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1、2013 SSC International Guidelines for Management of Severe Sepsis and Septic Shock2016中国急诊感染性休克临床实践指南,Speaker:Cai HanThe 1st Affiliated Hospital of Fujian Medical University,Index case,Name:Sun Zu Yu Age:63years Sex:female ID:0680716 admissiontime:2015.06.292015.07.06主诉:：repeated fatigue 13 years现病史
2、：入院前13年无明显诱因出现乏力、纳差，食欲减退为原来的1/2，就诊福州市传染病院，查转氨酶增高（未见单），行肝穿检查，肝穿病理示：慢性胆汁性肝硬化（轻度），予保肝处理后，好转出院。出院后未定期复查，1月余前无明显诱因再次出现乏力、纳差，伴眼黄、尿黄、皮肤瘙痒，就诊我院，门诊拟“肝硬化”收住入院。,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
3、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,肺部CT,上腹部MRI+增强,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39.1，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
4、，N90.8，急诊生化：AST123U/L，糖9.73mmol/L；肺部CT：双肺炎症,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。,查体：T36.5，P88次/分，R2
5、0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,2.14 19:00患者突发四肢抽
6、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，Morphy征可疑阳性，肠鸣音3次/分，双下肢无水肿。,Problem list:,In essence,atdifferentstagesofthe one same disease,SIRS,systemic inflammatory response syndrome General variablesFever(38.3C)，Hypothermia低体温(core tempera
7、ture 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,SIRS,Altered mental status Significant edema or positive fluid balance(20ml/kg over 24hr)Hyperglycemia高血糖症(p
8、lasma glucose 140mg/dl or 7.7 mmol/L)in the absence of diabetes,Definition,Sepsis,SIRS is secondary to documented or suspected infection.Sepsis-induced hypotensionLactate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,D
9、efinition,Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.,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(b
10、oth aerobic需氧 and anaerobic厌氧 bottles)be obtained before antimicrobial 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).,2.diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay(grade 2
11、B),mannan and 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,Recommendations:,Source ControlAntimicrobial TherapyVasopressorsCorticosteroids,Adjunctive Thera
12、py,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,Source Control,1）recommend crystalloids
13、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 crystalloids(grade 2C).3）recommend against the use of hydroxyethyl starches(羟乙基淀粉）for fluid r
14、esuscitation of severe sepsis and septic shock(grade 1B).,Source Control,；,Antimicrobial Therapy,1.Administration of effective 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 o
15、r 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),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,bu
16、t have no subsequent evidence of infection(grade 2C),4.duration of therapy:7 to 10 days,Antimicrobial Therapy,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,if the Initial fluid resuscitation did
17、 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,1.Norepinephrine（NE）as the first choice of vasopressor(grade 1B).2.Epinephrine(added to and substituted for no
18、repinephrine)(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 dosage;protect renal function(UG).,Vasopressors血管活性药物,4.Dopamine（DA)-an alternative vasopressor agent to NE.(2C)only in highly selec
19、ted patients(eg.patients with low risk of tachyarrhythmias and absolute or relative bradycardia心动过缓)Low-dose dopamine should not be used renal protection(grade 1A).,Vasopressors血管活性药物,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 t
20、he presence of:(a)myocardial dysfunction-elevate cardiac filling pressure,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,Corticosteroids类固醇激素,(1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic
21、shock patients if 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.,（2）Not using the ACTH stimulation test to identify adult
22、s 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(grade 1D).,Corticosteroids类固醇激素,Adjunctive
23、TherapyEmphasizes!,Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation,Analgesia,and Neuromuscular Blockade in Sepsis,Blood Product Administration血制品的输注,（1）recommen
24、d 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 circumstances:(a)myocardial ischemia(b)severe hypoxemia顽固性低氧血症(c)acute hemorrhage or ischemic coronary artery disease,（2）use fresh frozen pla
25、sma新鲜冰冻血浆.Not only to be corrected laboratory clotting abnormalities but also to be used in bleeding or planned invasive 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 b
26、leeding;PLT(2 0,000/L)if the patient has a significant risk of bleeding.（5）not using EPO as a specific treatment of anemia.,Blood Product Administration血制品的输注,not using intravenous immunoglobulins(grade 2B).History of Recommendations Regarding Use of Recombinant Activated Protein C(rhAPC)-no longer
27、available.重组人活性蛋白CNot using intravenous selenium硒收益风险,Immunoglobulins 免疫球蛋白,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.
28、15(grade 2B).5%NaHCO3（ml）=(24-HCO3-)*weight/3,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 prophylaxis(grade 2B).,Continuous Renal Replacement T
29、herapy(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 hemodynamically unstable septic patients(grade 2D).,Glucose Control血糖控制,Start insulin胰岛素 dosing when two
30、consecutive blood glucose levels are 180 mg/dL.(grade 1A).Target：110-180mg/dlMonitor blood glucose values q1hq2hq4h(grade 1C).,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 creat
31、inine clearance 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),Nutrition营养支持,suggest administering oral or enteral feedin
32、gs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).Avoidfullcaloricfeedinginthefirstweek,suggestlo
33、wdosefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B).,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 body weight（2）initial upper limit goal for Plateau pressures(平台压)30 cm H2O(grade 1B)；（3）
34、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 Hg(grade 2B)；（5）Recruitment maneuvers(肺复张)be used in sepsis patients with severe refractory h
35、ypoxemia顽固性低氧血症(grade 2C).,Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome(ARDS),（6）be maintained with the head of the bed elevated 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 use
36、d 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 routine use of the pulmonary artery catheter(肺动脉导管)；,Setting Goals of Care确立治疗目标,（1）Discuss goals of care and prognosis with patients and families
37、(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,utilizing 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).,Enha
38、nce theearlier recognition of sepsis.Resuscitation as soon as possible.Care of Evidence-basedmedicineEmphasizes the significance of adjuvant therapy集束化（BUNDLE）治疗策略,update,Sepsis resucitation bundle初始复苏,1)Measure lactate level 2)Obtain blood cultures prior to administration of antibiotics3)Administer
39、 broad spectrum 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:,Septic shock bundle 感染性休克,1)vasopressors to maintain MAP 65 mm Hg2)In the event of persistent arterial hypotension顽固性低血压 despite volume resusc
40、itation(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 lactate.6h内达成治疗目标及再次评估！,TO BE COMPLETED WITHI
41、N 6 HOURS:,2016中国急诊感染性休克临床实践指南update,2016中国急诊感染性休克临床实践指南update,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导向的补液试验功能性血流动力学参数：SVV、PPV、SPV超声：SV、CO、SVR被动抬腿试验,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
42、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,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,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,
