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1、感染性休克指南解读宣讲,感染性休克指南解读宣讲,Index case,查体：T37.5，P88次/分，R19次/分，BP125/68mmHg。神志清楚，全身皮肤、巩膜黄染，双侧肝掌，未见蜘蛛痣，浅表淋巴结未触及，双肺未闻及干湿性啰音，心律齐，各瓣膜区未闻及杂音，腹无压痛、反跳痛，肝脾肋下未触及，墨菲氏征阴性，移动性浊音阴性，肠鸣音3次/分，双下肢轻度浮肿。初步诊断：1.肝硬化失代偿期(胆汁淤积性)2.高血压病3.慢性胆囊炎治疗方案：思美泰、易善复、天晴甘美 保肝 前列地尔改善肝内循环 螺内酯利尿,2,感染性休克指南解读宣讲,Index case查体：T37.5，P88次/分，R19,肺部CT,
2、上腹部MRI+增强,3,感染性休克指南解读宣讲,Baseline（7.3）WBC6.104.54N%51.4,4,感染性休克指南解读宣讲,6.296.307.17.27.37.47.57.64感染性,5,感染性休克指南解读宣讲,WBC6.104.542.055.65N%51.449.5,Index case,Name: Chen Yi Ming Age: 75years Sex: male ID:M admissiontime:2016.02.142016.02.17主诉：sudden fever and shiver 6 hours现病史：入院前6小时无明显诱因出现畏冷、发热，体温最高39.
3、1，伴寒战、右侧胸痛，偶有咳嗽、咳痰，急诊我院，查血常规提示WBC12.44109/L，N11.30109/L，N90.8，急诊生化：AST123U/L，糖9.73mmol/L；肺部CT：双肺炎症,6,感染性休克指南解读宣讲,Index caseName: Chen Yi Ming,Index case,既往史：有高血压病10余年，不规则服用 “安内真、氯沙坦、双克”等药物，未监测血压；6年前出现反酸、嗳气，就诊我院行胃镜后诊断“反流性食管炎（1级），慢性浅表性胃炎（2级）”，间断服用保胃药，现仍偶有反酸；4年前因进行性排尿困难，就诊我院，诊断“前列腺增生症，膀胱多发结石，双肾囊肿”，行“经尿
4、道前列腺切除术膀胱切开取石术”，术后无再出现排尿困难。3月前因反复腹痛20天就诊我院，诊断“胆囊穿孔、胆囊结石并胆囊炎”，予保肝、解痉止痛等保守治疗后症状好转。,7,感染性休克指南解读宣讲,Index case既往史：有高血压病10余年，不规则服用,查体： T36.5，P88次/分，R20次/分，BP110/65mmHg。神清，精神疲乏，锁骨上等浅表淋巴结未触及肿大，双肺呼吸音粗，双下肺有闻及少许湿性啰音。心律齐，各瓣膜听诊区未闻及杂音，腹平软，全腹部无压痛，无反跳痛，Murphy征阴性，肝脾未触及，移动性浊音阴性，肠鸣音3次/分，双下肢无水肿。 初步诊断：1.肺炎2.高血压病3.脂肪肝4.胆
5、囊结石伴慢性胆囊炎5.反流性食管炎6.慢性胃炎7.单纯性肾囊肿8.前列腺增生9.颈动脉硬化10. 手术后状态(经尿道前列腺电切术+膀胱切开取石术)治疗方案：考虑患者为社区获得性肺炎，予头孢美唑抗感染，沐舒坦祛痰，薄芝糖肽提高免疫力，易善复保肝及补液营养支持,8,感染性休克指南解读宣讲,查体： T36.5，P88次/分，R20次/分，BP110,2.14 19:00患者突发四肢抽搐，伴发热、畏冷、寒战。查体：T38.5，P100次/分，R22次/分，BP88/50mmHg。神志欠清，双下肢皮肤花斑样改变，右侧乳头至脐水平广泛压痛，双肺呼吸音粗，双下肺有闻及少许湿性啰音。心律齐，无杂音，Morph
6、y征可疑阳性，肠鸣音3次/分，双下肢无水肿。,9,感染性休克指南解读宣讲,WBC12.4411.89N11.3010.86N%,10,感染性休克指南解读宣讲,10感染性休克指南解读宣讲,11,感染性休克指南解读宣讲,11感染性休克指南解读宣讲,Problem list:,In essence, atdifferentstagesofthe one same disease,12,感染性休克指南解读宣讲,Problem list:In essence, atdi,SIRS,systemic inflammatory response syndrome General variablesFever
7、( 38.3C)，Hypothermia低体温 (core temperature 90/min1 or more than two sd above the normal value for ageTachypnea呼吸急促 （20次/min, PaCO2 12,000/ L) Leukopenia (WBC count 4000/L)Normal WBC count with greater than 10% immature forms,Definition,13,感染性休克指南解读宣讲,SIRSsystemic inflammatory resp,SIRS, Altered menta
8、l status Significant edema or positive fluid balance(20ml/kg over 24hr) Hyperglycemia高血糖症(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes,Definition,14,感染性休克指南解读宣讲,SIRS Altered mental statusDef,Sepsis,SIRS is secondary to documented or suspected infection.Sepsis-induced hypotension
9、Lactate乳酸 above upper limits laboratory normalUrine output 176.8 mol/LAcute lung injury with Pao2/Fio2（OI） 34.2 mol/LPLT 1.5),Definition,15,感染性休克指南解读宣讲,SepsisSIRS is secondary to doc,Definition,Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.,16,
10、感染性休克指南解读宣讲,DefinitionSeptic shock is defi,Diagnostic,1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay ( 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic需氧 and anaerobic厌氧 bottles) be obtained before antim
11、icrobial therapy with at least 1 drawn percutaneously经皮地 and 1 drawn through each vascular access device，unless the device was recently (48hrs) inserted (grade 1C).,17,感染性休克指南解读宣讲,Diagnostic1. Cultures as cli,2. diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay (grade 2B), mannan an
12、d anti-mannan antibody assays (2C).葡聚糖试验、半乳甘露聚糖试验3. Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection (UG).,Diagnostic,18,感染性休克指南解读宣讲,2. diagnosis of fungus真菌 infe,Recommendations:,Source ControlAntimicrobial TherapyVasopres
13、sorsCorticosteroids,Adjunctive Therapy,Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in Sepsis,Evidence-basedmedicine,1
14、9,感染性休克指南解读宣讲,Recommendations:Source Control,Source Control,1）recommend crystalloids晶体液 be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).2）add to use of albumin白蛋白 in the fluid resuscitation when patients require substantial amounts of crystall
15、oids (grade 2C).3）recommend against the use of hydroxyethyl starches (羟乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (grade 1B).,20,感染性休克指南解读宣讲,Source Control1）recommend crys,Source Control,；,21,感染性休克指南解读宣讲,Source Control；achieve 30 mL,Antimicrobial Therapy,1.Administration of effec
16、tive intravenous antimicrobials within 1st hour2a. Initial empiric anti-infective therapy of one or more drugs， have activity against all likely pathogens (bacterial and/or fungal or viral) (grade 1B)2b. Antimicrobial regimen抗菌药物组合 should be reassessed daily for potential de-escalation降阶梯 (grade 1B)
17、,22,感染性休克指南解读宣讲,Antimicrobial Therapy 1.Admini,Antimicrobial Therapy,3. Use of low PCT levels or similar biomarkers to assist the clinicians in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C),23,感染性休克指南解读宣讲
18、,Antimicrobial Therapy 3. Use o,4.duration of therapy :7 to 10 days,Antimicrobial Therapy,24,感染性休克指南解读宣讲,Antimicrobial Therapy Neutro,5.Antiviral therapy抗病毒治疗 initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).,Antimicrobial Therapy,25,感染性休克指南解读宣
19、讲,Antimicrobial Therapy 25感染性休克指,if the Initial fluid resuscitation did not target a mean arterial pressure (MAP) of 65 mmHg，Vasopressor therapy can be added (grade 1C).,血管活性药物Vasopressors,Norepinephrine Compared With Dopamine in Severe Sepsis Summary of Evidence,26,感染性休克指南解读宣讲,if the Initial fluid
20、resuscita,1.Norepinephrine（NE） as the first choice of vasopressor (grade 1B).2.Epinephrine (added to and substituted for norepinephrine) (grade 2B) when an additional agent is needed to maintain adequate blood pressure.3.Vasopressin（ 0.03 IU/min） -to be added to NE. intent: raise MAP ; decrease NE d
21、osage; protect renal function (UG).,Vasopressors血管活性药物,27,感染性休克指南解读宣讲,1.Norepinephrine（NE） as the fi,4.Dopamine（DA)- an alternative vasopressor agent to NE. (2C) only in highly selected patients (eg.patients with low risk of tachyarrhythmias and absolute or relative bradycardia心动过缓) Low-dose dopamin
22、e should not be used renal protection (grade 1A).,Vasopressors血管活性药物,28,感染性休克指南解读宣讲,4.Dopamine（DA)- an alternati,A trial of dobutamine多巴酚丁胺 infusion up to 20 micrograms/kg/minbe administered or added to vasopressor (if in use)In the presence of: (a) myocardial dysfunction- elevate cardiac filling pr
23、essure, and low cardiac output, (b) hypoperfusion低灌注, despite achieving adequate intravascular volume and adequate MAP (grade 1C).,Vasopressors血管活性药物,29,感染性休克指南解读宣讲,A trial of dobutamine多巴酚丁胺 inf,Corticosteroids类固醇激素,(1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic shock patients i
24、f adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.In case,not achievable：hydrocortisone氢化可的松 200 mg qd. intravenous (grade 2A). When given, use continuous infusion (grade 2C). iv-p.优于iv.,30,感染性休克指南解读宣讲,Corticosteroids类固醇激素(1)Not us,（2） Not using the ACT
25、H stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).（3）reduce the treated patient from steroid therapy when vasopressors are no longer required (grade 2D).（4）Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grad
26、e 1D).,Corticosteroids类固醇激素,31,感染性休克指南解读宣讲,（2） Not using the ACTH stimula,Adjunctive TherapyEmphasizes!,Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analges
27、ia, and Neuromuscular Blockade in Sepsis,32,感染性休克指南解读宣讲,Adjunctive TherapyEmphasizes,Blood Product Administration血制品的输注,（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB) decreases to 70 g/L (grade 1B). to target a HGB of 70-90 g/L,inmergerofextenuating circums
28、tances: (a) myocardial ischemia (b) severe hypoxemia顽固性低氧血症 (c) acute hemorrhage or ischemic coronary artery disease,33,感染性休克指南解读宣讲,Blood Product Administration,（2） use fresh frozen plasma新鲜冰冻血浆. Not only to be corrected laboratory clotting abnormalities but also to be used in bleeding or planned in
29、vasive procedures (grade 2D) ；（3） recommend against antithrombin凝血酶 administration(grade 2D).（4） prophylactically Platelets Administration (grade 2D) PLT(1 0,000 / L) in the absence of apparent bleeding; PLT(2 0,000/ L) if the patient has a significant risk of bleeding.（5） not using EPO as a specifi
30、c treatment of anemia .,Blood Product Administration血制品的输注,34,感染性休克指南解读宣讲,（2） use fresh frozen plasma新鲜冰,not using intravenous immunoglobulins (grade 2B).History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)-no longer available. 重组人活性蛋白CNot using intravenous selenium硒收益
31、风险,Immunoglobulins 免疫球蛋白,35,感染性休克指南解读宣讲,not using intravenous immunogl,Bicarbonate Therapy碳酸氢盐,recommend against the use of sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH 7.15 (g
32、rade 2B).5%NaHCO3（ml）=(24-HCO3-)*weight/3,36,感染性休克指南解读宣讲,Bicarbonate Therapy碳酸氢盐recomme,Stress Ulcer Prophylaxis应激性溃疡预防,Stress ulcer prophylaxis using proton pump inhibitors (PPI) (grade 1B) rather than H2 receptor antagonists (H2RA) (grade 2C). PPI优于H2RAwithout risk factors should not receive proph
33、ylaxis (grade 2B).,37,感染性休克指南解读宣讲,Stress Ulcer Prophylaxis应激性溃疡,Continuous Renal Replacement Therapy(CRRT),suggest that CRRT and Intermittent Hemodialysis间断血透 are equivalent in patients with severe sepsis and acute renal failure (grade 2B) . CRRT to facilitate management of fluid balance in hemodyna
34、mically unstable septic patients (grade 2D).,38,感染性休克指南解读宣讲,Continuous Renal Replacement T,感染性休克指南解读宣讲培训课件,Deep Vein Thrombosis Prophylaxis深静脉血栓的预防,daily subcutaneous low-molecular weight heparin (LMWH) grade 1B versus UFH twice daily. grade 2C versus UFH given thrice daily. If creatinine clearance
35、is 30 mL/min, we recommend use of UFH (grade 1A).patients who have a contraindication禁忌症 to heparin receive mechanical prophylactic treatment充气性机械装置 (eg, thrombocytopenia血小板减少症, active bleeding, recent intracerebral hemorrhage脑内出血),40,感染性休克指南解读宣讲,Deep Vein Thrombosis Prophylax,Nutrition营养支持,suggest
36、administering oral or enteral feedings肠内营养,as tolerated, rather than either complete fasting禁食 or give only intravenous glucose within the first 48hrs (grade 2C). suggest using intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) in the first 7 days (grade 2B).Avoid
37、fullcaloricfeedinginthefirstweek,suggestlowdosefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B).,41,感染性休克指南解读宣讲,Nutrition营养支持suggest administ,Mechanical Ventilation机械通气 of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS),（1）Target a tidal volume(潮气量)of 6 mL/kg predicted
38、body weight（2）initial upper limit goal for Plateau pressures(平台压)30 cm H2O (grade 1B)；（3）Positive end-expiratory pressure (最低PEEP) be applied to avoid alveolar collapse肺泡塌陷 at end expiration (grade 1B).（4）Prone positioning(俯卧位通气)be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm H
39、g (grade 2B)；（5）Recruitment maneuvers(肺复张)be used in sepsis patients with severe refractory hypoxemia顽固性低氧血症 (grade 2C).,42,感染性休克指南解读宣讲,Mechanical Ventilation机械通气 of,Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS),（6）be maintained with the head of the bed elevated
40、 to 30-45 degrees to limit aspiration risk误吸 and ventilator-associated pneumonia呼吸机相关肺炎 (grade 1B)；（7）noninvasive mask ventilation无创面罩 be used in that minority of patients in whom the benefits of NIV have been carefully sonsidered and are thought to outweight the risks(grade 2B)；（8）Against the routi
41、ne use of the pulmonary artery catheter(肺动脉导管)；,43,感染性休克指南解读宣讲,Mechanical Ventilation of Seps,Setting Goals of Care确立治疗目标,（1）Discuss goals of care and prognosis with patients and families (grade 1B).将诊断及进一步治疗方案与患者家属沟通（2）Incorporate goals of care into treatment and end-of-life care planning, utilizin
42、g palliative care principles where appropriate (grade 1B).包括预后，终止生命的方式以及姑息治疗措施（3）Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2C).,44,感染性休克指南解读宣讲,Setting Goals of Care确立治疗目标（1,Enhance theearlier recognition of sepsis.Resuscitation as soon as p
43、ossible.Care of Evidence-basedmedicineEmphasizes the significance of adjuvant therapy集束化（BUNDLE）治疗策略,update,45,感染性休克指南解读宣讲,Enhance theearlier recognitio,Sepsis resucitation bundle初始复苏,1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum
44、 antibiotics广谱抗生素 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L 1h内使用抗菌药物，3h内启动监测和体液复苏！,TO BE COMPLETED WITHIN 3 HOURS:,46,感染性休克指南解读宣讲,Sepsis resucitation bundle初始复苏,Septic shock bundle 感染性休克,1) vasopressors to maintain MAP 65 mm Hg2) In the event of persistent arterial hypot
45、ension顽固性低血压 despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL): - Measure CVP * - Measure SCVO2 * -Remeasure lactate if initial lactate was elevated*Targets for quantitative resuscitation in cluded in the guidelines are CVP of 8 mm H2O, SCVO270%, and normalization of
46、 lactate.6h内达成治疗目标及再次评估！,TO BE COMPLETED WITHIN 6 HOURS:,47,感染性休克指南解读宣讲,Septic shock bundle 感染性休克1) v,2016中国急诊感染性休克临床实践指南update,48,感染性休克指南解读宣讲,2016中国急诊感染性休克临床实践指南update48感染,2016中国急诊感染性休克临床实践指南update,49,感染性休克指南解读宣讲,2016中国急诊感染性休克临床实践指南update49感染,2016中国急诊感染性休克临床实践指南update,容量反应评估方法,CVP指导的补液试验PAWP导向的补液试验
47、功能性血流动力学参数：SVV、PPV、SPV超声：SV、CO、SVR被动抬腿试验,50,感染性休克指南解读宣讲,2016中国急诊感染性休克临床实践指南update容量反应,2016中国急诊感染性休克临床实践指南update,Expound physiopathologicmechanismOpportunity of Steroids and immunomodulatory drugs,病原体,免疫细胞,细胞因子炎症介质,级联反应,SIRS,过量抗炎物质,CARS,感染性休克可以不依赖细菌和毒素的持续存在而发生和发展，细菌和毒素仅起到触发急性全身感染的作用，其发展与否及轻重程度完全取决于机体
48、的反应性。因此在治疗感染性休克时，应正确评价个体的免疫状态。,MODS,51,感染性休克指南解读宣讲,2016中国急诊感染性休克临床实践指南updateExpo,2016中国急诊感染性休克临床实践指南update,在SIRS反应初期，激素应用对患者有积极作用，但对于免疫抑制的患者应谨慎使用 保护血管内皮乌司他丁 抑制炎症介质的产生和释放 改善微循环,Expond physiopathologicmechanismOpportunity of Steroids and immunomodulatory drugs,SIRS,CARS,52,感染性休克指南解读宣讲,2016中国急诊感染性休克临床实践指南update在SIR,Thank you！,3.,确诊严重脓毒症,/,脓毒症休克,7,天内建议使用静脉糖制剂和,EN,，不建议完全,TPN,或,PN+EN,53,感染性休克指南解读宣讲,Thank you！3.确诊严重脓毒症/脓毒症休克7天内建,
