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2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016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12013SSCInternationalGuideliIndexcaseName:SunZuYuAge:63yearsSex:femaleID:0680716admissiontime:2015.06.292015.07.06主诉主诉:：repeatedfatigue13years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，好转出院。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，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。2IndexcaseName:SunZuYuIndexcase查体：查体：T37.5，P88次次/分，分，R19次次/分，分，BP125/68mmHg。神志清楚，。神志清楚，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，浅表淋巴结未触及，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、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3Indexcase查体：T37.5，P88次/分，R19肺部肺部CT上腹部上腹部MRI+增强增强4肺部CT上腹部MRI+增强46.296.307.17.27.37.47.57.656.296.307.17.27.37.47.57.6566IndexcaseName:ChenYiMingAge:75yearsSex:maleID:Madmissiontime:2016.02.142016.02.17主诉：主诉：suddenfeverandshiver6hours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，伴寒战、右侧胸痛，偶有咳嗽、咳痰，急诊我院，查血常规提示寒战、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：，急诊生化：AST123U/L，糖，糖9.73mmol/L；肺部；肺部CT：双肺炎症：双肺炎症7IndexcaseName:ChenYiMingIndexcase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”等等药物，未监测血压；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。8Indexcase既往史：有高血压病10余年，不规则服用查体：查体：T36.5，P88次次/分，分，R20次次/分，分，BP110/65mmHg。神清，。神清，精神精神疲乏疲乏，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，双下肺有闻及双肺呼吸音粗，双下肺有闻及少许湿性啰音少许湿性啰音。心律齐，各瓣膜听诊区未闻及杂音，腹平软，全腹部无。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，压痛，无反跳痛，Murphy征阴性，肝脾未触及，移动性浊音阴性，肠征阴性，肝脾未触及，移动性浊音阴性，肠鸣音鸣音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9查体：T36.5，P88次/分，R20次/分，BP1102.1419:00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，BP88/50mmHg。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。102.1419:00患者突发四肢抽搐，伴发热、畏冷、寒战。查11111212Problemlist:SIRSSepsis脓毒症SepticshockInessence,atdifferentstagesoftheonesamedisease13Problemlist:SIRSSepsis脓毒症SeptSIRSsystemicinflammatoryresponsesyndromeGeneralvariablesFever(38.3C)，Hypothermia低体温低体温(coretemperature90/min1ormorethantwosdabovethenormalvalueforageTachypnea呼吸急促呼吸急促（20次次/min,PaCO212,000/L)Leukopenia(WBCcount20ml/kgover24hr)Hyperglycemia高血糖症高血糖症(plasmaglucose140mg/dlor7.7mmol/L)intheabsenceofdiabetesDefinition15SIRSAlteredmentalstatusDefSepsisSIRSissecondarytodocumentedorsuspectedinfection.Sepsis-inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput176.8mol/LAcutelunginjurywithPao2/Fio2（OI）34.2mol/LPLT1.5)Definition16SepsisSIRSissecondarytodocDefinitionSepticshockisdefinedassepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitation.17DefinitionSepticshockisdefiDiagnostic1.Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay(45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厌氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(48hrs)inserted(grade1C).18Diagnostic1.Culturesascli2.diagnosisoffungus真菌infection-Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).葡聚糖试验、半乳甘露聚糖试验3.Imagingstudies、PlasmaC-reactiveprotein（CRP）、Plasmaprocalcitonin（PCT）Contributetoconfirmapotentialsourceofinfection(UG).Diagnostic192.diagnosisoffungus真菌infeRecommendations:SourceControlAntimicrobialTherapyVasopressorsCorticosteroidspAdjunctiveTherapylBloodProductAdministratiolMechanicalVentilationofSepsis-InducedARDslGlucoseControllStressUlcerProphylaxislDeepVeinThrombosisProphylaxislNutritionlRenalReplacementTherapylSedation,Analgesia,andNeuromuscularBlockadeinSepsispEvidence-basedmedicine20Recommendations:SourceControlSourceControl1）recommendcrystalloids晶体液晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock(grade1B).2）addtouseofalbumin白蛋白白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids(grade2C).3）recommendagainsttheuseofhydroxyethylstarches(羟乙基淀粉）forfluidresuscitationofseveresepsisandsepticshock(grade1B).21SourceControl1）recommendcrysSourceControl；achieve30mL/kgofcrystalloidsadministrationQuantity量量MAP、SVV、CO、SBP、HRmonitoringIndex监测指标监测指标CVP8-12mmH2O，MAP65mmHg，Urineoutput0.5ml/kg/h，ScvO270%或SvO265%GoalsforInitialResuscitation(6hrs)复苏目标复苏目标22SourceControl；achieve30mLAntimicrobialTherapy1.Administrationofeffectiveintravenousantimicrobialswithin1sthour2a.Initialempiricanti-infectivetherapyofoneormoredrugs，haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)2b.Antimicrobialregimen抗菌药物组合shouldbereassesseddailyforpotentialde-escalation降阶梯(grade1B)23AntimicrobialTherapy1.AdminiAntimicrobialTherapy3.UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C)24AntimicrobialTherapy3.Useo4.durationoftherapy:7to10daysAntimicrobialTherapyNeutropenicpatients粒缺multidrug-resistantAcinetobacter多重耐药菌不动杆菌Pseudomonasspp铜绿假单胞菌(grade2B)combinationempirictherapyhaveaslowclinicalresponseundrainableociofinfection感染灶无法很好的引流bacteremiawithS.aureus金葡;somefungalandviralinfectionsimmunologicdeficiencies(grade2C)longercourses25AntimicrobialTherapyNeutro5.Antiviraltherapy抗病毒治疗initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin(grade2C).AntimicrobialTherapy26AntimicrobialTherapy26iftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).血管活性药物血管活性药物VasopressorsNorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidence27iftheInitialfluidresuscita1.Norepinephrine（NE）asthefirstchoiceofvasopressor(grade1B).2.Epinephrine(addedtoandsubstitutedfornorepinephrine)(grade2B)whenanadditionalagentisneededtomaintainadequatebloodpressure.3.Vasopressin（0.03IU/min）-tobeaddedtoNE.intent:raiseMAP;decreaseNEdosage;protectrenalfunction(UG).Vasopressors血管活性药物血管活性药物281.Norepinephrine（NE）asthefi4.Dopamine（DA)-analternativevasopressoragenttoNE.(2C)onlyinhighlyselectedpatients(eg.patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心动过缓)Low-dosedopamineshouldnotbeusedrenalprotection(grade1A).Vasopressors血管活性药物血管活性药物294.Dopamine（DA)-analternatiAtrialofdobutamine多巴酚丁胺infusionupto20micrograms/kg/minbeadministeredoraddedtovasopressor(ifinuse)Inthepresenceof:(a)myocardialdysfunction-elevatecardiacfillingpressure,andlowcardiacoutput,(b)hypoperfusion低灌注,despiteachievingadequateintravascularvolumeandadequateMAP(grade1C).Vasopressors血管活性药物血管活性药物30Atrialofdobutamine多巴酚丁胺infCorticosteroids类固醇激素类固醇激素(1)Notusingintravenoushydrocortisone氢化可的松totreatadultsepticshockpatientsifadequatefluidresuscitationandvasopressortherapyareabletorestorehemodynamicstability.Incase,notachievable：hydrocortisone氢化可的松200mgqd.intravenous(grade2A).Whengiven,usecontinuousinfusion(grade2C).iv-p.优于iv.31Corticosteroids类固醇激素(1)Notus（2）NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone(grade2B).（3）reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired(grade2D).（4）Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock(grade1D).Corticosteroids类固醇激素类固醇激素32（2）NotusingtheACTHstimulaAdjunctiveTherapyEmphasizes!BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis33AdjunctiveTherapyEmphasizesBloodProductAdministration血制品的输注血制品的输注（1）recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration(HGB)decreasesto70g/L(grade1B).totargetaHGBof70-90g/L,inmergerofextenuatingcircumstances:(a)myocardialischemia(b)severehypoxemia顽固性低氧血症(c)acutehemorrhageorischemiccoronaryarterydisease34BloodProductAdministration（2）usefreshfrozenplasma新鲜冰冻血浆.Notonlytobecorrectedlaboratoryclottingabnormalitiesbutalsotobeusedinbleedingorplannedinvasiveprocedures(grade2D)；（3）recommendagainstantithrombin凝血酶administration(grade2D).（4）prophylacticallyPlateletsAdministration(grade2D)PLT(10,000/L)intheabsenceofapparentbleeding;PLT(20,000/L)ifthepatienthasasignificantriskofbleeding.（5）notusingEPOasaspecifictreatmentofanemia.BloodProductAdministration血制品的输注血制品的输注35（2）usefreshfrozenplasma新鲜冰notusingintravenousimmunoglobulins(grade2B).HistoryofRecommendationsRegardingUseofRecombinantActivatedProteinC(rhAPC)-nolongeravailable.重组人活性蛋白CNotusingintravenousselenium硒收益收益7.15(grade2B).5%NaHCO3（ml）=(24-HCO3-)*weight/337BicarbonateTherapy碳酸氢盐recommeStressUlcerProphylaxis应激性溃疡预防应激性溃疡预防Stressulcerprophylaxisusingprotonpumpinhibitors(PPI)(grade1B)ratherthanH2receptorantagonists(H2RA)(grade2C).PPI优于H2RAwithoutriskfactorsshouldnotreceiveprophylaxis(grade2B).38StressUlcerProphylaxis应激性溃疡ContinuousRenalReplacementTherapy(CRRT)suggestthatCRRTandIntermittentHemodialysis间断血透areequivalentinpatientswithseveresepsisandacuterenalfailure(grade2B).CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients(grade2D).39ContinuousRenalReplacementTGlucoseControl血糖控制血糖控制1.Startinsulin胰岛素dosingwhentwoconsecutivebloodglucoselevelsare180mg/dL.(grade1A).2.Target：110-180mg/dl3.Monitorbloodglucosevaluesq1hq2hq4h(grade1C).40GlucoseControl血糖控制StartinsuDeepVeinThrombosisProphylaxis深静脉血栓的预防深静脉血栓的预防dailysubcutaneouslow-molecularweightheparin(LMWH)grade1BversusUFHtwicedaily.grade2CversusUFHgiventhricedaily.Ifcreatinineclearanceis30mL/min,werecommenduseofUFH(grade1A).patientswhohaveacontraindication禁忌症toheparinreceivemechanicalprophylactictreatment充气性机械装置(eg,thrombocytopenia血小板减少症,activebleeding,recentintracerebralhemorrhage脑内出血)41DeepVeinThrombosisProphylaxNutrition营养支持营养支持suggestadministeringoralorenteralfeedings肠内营养,astolerated,ratherthaneithercompletefasting禁食orgiveonlyintravenousglucosewithinthefirst48hrs(grade2C).suggestusingintravenousglucoseandenteralnutritionratherthantotalparenteralnutrition(TPN)inthefirst7days(grade2B).Avoidfullcaloricfeedinginthefirstweek,suggestlowdosefeeding(eg,upto500caloriesperday),advancingonlyastolerated(grade2B).42Nutrition营养支持suggestadministMechanicalVentilation机械通气机械通气ofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（1）Targetatidalvolume(潮气量)of6mL/kgpredictedbodyweight（2）initialupperlimitgoalforPlateaupressures(平台压)30cmH2O(grade1B)；（3）Positiveend-expiratorypressure(最低PEEP)beappliedtoavoidalveolarcollapse肺泡塌陷atendexpiration(grade1B).（4）Pronepositioning(俯卧位通气)beusedinsepsis-inducedARDSpatientswithaPao2/Fio2ratio100mmHg(grade2B)；（5）Recruitmentmaneuvers(肺复张)beusedinsepsispatientswithsevererefractoryhypoxemia顽固性低氧血症(grade2C).43MechanicalVentilation机械通气ofMechanicalVentilationofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（6）bemaintainedwiththeheadofthebedelevatedto30-45degreestolimitaspirationrisk误吸andventilator-associatedpneumonia呼吸机相关肺炎(grade1B)；（7）noninvasivemaskventilation无创面罩beusedinthatminorityofpatientsinwhomthebenefitsofNIVhavebeencarefullysonsideredandarethoughttooutweighttherisks(grade2B)；（8）Againsttheroutineuseofthepulmonaryarterycatheter(肺动脉导管)；44MechanicalVentilationofSepsSettingGoalsofCare确立治疗目标确立治疗目标（1）Discussgoalsofcareandprognosiswithpatientsandfamilies(grade1B).将诊断及进一步治疗方案与患者家属沟通（2）Incorporategoalsofcareintotreatmentandend-of-lifecareplanning,utilizingpalliativecareprincipleswhereappropriate(grade1B).包括预后，终止生命的方式以及姑息治疗措施（3）Addressgoalsofcareasearlyasfeasible,butnolaterthanwithin72hoursofICUadmission(grade2C).45SettingGoalsofCare确立治疗目标（1Enhancetheearlierrecognitionofsepsis.Resuscitationassoonaspossible.CareofEvidence-basedmedicineEmphasizesthesignificanceofadjuvanttherapy集束化（BUNDLE）治疗策略update46EnhancetheearlierrecognitioSepsisresucitationbundle初始复苏初始复苏1)Measurelactatelevel2)Obtainbloodculturespriortoadministrationofantibiotics3)Administerbroadspectrumantibiotics广谱抗生素4)Administer30mL/kgcrystalloidforhypotensionorlactate4mmol/L1h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！TOBECOMPLETEDWITHIN3HOURS:47Sepsisresucitationbundle初始复苏Septicshockbundle感染性休克感染性休克1)vasopressorstomaintainMAP65mmHg2)Intheeventofpersistentarterialhypotension顽固性低血压despitevolumeresuscitation(septicshock)orinitiallactate4mmol/L(36mg/dL):-MeasureCVP*-MeasureSCVO2*-Remeasurelactateifinitiallactatewaselevated*TargetsforquantitativeresuscitationincludedintheguidelinesareCVPof8mmH2O,SCVO270%,andnormalizationoflactate.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！TOBECOMPLETEDWITHIN6HOURS:48Septicshockbundle感染性休克1)v2016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：SVV、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update容量反应2016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updateExpoundphysiopathologicmechanismOpportunityofSteroidsandimmunomodulatorydrugs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updateExpo2016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，但对于免疫抑制的患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ExpondphysiopathologicmechanismOpportunityofSteroidsandimmunomodulatorydrugsSIRSCARS532016中国急诊感染性休克临床实践指南update在SIRThank 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+EN54Thankyou！3.确诊严重脓毒症/脓毒症休克7天内建
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