SEPSIS的集束治疗策略培训课件.ppt

《SEPSIS的集束治疗策略培训课件.ppt》由会员分享，可在线阅读，更多相关《SEPSIS的集束治疗策略培训课件.ppt（58页珍藏版）》请在三一办公上搜索。

1、SEPSIS的集束治疗策略,SEPSIS的集束治疗策略,2002年欧洲危重病学会（ESICM）美国危重病学会（SCCM） 国际脓毒症论坛（ISF）SSC（surviving sepsis campaign）战役 “巴塞罗那宣言”5年降低脓毒症病死率25的目标。,2004年Critical Care MedicineIntensive Care MedicineSSC“循证医学为基础的脓毒症治疗指南” Crit Care Med 2004：32（3）；858-873,SEPSIS的集束治疗策略,2,2002年2004年SEPSIS的集束治疗策略2,研究课题 Delphi分级标准,建议分级 A 、

2、至少有 2 个第一水平的调查支持 B 、有 1 个第一水平的调查支持 C 、仅有第二水平的调查支持 D 、至少有 1 个第三水平的调查支持 E 、有第四或第五水平的证据支持 证据分级 1 、大型的随机化且有明确结果的试验；低风险假阳性错误（）和假阴性（）错误 2 、小型的随机化且结果不确定的试验；中到高风险的假阳性和或假阴性错误 3 、非随机化、但同期对照研究 4 、非随机化、历史对照和专家意见 5 、系列病例，非对照研究和专家意见,SEPSIS的集束治疗策略,3,研究课题 Delphi分级标准建议分级 SEPSIS的集束治,补充说明,分为 A-E 级，A级为最高。 需要指出的是，循证医学方法

3、主要适用于治疗性试验，而不适于对诊断技术的评估，因此，本指南中有关诊断技术方面的推荐意见多数都没有高水平的支持证据(如A、B、C、D级)，仅为专家意见。另外推荐等级并不代表特别建议，而只是文献的支持程度。指南的最后是儿童治疗推荐意见，与成人的推荐意见不同，只有分项而没有分级。,SEPSIS的集束治疗策略,4,补充说明分为 A-E 级，A级为最高。SEPSIS的集束治疗,治疗指南概要（）,1 早期复苏 1.1 一旦临床诊断严重感染，应尽快进行积极的液体复苏，6 h内达到复苏目标：中心静脉压(CVP) 812 cm H2O(1 cm H2O=0.098 kPa)；平均动脉压65 mm Hg；尿量0

4、.5 mlkg1h1；中心静脉或混合静脉血氧饱和度(ScvO2或SvO2)0.70(推荐级别：B级)。 1.2 若液体复苏后CVP达812 cm H2，而ScvO2或SvO2 仍未达到0.70，需输注浓缩红细胞使血细胞比容达到0.30以上，和（或）输注多巴酚丁胺(最大剂量至20 gkg1min1)以达到上述复苏目标(推荐级别：B级)。,SEPSIS的集束治疗策略,5,治疗指南概要（）1 早期复苏 SEPSIS的集束治疗策略5,治疗指南概要（二）,2 病源学诊断2.1 抗生素治疗前应首先进行及时正确的微生物培养(推荐级别：D级)。 2.2 为了确定感染源和致病病原体，应迅速采用诊断性检查，如影像

5、学检查和可疑感染源取样(推荐级别：E级)。,SEPSIS的集束治疗策略,6,治疗指南概要（二）2 病源学诊断SEPSIS的集束治疗策略6,治疗指南概要（三）,3 抗生素治疗3.1 诊断严重感染后1 h以内，立即给予静脉抗生素治疗(推荐级别：E级)。3.2 早期经验性抗感染治疗应根据社区或医院微生物流行病学资料，采用覆盖可能致病微生物(细菌或真菌)的广谱抗生素，而且抗生素在感染组织具有良好的组织穿透力(推荐级别：D级)。3.3 为阻止细菌耐药，降低药物毒性，减少花费，应用抗生素4872 h后，根据微生物培养结果和临床反应评估疗效，选择目标性的窄谱抗生素治疗。抗生素疗程一般710 d(推荐级别：E

6、级)。 3.4 若临床判断症状由非感染因素所致，应立即停用抗生素(推荐级别：E级)。,SEPSIS的集束治疗策略,7,治疗指南概要（三）3 抗生素治疗SEPSIS的集束治疗策略7,治疗指南概要（四）,4 控制感染源 4.1 评估和控制感染灶(推荐级别：E级)。 4.2 根据患者的具体情况，通过权衡利弊，选择适当的感染控制手段(推荐级别：E级)。4.3 若感染灶明确(如腹腔内脓肿、胃肠穿孔、胆囊炎或小肠缺血)，应在复苏开始的同时，尽可能控制感染源(推荐级别：E级)。4.4 若深静脉导管等血管内有创装置被认为是导致严重感染或感染性休克的感染源时，在建立其他的血管通路后，应立即去除(推荐级别：E级)

7、。,SEPSIS的集束治疗策略,8,治疗指南概要（四）4 控制感染源 SEPSIS的集束治疗策略,治疗指南概要（五）,5 液体治疗 5.1 复苏液体包括天然的或人工合成的晶体或胶体液，尚无证据表明某种液体的复苏效果优于其他液体(推荐级别：C级)。 5.2 对于疑有低容量状态的严重感染患者，应行快速补液试验，即在30 min内输入5001 000 ml晶体液或300500 ml胶体液，同时根据患者反应性(血压升高和尿量增加)和耐受性(血管内容量负荷过多)来决定是否再次给予快速补液试验(推荐级别：E级)。,SEPSIS的集束治疗策略,9,治疗指南概要（五）5 液体治疗 SEPSIS的集束治疗策略9

8、,治疗指南概要（六）,6 升压药的应用6.1 如果充分的液体复苏仍不能恢复动脉血压和组织灌注，有指征时应用升压药。存在威胁生命的低血压时，即使低血容量状态尚未纠正，液体复苏的同时可以暂时使用升压药以维持生命和器官灌注(推荐级别：E级)。 6.2 去甲肾上腺素和多巴胺是纠正感染性休克低血压的首选升压药(推荐级别：D级)。 6.3 小剂量多巴胺对严重感染患者无肾脏保护作用(推荐级别：B级)。6.4 条件许可的情况下，应用升压药的患者均应留置动脉导管，监测有创血压(推荐级别：E级)。6.5 对经过充分液体复苏，并应用大剂量常规升压药，血压仍不能纠正的难治性休克患者，可应用血管加压素，但不推荐将其代替

9、去甲肾上腺素和多巴胺等一线药物。成人使用剂量为0.010.04 U/min(推荐级别：E级)。,SEPSIS的集束治疗策略,10,治疗指南概要（六）6 升压药的应用SEPSIS的集束治疗策略,治疗指南概要（七）,7 强心药物的应用7.1 充分液体复苏后仍然存在低心排量，应使用多巴酚丁胺增加心排血量。若同时存在低血压，应联合使用升压药(推荐级别：E级)。 7.2 不推荐提高心排指数达到目标性的高氧输送(推荐级别：A级)。,SEPSIS的集束治疗策略,11,治疗指南概要（七）7 强心药物的应用SEPSIS的集束治疗策,治疗指南概要（八）,8 糖皮质激素的应用 8.1 对于经足够的液体复苏仍需升压药

10、来维持血压的感染性休克患者，推荐静脉使用糖皮质激素，氢化可的松200300 mg/d，分34次或持续给药，持续7 d(推荐级别：C级)。8.2 每日氢化可的松剂量不高于300 mg(推荐级别：A级)。 8.3 无休克的全身性感染患者，不推荐应用糖皮质激素。但对于长期服用激素或有内分泌疾病者，可继续应用维持量或给予冲击量(推荐级别：E级)。,SEPSIS的集束治疗策略,12,治疗指南概要（八）8 糖皮质激素的应用 SEPSIS的集束治,治疗指南概要（九）,9 重组活化蛋白C(rh-APC)：对于急性生理学和既往健康评分(APACHE)25分、感染导致多器官功能障碍综合征(MODS)、感染性休克或

11、感染导致的急性呼吸窘迫综合征(ARDS)等高危的严重感染患者，若无严重出血的危险性，推荐早期使用rh-APC(推荐级别：B级)。,SEPSIS的集束治疗策略,13,治疗指南概要（九）9 重组活化蛋白C(rh-APC)：对于急,治疗指南概要（十）,10 血液制品的应用10.1 一旦组织低灌注纠正，同时无严重冠心病、急性出血或乳酸酸中毒等，若血红蛋白5010 9/(推荐级别：E级)。,SEPSIS的集束治疗策略,14,治疗指南概要（十）10 血液制品的应用SEPSIS的集束治疗,治疗指南概要（十一）,11 感染所致急性肺损伤(ALI)和(或)ARDS的机械通气 11.1 ALI和(或)ARDS患者

12、应避免高潮气量和高气道平台压，早期应采用较低的潮气量(如在理想体重下6 ml/kg)，使吸气末平台压不超过30 cm H2O(推荐级别：B级)。 11.2 采用小潮气量通气和限制气道平台压力，允许动脉血二氧化碳分压(PaCO2)高于正常，即达到允许性高碳酸血症(推荐级别：C级)。11.3 采用能防止呼气末肺泡塌陷的最低呼气末正压(PEEP)(推荐级别：E级)。11.4 应用高吸氧浓度(FiO2)或高气道平台压通气的ARDS患者，若体位改变无明显禁忌证，可采用俯卧位通气(推荐级别：E级)。,SEPSIS的集束治疗策略,15,治疗指南概要（十一）11 感染所致急性肺损伤(ALI)和(或,治疗指南概

13、要（十一）,11.5 机械通气的患者应采用45角半卧位，以防止呼吸机相关肺炎的发生(推荐级别：C级)。11.6 当患者满足以下条件时，应进行自主呼吸测试(SBT)，以评估是否可以脱机。其条件包括：清醒；血流动力学稳定(未使用升压药)；无新的潜在严重病变；需要低的通气条件及PEEP；面罩或鼻导管吸氧可达到所需的FiO2。如果SBT成功，则考虑拔管。SBT时可采用5 cm H2O持续气道正压通气或T管(推荐级别：A级)。,SEPSIS的集束治疗策略,16,治疗指南概要（十一）11.5 机械通气的患者应采用45角半,治疗指南概要（十二）,12 镇静、镇痛和肌松药使用12.1 首先需制订具体的镇静方案

14、，包括镇静目标和镇静效果评估(推荐级别：B级)。12.2 无论是间断静脉推注或持续静脉注射给药，每天均需中断或减少持续静脉给药的剂量，以使患者完全清醒，并重新调整用药剂量 (推荐级别：B级)。 12.3 肌松药有延长机械通气时间的危险，应避免使用(推荐级别：E级)。,SEPSIS的集束治疗策略,17,治疗指南概要（十二）12 镇静、镇痛和肌松药使用SEPSIS,治疗指南概要（十三）,13 控制血糖13.1 严重感染患者早期病情稳定后应维持血糖水平低于8.3 mmol/L(150 mg/dl)。研究表明，可通过持续静脉输注胰岛素和葡萄糖来维持血糖水平。早期应每隔3060 min测定一次血糖，稳定

15、后每4 h测定一次(推荐级别：D级)。13.2 严重的脓毒症患者的血糖控制需制订肠内营养方案(推荐级别：E级)。,SEPSIS的集束治疗策略,18,治疗指南概要（十三）13 控制血糖SEPSIS的集束治疗策略,治疗指南概要（十四）,14 肾脏替代治疗:并发急性肾功能衰竭时，持续静脉-静脉血液滤过与间断血液透析治疗效果相同。但对于血流动力学不稳定的全身性感染患者，持续血液滤过能够更好地控制液体平衡(推荐级别：B级)。,SEPSIS的集束治疗策略,19,治疗指南概要（十四）14 肾脏替代治疗:并发急性肾功能衰竭时,治疗指南概要（十五）,15 碳酸氢盐治疗：pH7.15时不推荐应用碳酸氢盐治疗(推荐

16、级别：C级)。,SEPSIS的集束治疗策略,20,治疗指南概要（十五）15 碳酸氢盐治疗：pH7.15时不推,治疗指南概要（十六）,16 深静脉血栓(DVT)的预防：严重感染患者应使用小剂量肝素或低分子肝素预防DVT。有肝素使用禁忌证(血小板减少、重度凝血病、活动性出血、近期脑出血)者，推荐使用物理性的预防措施(弹力袜、间歇压缩装置)。既往有DVT史的严重感染患者，应联合应用抗凝药物和物理性预防措施(推荐级别：A级)。,SEPSIS的集束治疗策略,21,治疗指南概要（十六）16 深静脉血栓(DVT)的预防：严重感,治疗指南概要（十七）,17 应激性溃疡的预防：所有严重感染患者都需预防应激性溃疡

17、。H2受体阻滞剂比硫糖铝更为有效。在提高胃液pH值方面，质子泵抑制剂可能优于H2受体抑制剂(推荐级别：A级)。,SEPSIS的集束治疗策略,22,治疗指南概要（十七）17 应激性溃疡的预防：所有严重感染患者,治疗指南概要（十八）,18限制支持治疗应当与患者及其家属讨论和交流可能的治疗结果以及理想的治疗目标，以患者的最佳利益为原则来决定治疗和支持的强度(推荐级别：E级)。,SEPSIS的集束治疗策略,23,治疗指南概要（十八）18限制支持治疗SEPSIS的集束治疗,治疗指南概要（十八）,19 儿科患者治疗指南19.1机械通气19.2液体复苏19.3血管活性药物19.4治疗终点19.5儿童感染性休

18、克19.6激素治疗19.7蛋白C 活化蛋白C19.8集落刺激因子19.9深静脉血栓预防19.10应激性溃疡预防19.11肾脏替代治疗19.12血糖控制19.13镇静镇痛19.14血制品19.15静脉免疫球蛋白19.16ECMO,SEPSIS的集束治疗策略,24,治疗指南概要（十八）19 儿科患者治疗指南SEPSIS的集束,Surviving Sepsis,Phase1 Barcelona declarationPhase2 Evidence based guidelinesPhase3 Implementation and education The last phase of the cam

19、paign involves translating the guidelines into clinical practice to create a global best practice for sepsis management,SEPSIS的集束治疗策略,25,Surviving SepsisPhase1 Barcelo,Objective of guideline,1 To increase clinician and public awareness of the incidence of sepsis2 To develop guidelines for the manage

20、ment of severe sepsis 3 To change the standard of care for the reduction in mortality,SEPSIS的集束治疗策略,26,Objective of guideline1 To inc,在指南最后提出： The first step in this next phase will be a joint effort with the Institute of Healthcare Improvement to deploy a “change bundle” based on a core set of the

21、previous recommendations into the Institute of Healthcare Improvement collaborative system.,SEPSIS的集束治疗策略,27,在指南最后提出： SEPSIS的集束治疗策略27,Bundle的概念,Bundles are selected sets of interventions or processes of care distilled from evidence-based practice guidelines that, when instituted over the same time f

22、rame for a specifics diagnosis of process, are likely to improve outcome.,SEPSIS的集束治疗策略,28,Bundle的概念BundlesSEPSIS的集束治疗策略2,The SSC sepsis bundles are an important step to improving outcome in severe sepsis .As new evidence is published, as experience is gained with the bundles,and as experts ponder h

23、ow the guidelines should best be expressed in the bundles, the sepsis bundles will be adapted to optimize their utility.,SEPSIS的集束治疗策略,29,The SSC sepsis bundles are an,How are new positive clinical-trial results used or not used,1 No change of behavior hindered by a variety of barriers 1.1 knowledge

24、 attitude behavior (Lack of awareness and familiarity ; nonagreement with interpretation of evidence;The inertia of previous practice;Lack of outcome expectation) 1.2 environment factors(insufficient time;insufficient resources;organizational barriers) 1.3 Patient, system, physician factors,?,SEPSIS

25、的集束治疗策略,30,How are new positive clinical-,How are new positive clinical-trial results used or not used,2 Ineffectiveness of guidelines 2.1 More than half of the guidelines published before 2000 were based on no randomized controlled trials 2.2Traditional clinicians recommendations supporting evidenc

26、e 2.3 evidence fails to change clinical patterns Even a global standard guideline for the treatment of pulmonary infections in ICUs has not yet been developed,gap,SEPSIS的集束治疗策略,31,How are new positive clinical-,How are new positive clinical-trial results used or not used,3 What does change behavior?

27、3.1The working team multiprofessional and knowledgeable - daily planning documentation communication education evaluation of activities3.2 A leadership group remove barriers provides resources monitors global progress et al3.3 Providers and stakeholder receive their feedbackReliability, organization

28、al learning, and standardization are very important topics for successful change .,SEPSIS的集束治疗策略,32,How are new positive clinical-,Translation of guidelines into tools to improve performance,1 Bundles: guideline at the bedside To improve patient outcomes will come not from discovering new treatments

29、 but from more effective delivery of existing, accepted therapies.2 Intensive care unit collaboratives Adherence to guideline depends on the specialty and training status of prescribing physicians Adherence to guideline depends on an intensive guideline implementation strategy(real-time remainders,c

30、ontinuous quality-improvement activities)3 Change process,SEPSIS的集束治疗策略,33,Translation of guidelines into,SOP-standard operating procedure,Objective：To assess the impact of standard operating procedure of resuscitation (EGDT, glycemic control, stress doses steroid, and rhAPC)on organ dysfunction and

31、 outcome in septic shockRetrospective cohort studyTen-bed ICU of a university hospital30 pats with septic shock, treated (Sep 2002 until Dec 2003) after implementation of SOP for severe sepsis30 pats with septic shock treated from Jan until Aug 2002 in the same unit, who served as controls Crit Care

32、 Med 2006; 34:943949,SEPSIS的集束治疗策略,34,SOP-standard operating procedu,SOP-standard operating procedure,Methods:1 EDGT(6h)2 Intensive insulin therapy(80-110mg/dL intermittently, continuously,or both)3 Hydrocortisone administration(100mg150mg/day until cessation of vasopressor therapy)4 RhAPC administr

33、ation(24g/kg/hr for a total of 96hrs)5 Lung-protective ventilation with low tidal volumes and optimized positive end expiratory pressure levels,empirical antibiotic therapy,and source controlEmpirical antibiotic therapy,and source control were applied to the control group as well.,SEPSIS的集束治疗策略,35,S

34、OP-standard operating procedu,SOP-standard operating procedure,SEPSIS的集束治疗策略,36,SOP-standard operating procedu,SOP-standard operating procedure,Control SOP Packed red blood cells within 6 hrs 5 5 Packed red blood cells within 24 hrs 8 12Dobutamine within 6 hrs 0 6Dobutamine within 24 hrs 2 12#Dobuta

35、mine during ICU stay 5 21#Insulin 18 30#Hydrocortise 13 30#rhAPC 0 7#Vasopressin 1 6,SEPSIS的集束治疗策略,37,SOP-standard operating procedu,SOP-standard operating procedure,Control SOPDuration of vasopressor therapy(hrs) 90(53.3/152.8) 68(36/110)Maximum dosage of norepinephrine(g/kg/min)0.91(0.36/3.04) 0.3

36、65(0.21/1)#Time till initiation of dobutamine(hrs) 79(17.8/108) 22(2.8/54.5)Duration of dobutamine therapy(hrs) 73(19.5/128.5) 71(45.8/107.3)Maximum dosage of dobutamine(g/kg/min) 5.5(4.68/9.44) 7.5(5.94/10.63)Time till initiation of hydrocortisone therapy(hrs) 14(2.5/28.8) 4(2/12)Duration of hydroc

37、ortisone therapy(hrs) 80(56.8/106.3) 100(74/150)Time till initiation of blood glucose control(hrs) 10(2/26) 0(0/1)#Duration of insulin therapy(hrs) 139(102/184) 155(73/314),SEPSIS的集束治疗策略,38,SOP-standard operating procedu,SOP-standard operating procedure,Blood glucose level * day2 and day4;Blood lact

38、ate level* day4,SEPSIS的集束治疗策略,39,SOP-standard operating procedu,SOP-standard operating procedure,Sequential Organ Failure Assessment (SOFA) scores were elevated in both groups similarly on day0, with no apparent differences between the two groups,Significant lower SOFA scores in the SOP group on day

39、 2, day 6, and day8. day4 decrease trend,SEPSIS的集束治疗策略,40,SOP-standard operating procedu,SOP-standard operating procedure,Mortality was 53% in the historical control group and 27% after Implementation of the SOP (p0.05),SEPSIS的集束治疗策略,41,SOP-standard operating procedu,SOP-standard operating procedure

40、,Conclusion:The combined approach of early goal-directed therapy, intensive insulin therapy, hydrocortisone administration, and additional application of rhAPC in selected cases seems to favorably influence outcome. The present data from a small ,single-center assessment of the impact of an SOP on o

41、utcome suggest that evidence-based recommendations for this high-risk population can be successfully implemented by means of an SOP to improve the standard of care.,SEPSIS的集束治疗策略,42,SOP-standard operating procedu,Sepsis bundles,Sepsis resuscitation bundle resuscitation as 6h bundle Sepsis management

42、 bundle4 management goalsWithin 24h,Critical Care 2005,9:R764-R770,SEPSIS的集束治疗策略,43,Sepsis bundlesSepsis resuscita,SEPSIS的集束治疗策略培训课件,早期目标导向治疗流程图,SEPSIS的集束治疗策略,45,早期目标导向治疗流程图 SEPSIS的集束治疗策略45,Sepsis Resuscitation BundleTo be started immediately and completed within 6 hours,1 blood cultures2 antibiotic

43、s3 early goal-directed therapy indicators,SEPSIS的集束治疗策略,46,Sepsis Resuscitation BundleTo,6hr Bundle & Hosp Mortality,6hr bundle yes,6hr bundle no,Mortality,50%,30%,10%,23%,49%,P=0.01,SEPSIS的集束治疗策略,47,6hr Bundle & Hosp Mortality6hr,Sepsis Management BundleTo be started immediately and completed withi

44、n 24 hours,Low-dose steroidsRecombinant human activated protein C according to hospital policyControl of blood glucose levels(maintained lower limit of normal, but 150mg/dl(8.3mmol/L).Lung-protective ventilation strategy(For mechanically ventilated patients inspiratory plateau pressures maintained30

45、 cm H2O),SEPSIS的集束治疗策略,48,Sepsis Management BundleTo be,24hr Bundle & Hosp Mortality,24hr bundle yes,24hr bundle no,Mortality,50%,30%,10%,29%,50%,P=0.16,SEPSIS的集束治疗策略,49,24hr Bundle & Hosp Mortality24,Conclusion,The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in

46、 patients with severe sepsis-Non-compliance with the 6-hour sepsis bundle was associated with a more than twofold increase in hospital mortality-Non-complicance with the 24-hour sepsis bundle resulted in a 76% increase in risk for hospital death.All medical staff should practise these relatively sim

47、ple ,easy and cheap bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.,SEPSIS的集束治疗策略,50,ConclusionThe impact of compli,Ventilator bundle,1 head-of-bed elevation2 sedation and analgesia3 stress ulcer prophylaxis4 deep-vein thrombosis prophylax

48、isA marked reduction in VAP,SEPSIS的集束治疗策略,51,Ventilator bundle1 head-of-bed,Rapid-response teams,Most patient is not yet an ICU patientCritical care at outside of ICU: ICU without walls phenomenon Some studies have demonstrated benefit, but a recent large cluster-randomized study of RRTs found no be

49、nefit.The control hospitals (no RRT) demonstrated similar improvements to the intervention (RRT) hospitals for an unexplained reason.,SEPSIS的集束治疗策略,52,Rapid-response teamsMost patie,Rapid-response teams,AIM: To determine how the incidence and outcomes of cardiac arrests have changed following increa

50、sed use of METMedical emergency team (MET) responses have been implemented to reduce inpatient mortalityUniversity of Pittsburgh Medical Center, Presbyterian Hospital,SEPSIS的集束治疗策略,53,Rapid-response teamsAIM: To de,Rapid-response teams,Increased use of MET may be associated with fewer cardiopulmonar