医学课件-感染性休克指南解读课件.ppt

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中国急诊感染性休克临床实践指南1Index caseName:Sun Zu Yu Age:63years Sex:female ID:0680716 admission time:2015.06.292015.07.06主诉主诉:：repeated fatigue 13 years现病史：入院前现病史：入院前13年无明显诱因出现乏力、纳差，食欲减退为原来的年无明显诱因出现乏力、纳差，食欲减退为原

2、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，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，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，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，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，门诊拟伴眼黄、尿黄、皮肤瘙痒，就诊我院，门诊拟“肝硬化肝硬化”收住入院。收住入院。2Index case查体：查体：T37.5，P88次次/分，分，R19次次/分，分，BP125/68mmHg。神志清。神志

3、清楚，楚，全身皮肤、巩膜黄染，双侧肝掌，全身皮肤、巩膜黄染，双侧肝掌，未见蜘蛛痣，浅表淋巴结未触未见蜘蛛痣，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，肠鸣音鸣音3次次/分，分，双下肢轻度浮肿双下肢轻度浮肿。初步诊断：初步诊断：1.肝硬化失代偿期肝硬化失代偿期(胆汁淤积性胆汁淤积性)2.高血压病高血压病 3.慢性胆囊炎慢性胆囊炎治疗方案：思美泰、易善复、天晴甘美治疗方案：思美泰、易善复、天

4、晴甘美 保肝保肝 前列地尔前列地尔改善肝内循环改善肝内循环 螺内酯螺内酯利尿利尿3肺部肺部CT上腹部上腹部MRI+增强增强46.296.307.17.27.37.47.57.656Index caseName:Chen Yi Ming Age:75years Sex:male ID:M admission time:2016.02.142016.02.17主诉：主诉：sudden fever and shiver 6 hours现病史：入院前现病史：入院前6小时无明显诱因出现畏冷、发热，体温最高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

5、提示伴寒战、右侧胸痛，偶有咳嗽、咳痰，急诊我院，查血常规提示WBC 12.44109/L，N 11.30109/L，N 90.8，急诊生化：，急诊生化：AST 123U/L，糖，糖 9.73mmol/L；肺部；肺部CT：双肺炎症：双肺炎症7Index case既往史：有高血压病既往史：有高血压病10余年，不规则服用余年，不规则服用“安内真、氯沙坦、双克安内真、氯沙坦、双克”等药物，未监测血压；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年前出现反酸、嗳气，就诊我院行胃镜后诊断“反流性食管炎（反流性食管炎（1级）级），慢性浅表性胃炎（，慢性浅表性胃炎（2级）级）”，间断服用保胃

6、药，现仍偶有反酸；，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，膀胱多发前列腺增生症，膀胱多发结石，双肾囊肿结石，双肾囊肿”，行，行“经尿道前列腺切除术膀胱切开取石术经尿道前列腺切除术膀胱切开取石术”，术，术后无再出现排尿困难。后无再出现排尿困难。3月前因反复腹痛月前因反复腹痛20天就诊我院，诊断天就诊我院，诊断“胆囊穿孔、胆囊结石并胆囊炎胆囊穿孔、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。，予保肝、解痉止痛等保守治疗后症状好转。8查体：查体：T36.5，P88次次/分，分，R20次次/分，分，BP11

7、0/65mmHg。神清，。神清，精精神疲乏神疲乏，锁骨上等浅表淋巴结未触及肿大，锁骨上等浅表淋巴结未触及肿大，双肺呼吸音粗，双下肺有闻双肺呼吸音粗，双下肺有闻及少许湿性啰音及少许湿性啰音。心律齐，各瓣膜听诊区未闻及杂音，腹平软，全腹部。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，无压痛，无反跳痛，Murphy征阴性，肝脾未触及，移动性浊音阴性，征阴性，肝脾未触及，移动性浊音阴性，肠鸣音肠鸣音3次次/分，双下肢无水肿。分，双下肢无水肿。初步诊断：初步诊断：1.肺炎肺炎 2.高血压病高血压病 3.脂肪肝脂肪肝 4.胆囊结石伴慢性胆囊炎胆囊结石伴慢性胆囊炎 5.反流反流性食管炎性

8、食管炎 6.慢性胃炎慢性胃炎 7.单纯性肾囊肿单纯性肾囊肿 8.前列腺增生前列腺增生 9.颈动脉硬化颈动脉硬化 10.手手术后状态术后状态(经尿道前列腺电切术经尿道前列腺电切术+膀胱切开取石术膀胱切开取石术)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痰，薄芝糖肽提高免疫力，易善复保肝及补液营养支持92.14 19:00患者突发四肢抽搐，伴发热、患者突发四肢抽搐，伴发热、畏冷、寒战。查体：畏冷、寒战。查体：T38.5，P100次次/分，分，R22次次/分，分，BP88

9、/50mmHg。神志。神志欠清，双下肢皮肤花斑样改变，右侧乳欠清，双下肢皮肤花斑样改变，右侧乳头至脐水平广泛压痛，头至脐水平广泛压痛，双肺呼吸音粗，双肺呼吸音粗，双下肺有闻及少许湿性啰音。心律齐，双下肺有闻及少许湿性啰音。心律齐，无杂音，无杂音，Morphy征可疑阳性征可疑阳性，肠鸣音，肠鸣音3次次/分，双下肢无水肿。分，双下肢无水肿。101112Problem list:SIRSSepsis脓毒症Septic shock In essence,at different stages of the one same disease13SIRSsystemic inflammatory resp

10、onse syndrome General variables Fever(38.3C)，Hypothermia低体温低体温(core temperature 90/min1 or more than two sd above the normal value for age Tachypnea呼吸急促呼吸急促（20次次/min,PaCO2 12,000/L)Leukopenia(WBC count 20ml/kg over 24hr)Hyperglycemia高血糖症高血糖症(plasma glucose 140mg/dl or 7.7 mmol/L)in the absence of di

11、abetes Definition15SepsisSIRS 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)Definition16DefinitionSeptic shock is defined as sepsis-induced hypote

12、nsion persisting despite adequate fluid resuscitation.17Diagnostic1.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 a

13、ntimicrobial 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).182.diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay(grade 2B),mannan and anti-mannan antibody assays(2C).葡聚糖试验、半乳甘露聚

14、糖试验3.Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection(UG).Diagnostic19Recommendations:Source Control Antimicrobial Therapy Vasopressors CorticosteroidspAdjunctive TherapylBlood Product Administratio lMechanical Ventilation

15、of Sepsis-Induced ARDslGlucose ControllStress Ulcer ProphylaxislDeep Vein Thrombosis Prophylaxis lNutritionlRenal Replacement TherapylSedation,Analgesia,and Neuromuscular Blockade in Sepsisp Evidence-based medicine20Source Control1）recommend crystalloids晶体液晶体液 be used as the initial fluid of choice

16、in the resuscitation of severe sepsis and septic shock(grade 1B).2）add to use of albumin白蛋白白蛋白 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 resuscitation of severe sepsis and septic

17、 shock(grade 1B).21Source Control；achieve 30 mL/kg of crystalloids administrationQuantity量量MAP、SVV、CO、SBP、HRmonitoring Index监测指标监测指标CVP 8-12mmH2O，MAP65 mmHg，Urine output 0.5ml/kg/h，ScvO270%或SvO265%Goals for Initial Resuscitation(6hrs)复苏目标复苏目标22Antimicrobial Therapy 1.Administration of effective intr

18、avenous 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)23Antimicrobial

19、 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)244.duration of therapy:7 to 10 days Antimicrobial Therapy Neutropenic patient

20、s粒缺 multidrug-resistant Acinetobacter多重耐药菌不动杆菌Pseudomonas spp铜绿假单胞菌(grade 2B)combination empiric therapy have a slow clinical response undrainable oci of infection感染灶无法很好的引流 bacteremia with S.aureus金葡;some fungal and viral infections immunologic deficiencies(grade 2C)longer courses255.Antiviral ther

21、apy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 26if the Initial fluid resuscitation did not target a mean arterial pressure(MAP)of 65 mmHg，Vasopressor therapy can be added(grade 1C).血管活性药物血管活性药物VasopressorsNorepi

22、nephrine Compared With Dopamine in Severe Sepsis Summary of Evidence271.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）

23、-to be added to NE.intent:raise MAP;decrease NE dosage;protect renal function(UG).Vasopressors血管活性药物血管活性药物284.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 dopam

24、ine should not be used renal protection(grade 1A).Vasopressors血管活性药物血管活性药物29A 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 pressure,and low cardiac output,(b)hypoperf

25、usion低灌注,despite achieving adequate intravascular volume and adequate MAP(grade 1C).Vasopressors血管活性药物血管活性药物30Corticosteroids类固醇激素类固醇激素(1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodyn

26、amic 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.31（2）Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone(grade 2B).（3）reduce the treated patient fro

27、m 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类固醇激素类固醇激素32Adjunctive TherapyEmphasizes!Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsG

28、lucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation,Analgesia,and Neuromuscular Blockade in Sepsis33Blood Product Administration血制品的输注血制品的输注（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB)decreases

29、 to 70 g/L(grade 1B).to target a HGB of 70-90 g/L,in merger of extenuating circumstances:(a)myocardial ischemia(b)severe hypoxemia顽固性低氧血症(c)acute hemorrhage or ischemic coronary artery disease34（2）use fresh frozen plasma新鲜冰冻血浆.Not only to be corrected laboratory clotting abnormalities but also to be

30、 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 bleeding;PLT(2 0,000/L)if the patient has a significant risk of bleeding.（5）not usin

31、g EPO as a specific treatment of anemia.Blood Product Administration血制品的输注血制品的输注35not 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 收益收益7.15(grade 2B).5%NaHCO3

32、（ml）=(24-HCO3-)*weight/3 37Stress Ulcer Prophylaxis应激性溃疡预防应激性溃疡预防 Stress ulcer prophylaxis using proton pump inhibitors(PPI)(grade 1B)rather than H2 receptor antagonists(H2RA)(grade 2C).PPI优于H2RA without risk factors should not receive prophylaxis(grade 2B).38Continuous Renal Replacement Therapy(CRR

33、T)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).39Glucose Control血糖控制血糖控制1.Start insulin胰岛素 dosing when two conse

34、cutive blood glucose levels are 180 mg/dL.(grade 1A).2.Target：110-180mg/dl3.Monitor blood glucose values q1hq2hq4h(grade 1C).40Deep Vein Thrombosis Prophylaxis深静脉血栓的预防深静脉血栓的预防daily subcutaneous low-molecular weight heparin(LMWH)grade 1B versus UFH twice daily.grade 2C versus UFH given thrice daily.I

35、f creatinine 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)41Nutrition营养支持营养支持suggest administering oral or ent

36、eral 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 full caloric feeding in the fi

37、rst week,suggest low dose feeding(eg,up to 500 calories per day),advancing only as tolerated(grade 2B).42Mechanical Ventilation机械通气机械通气 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 pres

38、sures(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 Hg(grade 2B)；（5）Recruitment maneuvers(肺复张)be used in sepsis

39、patients with severe refractory hypoxemia顽固性低氧血症(grade 2C).43Mechanical 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）noninv

40、asive 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 routine use of the pulmonary artery catheter(肺动脉导管)；44Setting Goals of Care确立治疗目标确立治疗目标（1）Discuss goals of care a

41、nd 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,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

42、 hours of ICU admission(grade 2C).45 Enhance the earlier recognition of sepsis.Resuscitation as soon as possible.Care of Evidence-based medicine Emphasizes the significance of adjuvant therapy 集束化（BUNDLE）治疗策略update46Sepsis resucitation bundle初始复苏初始复苏 1)Measure lactate level 2)Obtain blood cultures p

43、rior to administration of antibiotics 3)Administer 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，内使用抗菌药物，3h内启动监测和体液复苏！内启动监测和体液复苏！TO BE COMPLETED WITHIN 3 HOURS:47Septic shock bundle 感染性休克感染性休克1)vasopressors to maintain MAP 65 mm Hg2)In

44、 the event of persistent arterial hypotension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,SC

45、VO270%,and normalization of lactate.6h内达成治疗目标及再次评估！内达成治疗目标及再次评估！TO BE COMPLETED WITHIN 6 HOURS:482016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update492016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update502016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update 容量反应评估方法容量反应评估方法 CVP指导的补液试验指导的补液试验 PAWP导向的补液试验导向的补液试验 功能性血流动力学参数：功能性血流动力学参数：SV

46、V、PPV、SPV 超声：超声：SV、CO、SVR 被动抬腿试验被动抬腿试验512016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update Expound physiopathologic mechanism Opportunity of Steroids and immunomodulatory drugs病原体病原体免疫细胞免疫细胞细胞因子细胞因子炎症介质炎症介质级联反应级联反应SIRS过量抗炎物质过量抗炎物质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，细菌和毒素仅起到毒素仅起到触发触发急性

47、全身感染的作用，其发展与否及轻重程度完全取急性全身感染的作用，其发展与否及轻重程度完全取决于决于机体的反应性机体的反应性。因此在治疗感染性休克时，应正确评价个体的免疫状态。因此在治疗感染性休克时，应正确评价个体的免疫状态。MODS522016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update在在SIRS反应反应初期初期，激素激素应用对患者有积极作用，但对于免疫抑制的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患者应谨慎使用 保护血管内皮保护血管内皮乌司他丁乌司他丁 抑制炎症介质的产生和释放抑制炎症介质的产生和释放 改善微循环改善微循环 Expond physiopathologic mechanism Opportunity of Steroids and immunomodulatory drugsSIRSCARS5354