................................................................................... 57
Hoe maken we diagnose van shock?......................................................................................... 57
Arteriële BD ............................................................................................................................... 57
Arteriële pols ......................................................................................................................... 58
Hyperkinetische pols ......................................................................................................... 58
Pulsus tardus, pulsus parvus ............................................................................................. 58
De arteriële BD ...................................................................................................................... 59
Cannuleren centrale vene: de jugularispols .............................................................................. 60
De centrale veneuze druk...................................................................................................... 60
Plaatsing centraal veneuze lijn .............................................................................................. 60
Waarom belangrijk? Principes van behandeling ................................................................... 61
Haarvaten? Capillaire refill ........................................................................................................ 61
Meten CO (cardiac output)........................................................................................................ 61
Swan-Ganz katheterisatie...................................................................................................... 61
Hemodynamische profielen .................................................................................................. 62
Systemische signalen van cellulaire schade .............................................................................. 62
5
, Principes van diagnose; hoe helpt het labo?......................................................................... 63
ROS detoxificatie is een significante activiteit van RBC’s ...................................................... 63
Hoe meten we weefselhypoxie? ............................................................................................... 63
Aanbod .................................................................................................................................. 63
Zuurstoftransport .................................................................................................................. 64
Verwerking ............................................................................................................................ 64
Gemengd veneuze zuurstofsaturatie .................................................................................... 64
Lokale PO2 of lokale metabole activiteit ............................................................................... 65
Dus ............................................................................................................................................. 65
Cardiogene shock .............................................................................................................................. 66
Definitie ..................................................................................................................................... 66
Fysiopathologie ......................................................................................................................... 66
Epidemiologie ............................................................................................................................ 67
Kliniek van cardiogene shock .................................................................................................... 67
Klinische kenmerken ............................................................................................................. 67
Dyspnoe (vooral linkerhart)................................................................................................... 68
Oedeem ................................................................................................................................. 68
Longstuwing .......................................................................................................................... 69
Hemodynamische parameters .............................................................................................. 70
Enkele aanvulling… ................................................................................................................ 70
Hemodynamische subsets ..................................................................................................... 70
Acuut myocardinfarct ............................................................................................................ 71
Beschrijving van circulatie in klinische praktijk ..................................................................... 71
Hemodynamische profielen .................................................................................................. 71
Acuut myocardinfarct ............................................................................................................ 71
Zuurstofaanbod ..................................................................................................................... 72
Hypovolemische shock ...................................................................................................................... 72
Stadia van shock ........................................................................................................................ 72
Hemodynamische profielen ...................................................................................................... 72
Hoofdkenmerken....................................................................................................................... 72
Oorzaken – voorbeelden ........................................................................................................... 73
Hypovolemie: kliniek ................................................................................................................. 73
Verband tussen zuurstofaanbod en -verbruik bij...................................................................... 74
6
, Septische shock ................................................................................................................................. 74
Infectie ....................................................................................................................................... 74
Bacteriëmie ............................................................................................................................... 75
SIRS ............................................................................................................................................ 75
Sepsis ......................................................................................................................................... 75
Ernstige sepsis ....................................................................................................................... 75
Septische shock ..................................................................................................................... 76
Nieuwe definitie van sepsis ....................................................................................................... 76
Definitie ..................................................................................................................................... 76
Lactaat ....................................................................................................................................... 77
Klinisch beeld............................................................................................................................. 77
Kenmerken ................................................................................................................................ 77
Sequentie van pathogenetische stappen .................................................................................. 78
Hemodynamische veranderingen ............................................................................................. 78
Tekens ter hoogte van de huid .................................................................................................. 79
De darm/lever bij shock ........................................................................................................................ 80
Darm .................................................................................................................................................. 80
Bloedvaten................................................................................................................................. 80
Truncus coeliacus .................................................................................................................. 80
Mesenterica superior ............................................................................................................ 80
Mesenterica inferior .............................................................................................................. 81
Fysiologie ................................................................................................................................... 81
Splanchnische circulatie ............................................................................................................ 81
Pathofysiologie van ischemische enteritis ................................................................................ 82
Hypoperfusie van de darm ........................................................................................................ 83
Hypovolemische shock .............................................................................................................. 83
Ischemie en infarct .................................................................................................................... 83
Necrose en sepsis ...................................................................................................................... 84
Klinisch beeld............................................................................................................................. 84
Diagnose .................................................................................................................................... 85
Beeldvorming ........................................................................................................................ 85
Endoscopie ............................................................................................................................ 85
Diagnostiek ................................................................................................................................ 86
7
, Dunne darm ischemie ............................................................................................................... 86
Ischemische colitis ..................................................................................................................... 86
Bacteriële translocatie............................................................................................................... 86
Behandeling van acute intestinale ischemie ............................................................................. 87
Behandeling ............................................................................................................................... 87
Lever .................................................................................................................................................. 87
Anatomie ................................................................................................................................... 87
Ischemische hepatitis (shocklever) ........................................................................................... 88
Lever .......................................................................................................................................... 88
Klinisch beeld: evolutie naar acuut leverfalen? ........................................................................ 88
Behandeling ............................................................................................................................... 89
Take home messages ........................................................................................................................ 89
Het hart bij shock .................................................................................................................................. 90
Regulatie van bloeddruk tijdens shock.............................................................................................. 90
Het cardiovasculair systeem ...................................................................................................... 90
Acute regulatie van arteriële druk............................................................................................. 90
Mechanismen binnen seconden of minuten......................................................................... 90
Arteriële baroreceptor reflex ............................................................................................ 90
Chemoreceptor reflex ....................................................................................................... 91
CZS ischemische respons ................................................................................................... 91
Mechanismen na minuten tot uren ...................................................................................... 91
Renine-angiotensine systeem ........................................................................................... 91
Shift van vocht doorheen de weefselcapillaire wanden ................................................... 92
Conclusies .............................................................................................................................. 92
Effect van shock op het cardiovasculair systeem .............................................................................. 92
Septische shock ......................................................................................................................... 92
Sepsis geïnduceerde cardiomyopathie ................................................................................. 93
Microcirculatoire dysfunctie in septische shock ................................................................... 93
Cardiogene shock .............................................................................................................................. 94
Definitie ..................................................................................................................................... 94
Etiologie ..................................................................................................................................... 94
Acuut myocard infarct gerelateerde cardiogene shock ............................................................ 94
Prognose ................................................................................................................................ 94
8
, LV falen .................................................................................................................................. 95
Papillairspieren ruptuur (= mechanische complicatie AMI) .................................................. 95
Ventrikel septum ruptuur (= mechanische complicatie AMI) ............................................... 95
Vrije wand ruptuur (= mechanische complicatie AMI).......................................................... 95
Mechanische complicaties .................................................................................................... 95
Management ............................................................................................................................. 96
Vroege revascularizatie ......................................................................................................... 96
Inotroop support ................................................................................................................... 96
Mechanisch circulatoir support ............................................................................................. 96
Intra-aortische ballon pomp .............................................................................................. 97
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) .................................. 97
Conclusies .................................................................................................................................. 97
De long bij shock (ARDS) ....................................................................................................................... 98
Het verhaal… ..................................................................................................................................... 98
Definitie ............................................................................................................................................. 98
ARDS vs acute lung injury .................................................................................................................. 98
Risicofactoren .................................................................................................................................... 98
Direct ......................................................................................................................................... 98
Indirect ...................................................................................................................................... 98
De spelers .......................................................................................................................................... 99
Bronchoalveolaire lavage .......................................................................................................... 99
Verschillende stappen ............................................................................................................... 99
Elastase ...................................................................................................................................... 99
Epitheel.................................................................................................................................... 100
3 stadia ............................................................................................................................................ 100
ARDS ................................................................................................................................................ 100
COVID .............................................................................................................................................. 100
4 basisconcepten fysiopathogenese ............................................................................................... 101
Gasuitwisseling ........................................................................................................................ 101
Compliantie ............................................................................................................................. 101
Pulmonale hypertensie............................................................................................................ 101
Verhoogde ademarbeid........................................................................................................... 101
Radiologische evaluatie ................................................................................................................... 101
9
Inleiding en fysiopathologie van shock ................................................................................................. 15
Zuurstofradicalen .............................................................................................................................. 15
Reactive Oxygen Species (ROS) ................................................................................................. 16
“ROS” beschadigen de belangrijkste klassen van macromoleculen ......................................... 17
Vrije zuurstofradicalen .............................................................................................................. 17
Ischemie-reperfusie ................................................................................................................... 18
Reperfusie schade: bv. na de ischemie bij een acuut myocardinfarct .................................. 18
Eliminatie van “ROS” ................................................................................................................. 19
Vitamine C is een goed antioxidant ....................................................................................... 19
Antioxidant enzymen ............................................................................................................ 19
Herstel van beschadigde moleculen.......................................................................................... 19
Lipide peroxiden .................................................................................................................... 19
Te onthouden ............................................................................................................................ 20
Necrose-apoptose ............................................................................................................................. 20
Necrose...................................................................................................................................... 20
Apoptose ................................................................................................................................... 20
Wanneer zie je apoptose? ..................................................................................................... 20
Apoptose necrose................................................................................................................. 21
Apoptose ................................................................................................................................... 22
Histologie ................................................................................................................................... 23
Te onthouden ............................................................................................................................ 23
Inflammatie ....................................................................................................................................... 23
Inflammatoir proces .................................................................................................................. 23
Acute inflammatie – big picture ................................................................................................ 23
Lipide A ...................................................................................................................................... 24
Superantigen ............................................................................................................................. 24
Wat is sepsis? ............................................................................................................................ 24
Mediatoren van sepsis .............................................................................................................. 25
Sepsis cascade ........................................................................................................................... 25
Geactiveerde cascades .............................................................................................................. 25
Acute fase respons ‼ ................................................................................................................. 26
1
, Fibrinogeen................................................................................................................................ 26
Acute fase eiwitten.................................................................................................................... 26
Positieve acute fase reagents ................................................................................................ 27
Endotheliale schade .................................................................................................................. 27
iNO ............................................................................................................................................. 27
Bij ischemie, sepsis… veranderingen thv darm ......................................................................... 28
Bacteriële translocatie............................................................................................................... 28
3 HIT hypothese..................................................................................................................... 29
Maag-lymfe theorie ................................................................................................................... 29
Te onthouden… ......................................................................................................................... 29
Ischemie reperfusie ........................................................................................................................... 30
Inflammatie ............................................................................................................................... 30
Ischemie..................................................................................................................................... 30
Reperfusie.................................................................................................................................. 30
Reperfusie schade ..................................................................................................................... 30
Oxidatieve stress ....................................................................................................................... 31
Stikstofoxide (NO) ..................................................................................................................... 31
Synthese ................................................................................................................................ 31
Positieve acties ...................................................................................................................... 31
Negatieve acties .................................................................................................................... 31
Endotheline – een vasoactieve peptide .................................................................................... 31
Eicosanoïden bij I/R injury ......................................................................................................... 32
Cytokines ................................................................................................................................... 32
Chemokines ........................................................................................................................... 32
Tumor Necrose Factor (TNF) ................................................................................................. 32
Platelet activating factor (PAF) .................................................................................................. 32
Reperfusie schade ..................................................................................................................... 33
Te onthouden ............................................................................................................................ 33
Biochemische aspecten ..................................................................................................................... 34
Celschade................................................................................................................................... 34
Manifestaties van celschade: cellulaire accumulaties van ........................................................ 34
Metabole respons bij shock ...................................................................................................... 34
Te onthouden ............................................................................................................................ 35
2
,Zuur-base ........................................................................................................................................... 35
Zuur base evenwicht ................................................................................................................. 35
Normale H+ concentraties......................................................................................................... 35
H+ units...................................................................................................................................... 35
CO2: de majeure bron van zuur in het lichaam......................................................................... 36
Dagelijkse H+ turnover (mmol/24h) .......................................................................................... 36
Bufferen ..................................................................................................................................... 36
Zuur base controle................................................................................................................. 37
Andere buffers: haemoglobine CO2 van weefsel respiratie ................................................. 37
Andere buffers: fosfaat ......................................................................................................... 37
Anion gap................................................................................................................................... 37
H+ ‘excretie’............................................................................................................................... 38
Beoordeling van zuur base status ............................................................................................. 38
Metabole respons bij shock ...................................................................................................... 39
Te onthouden ............................................................................................................................ 39
Bloed: stolling .................................................................................................................................... 39
Functies van bloed..................................................................................................................... 39
Bloedstolling .............................................................................................................................. 39
Overzicht van stollingscascade .................................................................................................. 40
Extrinsieke pathway .............................................................................................................. 40
Finale common pathway ....................................................................................................... 40
Intrinsieke pathway ............................................................................................................... 40
DIC = disseminated intravasculaire coagulatie.......................................................................... 41
Te onthouden ............................................................................................................................ 41
Hemoglobine en zuurstoftransport ................................................................................................... 42
O2 diffusie doorheen de alveolocapillaire membraan .............................................................. 42
Zuurstoftransport ...................................................................................................................... 42
Hemoglobine ............................................................................................................................. 42
Functie van hemoglobine .......................................................................................................... 42
Recyclage van hemoglobine componenten .............................................................................. 42
Binding van O2 aan heem.......................................................................................................... 43
CO vergiftiging ........................................................................................................................... 43
Hemogobine O2 binding curve (zuurstofdissociatie curve) ...................................................... 43
3
, Coöperativiteit bij binden O2 .................................................................................................... 43
Hemoglobine en de perifere weefsels ...................................................................................... 44
O2 flow ...................................................................................................................................... 44
Het Bohr effect .......................................................................................................................... 45
Te onthouden ............................................................................................................................ 45
Cellulaire hypoxie en weefselhypoxie ............................................................................................... 45
Celhypoxie ................................................................................................................................. 45
Celdood ..................................................................................................................................... 46
Chemie gasuitwisseling ............................................................................................................. 46
Bohr vs Haldane effect .............................................................................................................. 46
Hypoxie ...................................................................................................................................... 47
Oorzaken ............................................................................................................................... 47
Zuurstofaanbod ......................................................................................................................... 47
Zuurstofverbruik ........................................................................................................................ 47
Zuurstoftransport ...................................................................................................................... 48
VO2 en DO2 ............................................................................................................................... 48
Weefselhypoxie ......................................................................................................................... 48
Definitie ................................................................................................................................. 48
Oorzaken ............................................................................................................................... 48
Oorzaken van arteriële hypoxie ........................................................................................ 49
Oorzaken van anemische hypoxie ..................................................................................... 49
Oorzaken van hypokinetische hypoxie .............................................................................. 49
Oorzaken van weefselhypoxie............................................................................................... 49
Gevolgen................................................................................................................................ 50
Te onthouden ............................................................................................................................ 50
Autonoom zenuwstelsel .................................................................................................................... 51
Neurotransmitters ..................................................................................................................... 51
Sympathische stimulatie ........................................................................................................... 51
Adrenerge receptoren ‼ ............................................................................................................ 51
Parasympathisch zenuwstelsel .................................................................................................. 52
Adrenaline ................................................................................................................................. 52
Te onthouden ............................................................................................................................ 52
Circulatie............................................................................................................................................ 52
4
, Componenten van circulatie ..................................................................................................... 52
Distributie bloedvolume en rol veneus systeem in vulling hart ................................................ 53
Nerveuze, humorale en locale regulatie van het cardiovasculaire systeem ............................. 53
Sympathicus-activatie ............................................................................................................... 53
Nerveuze controle circulatie → snelle controle BD ................................................................. 53
Hartdebiet ................................................................................................................................. 54
Positieve feedback shock ....................................................................................................... 54
Te onthouden ............................................................................................................................ 54
Kliniek en fysiopathologie geïntegreerd................................................................................................ 55
Definitie shock ................................................................................................................................... 55
Klinische vormen ............................................................................................................................... 55
MOF (MODS) ............................................................................................................................. 55
Vormen van shock ..................................................................................................................... 55
Algemene symptomatologie ............................................................................................................. 56
Kliniek van shock ....................................................................................................................... 56
Cyanose ..................................................................................................................................... 56
Multipel Orgaan Falen (MOF – MODS)...................................................................................... 57
Diagnose, labo, hemodynamisch profiel ........................................................................................... 57
Hoe maken we diagnose van shock?......................................................................................... 57
Arteriële BD ............................................................................................................................... 57
Arteriële pols ......................................................................................................................... 58
Hyperkinetische pols ......................................................................................................... 58
Pulsus tardus, pulsus parvus ............................................................................................. 58
De arteriële BD ...................................................................................................................... 59
Cannuleren centrale vene: de jugularispols .............................................................................. 60
De centrale veneuze druk...................................................................................................... 60
Plaatsing centraal veneuze lijn .............................................................................................. 60
Waarom belangrijk? Principes van behandeling ................................................................... 61
Haarvaten? Capillaire refill ........................................................................................................ 61
Meten CO (cardiac output)........................................................................................................ 61
Swan-Ganz katheterisatie...................................................................................................... 61
Hemodynamische profielen .................................................................................................. 62
Systemische signalen van cellulaire schade .............................................................................. 62
5
, Principes van diagnose; hoe helpt het labo?......................................................................... 63
ROS detoxificatie is een significante activiteit van RBC’s ...................................................... 63
Hoe meten we weefselhypoxie? ............................................................................................... 63
Aanbod .................................................................................................................................. 63
Zuurstoftransport .................................................................................................................. 64
Verwerking ............................................................................................................................ 64
Gemengd veneuze zuurstofsaturatie .................................................................................... 64
Lokale PO2 of lokale metabole activiteit ............................................................................... 65
Dus ............................................................................................................................................. 65
Cardiogene shock .............................................................................................................................. 66
Definitie ..................................................................................................................................... 66
Fysiopathologie ......................................................................................................................... 66
Epidemiologie ............................................................................................................................ 67
Kliniek van cardiogene shock .................................................................................................... 67
Klinische kenmerken ............................................................................................................. 67
Dyspnoe (vooral linkerhart)................................................................................................... 68
Oedeem ................................................................................................................................. 68
Longstuwing .......................................................................................................................... 69
Hemodynamische parameters .............................................................................................. 70
Enkele aanvulling… ................................................................................................................ 70
Hemodynamische subsets ..................................................................................................... 70
Acuut myocardinfarct ............................................................................................................ 71
Beschrijving van circulatie in klinische praktijk ..................................................................... 71
Hemodynamische profielen .................................................................................................. 71
Acuut myocardinfarct ............................................................................................................ 71
Zuurstofaanbod ..................................................................................................................... 72
Hypovolemische shock ...................................................................................................................... 72
Stadia van shock ........................................................................................................................ 72
Hemodynamische profielen ...................................................................................................... 72
Hoofdkenmerken....................................................................................................................... 72
Oorzaken – voorbeelden ........................................................................................................... 73
Hypovolemie: kliniek ................................................................................................................. 73
Verband tussen zuurstofaanbod en -verbruik bij...................................................................... 74
6
, Septische shock ................................................................................................................................. 74
Infectie ....................................................................................................................................... 74
Bacteriëmie ............................................................................................................................... 75
SIRS ............................................................................................................................................ 75
Sepsis ......................................................................................................................................... 75
Ernstige sepsis ....................................................................................................................... 75
Septische shock ..................................................................................................................... 76
Nieuwe definitie van sepsis ....................................................................................................... 76
Definitie ..................................................................................................................................... 76
Lactaat ....................................................................................................................................... 77
Klinisch beeld............................................................................................................................. 77
Kenmerken ................................................................................................................................ 77
Sequentie van pathogenetische stappen .................................................................................. 78
Hemodynamische veranderingen ............................................................................................. 78
Tekens ter hoogte van de huid .................................................................................................. 79
De darm/lever bij shock ........................................................................................................................ 80
Darm .................................................................................................................................................. 80
Bloedvaten................................................................................................................................. 80
Truncus coeliacus .................................................................................................................. 80
Mesenterica superior ............................................................................................................ 80
Mesenterica inferior .............................................................................................................. 81
Fysiologie ................................................................................................................................... 81
Splanchnische circulatie ............................................................................................................ 81
Pathofysiologie van ischemische enteritis ................................................................................ 82
Hypoperfusie van de darm ........................................................................................................ 83
Hypovolemische shock .............................................................................................................. 83
Ischemie en infarct .................................................................................................................... 83
Necrose en sepsis ...................................................................................................................... 84
Klinisch beeld............................................................................................................................. 84
Diagnose .................................................................................................................................... 85
Beeldvorming ........................................................................................................................ 85
Endoscopie ............................................................................................................................ 85
Diagnostiek ................................................................................................................................ 86
7
, Dunne darm ischemie ............................................................................................................... 86
Ischemische colitis ..................................................................................................................... 86
Bacteriële translocatie............................................................................................................... 86
Behandeling van acute intestinale ischemie ............................................................................. 87
Behandeling ............................................................................................................................... 87
Lever .................................................................................................................................................. 87
Anatomie ................................................................................................................................... 87
Ischemische hepatitis (shocklever) ........................................................................................... 88
Lever .......................................................................................................................................... 88
Klinisch beeld: evolutie naar acuut leverfalen? ........................................................................ 88
Behandeling ............................................................................................................................... 89
Take home messages ........................................................................................................................ 89
Het hart bij shock .................................................................................................................................. 90
Regulatie van bloeddruk tijdens shock.............................................................................................. 90
Het cardiovasculair systeem ...................................................................................................... 90
Acute regulatie van arteriële druk............................................................................................. 90
Mechanismen binnen seconden of minuten......................................................................... 90
Arteriële baroreceptor reflex ............................................................................................ 90
Chemoreceptor reflex ....................................................................................................... 91
CZS ischemische respons ................................................................................................... 91
Mechanismen na minuten tot uren ...................................................................................... 91
Renine-angiotensine systeem ........................................................................................... 91
Shift van vocht doorheen de weefselcapillaire wanden ................................................... 92
Conclusies .............................................................................................................................. 92
Effect van shock op het cardiovasculair systeem .............................................................................. 92
Septische shock ......................................................................................................................... 92
Sepsis geïnduceerde cardiomyopathie ................................................................................. 93
Microcirculatoire dysfunctie in septische shock ................................................................... 93
Cardiogene shock .............................................................................................................................. 94
Definitie ..................................................................................................................................... 94
Etiologie ..................................................................................................................................... 94
Acuut myocard infarct gerelateerde cardiogene shock ............................................................ 94
Prognose ................................................................................................................................ 94
8
, LV falen .................................................................................................................................. 95
Papillairspieren ruptuur (= mechanische complicatie AMI) .................................................. 95
Ventrikel septum ruptuur (= mechanische complicatie AMI) ............................................... 95
Vrije wand ruptuur (= mechanische complicatie AMI).......................................................... 95
Mechanische complicaties .................................................................................................... 95
Management ............................................................................................................................. 96
Vroege revascularizatie ......................................................................................................... 96
Inotroop support ................................................................................................................... 96
Mechanisch circulatoir support ............................................................................................. 96
Intra-aortische ballon pomp .............................................................................................. 97
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) .................................. 97
Conclusies .................................................................................................................................. 97
De long bij shock (ARDS) ....................................................................................................................... 98
Het verhaal… ..................................................................................................................................... 98
Definitie ............................................................................................................................................. 98
ARDS vs acute lung injury .................................................................................................................. 98
Risicofactoren .................................................................................................................................... 98
Direct ......................................................................................................................................... 98
Indirect ...................................................................................................................................... 98
De spelers .......................................................................................................................................... 99
Bronchoalveolaire lavage .......................................................................................................... 99
Verschillende stappen ............................................................................................................... 99
Elastase ...................................................................................................................................... 99
Epitheel.................................................................................................................................... 100
3 stadia ............................................................................................................................................ 100
ARDS ................................................................................................................................................ 100
COVID .............................................................................................................................................. 100
4 basisconcepten fysiopathogenese ............................................................................................... 101
Gasuitwisseling ........................................................................................................................ 101
Compliantie ............................................................................................................................. 101
Pulmonale hypertensie............................................................................................................ 101
Verhoogde ademarbeid........................................................................................................... 101
Radiologische evaluatie ................................................................................................................... 101
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