感染性休克指南解读宣讲培训ppt课件

感染性休克指南解读宣讲感染性休克指南解读宣讲1Indexcase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2感染性休克指南解读宣讲Indexcase查体：T37.5，P88次/分，R192Baseline（6.29）（7.3）WBC6.104.54N%51.449.5Lac/PH/TB67.256.5ALB24.530.4ALT2935CHE11971281Cr74.675GRR56.8358.11CRP9.2614.22PCT12PH/7.25TB67.256.546.9ALB24.530.425.7ALT293531CHE11971281772Cr74.675121.1212.6GRR56.8358.11CRP9.2614.2213.2822.92PCT5000Pro-BNP168/4100INR1.531.532.19culturesEscherichiacoli(+)*25感染性休克指南解读宣讲WBC6.104.542.055.65N%51.449.55IndexcaseName: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6感染性休克指南解读宣讲IndexcaseName:ChenYiMing6Indexcase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。7感染性休克指南解读宣讲Indexcase既往史：有高血压病10余年，不规则服用7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8感染性休克指南解读宣讲查体：T36.5，P88次/分，R20次/分，BP1108门诊门诊（2.14）变症变症（2.14）WBC12.4411.89N11.3010.86N%90.891.4Cr83.3CRP120PCT10Pro-BNP4800INR1.432.1419:00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。9感染性休克指南解读宣讲WBC12.4411.89N11.3010.86N%910感染性休克指南解读宣讲10感染性休克指南解读宣讲1011感染性休克指南解读宣讲11感染性休克指南解读宣讲11Problemlist:Inessence,atdifferentstagesoftheonesamedisease12感染性休克指南解读宣讲Problemlist:Inessence,atdi12SIRSsystemicinflammatoryresponsesyndromeGeneralvariablesFever(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)intheabsenceofdiabetesDefinition14感染性休克指南解读宣讲SIRSAlteredmentalstatusDef14SepsisSIRSissecondarytodocumentedorsuspectedinfection.Sepsis-inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput176.8mol/LAcutelunginjurywithPao2/Fio2（OI）34.2mol/LPLT1.5)Definition15感染性休克指南解读宣讲SepsisSIRSissecondarytodoc15DefinitionSepticshockisdefinedassepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitation.16感染性休克指南解读宣讲DefinitionSepticshockisdefi16Diagnostic1.Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay(45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厌氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(48hrs)inserted(grade1C).17感染性休克指南解读宣讲Diagnostic1.Culturesascli172.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).Diagnostic18感染性休克指南解读宣讲2.diagnosisoffungus真菌infe18Recommendations:lSourceControllAntimicrobialTherapylVasopressorslCorticosteroidspAdjunctiveTherapylBloodProductAdministratiolMechanicalVentilationofSepsis-InducedARDslGlucoseControllStressUlcerProphylaxislDeepVeinThrombosisProphylaxislNutritionlRenalReplacementTherapylSedation,Analgesia,andNeuromuscularBlockadeinSepsispEvidence-basedmedicine19感染性休克指南解读宣讲Recommendations:SourceControl19SourceControl1）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).20感染性休克指南解读宣讲SourceControl1）recommendcrys20SourceControl；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21感染性休克指南解读宣讲SourceControl；achieve30mL21AntimicrobialTherapy1.Administrationofeffectiveintravenousantimicrobialswithin1sthour2a.Initialempiricanti-infectivetherapyofoneormoredrugs，haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)2b.Antimicrobialregimen抗菌药物组合shouldbereassesseddailyforpotentialde-escalation降阶梯(grade1B)22感染性休克指南解读宣讲AntimicrobialTherapy1.Admini22AntimicrobialTherapy3.UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C)23感染性休克指南解读宣讲AntimicrobialTherapy3.Useo234.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)longercourses24感染性休克指南解读宣讲AntimicrobialTherapyNeutro245.Antiviraltherapy抗病毒治疗initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin(grade2C).AntimicrobialTherapy25感染性休克指南解读宣讲AntimicrobialTherapy25感染性休克指25iftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).血管活性药物血管活性药物VasopressorsNorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidenceOutcomesAssumedriskCorrespondingriskRelativeeffectNo.ofparticipantsDANE0.91(0.83to0.99)2043(6studies)Short-termmortality530/1000482/1000(440to524)supraventriculararrhythmias229/100082/1000(34to195)0.47(0.38to0.58)1931(2studies)ventriculararrhythmias39/100015/1000(8to27)0.35(0.19to0.66)1931(2studies)26感染性休克指南解读宣讲iftheInitialfluidresuscita261.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27感染性休克指南解读宣讲1.Norepinephrine（NE）asthefi274.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28感染性休克指南解读宣讲4.Dopamine（DA)-analternati28Atrialofdobutamine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29感染性休克指南解读宣讲Atrialofdobutamine多巴酚丁胺inf29Corticosteroids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.30感染性休克指南解读宣讲Corticosteroids类固醇激素(1)Notus30（2）NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone(grade2B).（3）reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired(grade2D).（4）Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock(grade1D).Corticosteroids类固醇激素类固醇激素31感染性休克指南解读宣讲（2）NotusingtheACTHstimula31AdjunctiveTherapyEmphasizes!BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis32感染性休克指南解读宣讲AdjunctiveTherapyEmphasizes32BloodProductAdministration血制品的输注血制品的输注u（1）recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration(HGB)decreasesto70g/L(grade1B).utotargetaHGBof70-90g/L,inmergerofextenuatingcircumstances:(a)myocardialischemia(b)severehypoxemia顽固性低氧血症(c)acutehemorrhageorischemiccoronaryarterydisease33感染性休克指南解读宣讲BloodProductAdministration33（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34感染性休克指南解读宣讲（2）usefreshfrozenplasma新鲜冰34notusingintravenousimmunoglobulins(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/336感染性休克指南解读宣讲BicarbonateTherapy碳酸氢盐recomme36StressUlcerProphylaxis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).37感染性休克指南解读宣讲StressUlcerProphylaxis应激性溃疡37ContinuousRenalReplacementTherapy(CRRT)suggestthatCRRTandIntermittentHemodialysis间断血透areequivalentinpatientswithseveresepsisandacuterenalfailure(grade2B).CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients(grade2D).38感染性休克指南解读宣讲ContinuousRenalReplacementT38感染性休克指南解读宣讲培训ppt课件39DeepVeinThrombosisProphylaxis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)40感染性休克指南解读宣讲DeepVeinThrombosisProphylax40Nutrition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).41感染性休克指南解读宣讲Nutrition营养支持suggestadminist41MechanicalVentilation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).42感染性休克指南解读宣讲MechanicalVentilation机械通气of42MechanicalVentilationofSepsis-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)；43感染性休克指南解读宣讲MechanicalVentilationofSeps43SettingGoalsofCare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).44感染性休克指南解读宣讲SettingGoalsofCare确立治疗目标（144Enhancetheearlierrecognitionofsepsis.Resuscitationassoonaspossible.CareofEvidence-basedmedicineEmphasizesthesignificanceofadjuvanttherapy集束化（BUNDLE）治疗策略update45感染性休克指南解读宣讲Enhancetheearlierrecognitio45Sepsisresucitationbundle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:46感染性休克指南解读宣讲Sepsisresucitationbundle初始复苏46Septicshockbundle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:47感染性休克指南解读宣讲Septicshockbundle感染性休克1)v472016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update48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update49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492016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502016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。MODS51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updateExpo512016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ExpondphysiopathologicmechanismOpportunityofSteroidsandimmunomodulatorydrugsSIRSCARS52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SIR52Thank 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+EN53感染性休克指南解读宣讲Thankyou！3.确诊严重脓毒症/脓毒症休克7天内建53