脓毒症及脓毒性休克-课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Sepsis and Septic Shock,脓毒症及脓毒性休克,Sepsis and Septic Shock脓毒症及脓毒,Definitions,Systemic Inflamatory Response Syndrome (SIRS):,The systemic inflammatory response to a variety of severe clinical insults (For example, infection).,Clinically recognized by the presence of,2 or more,of the following:,Temperature 38,o,C or 90bpm,Respiratory Rate 20bpm or PaCO2 12,000, 10% immature forms,DefinitionsSystemic Inflamato,Definitions,Sepsis,：,SIRS criteria,plus,evidence of infection, or:,White cells in normally sterile body fluid,Perforated viscus,Radiographic evidence of pneumonia,Syndrome associated with a high risk of infection,DefinitionsSepsis：,脓毒症及脓毒性休克-课件,Definitions,Severe Sepsis,:,Sepsis,plus,1 organ dysfunction.,MODS.,Septic Shock:,sepsis with hypotension despite adequate fluid resuscitation, with perfusion abnormalities that could include, but are not limited to, lactic acidosis, oliguria, and/or acute mental status.,DefinitionsSevere Sepsis:,Definitions,Severe Sepsis,:,Sepsis criteria + evidence of organ dysfunction, including:,CV: Systolic BP,90 mmHg, MAP,70 mm Hg for at least 1 hour despite volume resuscitation, or the use of vasopressors.,Renal: Urine output 0.5 ml/kg body weight/hr for 1 hour despite volume resuscitation,Pulmonary: PaO2/FiO2,250 if other organ dysfunction present or,200 if the lung is the only dysfunctional organ.,Hematologic: Platelet count,80K or decreased by 50% in 3 days,Metabolic: pH, 1.5 x upper normal,DefinitionsSevere Sepsis:,Definitions,Infection,:,microbial phenomenon characterised by an inflammatory response to the presence of micro organisms or the invasion of normally sterile host tissue by these organisms,Bacteraemia,: the presence of bacteria in the bloodstream,DefinitionsInfection: microbia,SIRS and Sepsis,SIRS: Systemic Inflammatory Response Syndrome,Fever, leucocytosis, organ failure,Recognises difficulty of always identifying infection, but,As a result, high sensitivity but low specificity,SIRS and SepsisSIRS: Systemic,N Engl J Med 2015;372:1629-38.,Of 1,171,797 patients, a total of 109,663 had infection and organ failure. Among these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%),had SIRS-negative severe sepsis.,N Engl J Med 2015;372:1629-38.,Infection,Parasite,Virus,Fungus,Bacteria,Trauma,Burns,Sepsis,SIRS,Severe,Sepsis,Severe,SIRS,shock,BSI,InfectionParasiteVirusFungusBa,脓毒症及脓毒性休克-课件,Epidemiology,Epidemiology,2002,年目标：,5,年内死亡率降低,25%,2012,年现实：严重脓毒症的病死率,30-70%,2002年目标：5年内死亡率降低25%2012年现实：严重脓,脓毒症及脓毒性休克-课件,Crit Care Med. 2014 Mar; 42(3): 625631,Crit Care Med. 2014 Mar; 42(3),“,Severe Sepsis” is the leading cause of death in (non coronary) ICU,11th leading cause of death overall,More than 750,000 cases of severe sepsis in US annually.,In the US, more than 500 patients die of severe sepsis daily,In European ICUs, sepsis and severe sepsis occur in 30% and 37% of the patients,severe sepsis as the third most common cause of death in the United States after heart disease and malignant tumors,Why worry about sepsis?,“Severe Sepsis” is the leading,Epidemiology,Sepsis consumes significant healthcare resources.,Sepsis accounts for 40% ICU expenditures,In a study of Patients who contract nosocomial infections, develop sepsis and survive:,ICU stay prolonged an additional 8 days.,Additional costs incurred were $40,890/ patient.,EpidemiologySepsis consumes si,sepsis is becoming more common, especially in the hospital, as a result of:,Medical and technological advances associated with treatments,The increasing number of elderly or debilitated people, and patients with underlying diseases such as cancer, who require therapy,The widespread use of antibiotics, which encourages the growth of drug-resistant microorganisms,Epidemiology,sepsis is becoming more common,Martin et al: N Engl J Med 2003:348:1546,Martin et al: N Engl J Med 200,US National Centre Health Statistics June 2011,US National Centre Health Stat,Martin et al: N Engl J Med 2003:348:1546,Martin et al: N Engl J Med 200,Epidemiology,Mortality,Sepsis: 30% - 50%,Septic Shock: 50% - 60%,EpidemiologyMortality,Mortality,：,1. Inferior AMI 5%,2. Trauma ISS 16-24 7%,3. GIH + low BP 11%,4. Septic Shock 25%,5. Severe DKA 45 minutes) in antimicrobial administration.,To optimize identication of causative organisms, we recommend at least two blood cultures be obtained before antibiotics with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (48 hrs) inserted.,Get 10mLperdraw.,MANAGEMENT OF SEVERE SEPSIS,Diagnosis,We recommend obtaining appropr,Cultures of other sites (preferably quantitative where appropriate), such as urine, cerebrospinal uid, wounds, respiratory secretions, or other body uids that may be the source of infection should also be obtained before antibiotic therapy if not associated with signicant delay in antibiotic administration (grade 1C).,We recommend that imaging studies be performed promptly in attempts to conrm a potential source of infection. Sampling of potential sources of infection should occur as they are identied; however, some patients may be too unstable to warrant certain invasive procedures or transport outside of the ICU. Bedside studies, such as ultrasound, are useful in these circumstances (grade 1C).,MANAGEMENT OF SEVERE SEPSIS,Diagnosis,Cultures of other sites (prefe,If the blood culture drawn from the vascularaccess device turns positive 2 hoursbefore the peripheral blood,culture,data supports that the vascular access device is the source of the infection.,We suggest the use of the 1,3 beta-D-glucan assay (2B), mannan and anti-mannan antibody assays for the early diagnosis of invasive candidiasis (Grade 2C),MANAGEMENT OF SEVERE SEPSIS,Diagnosis,If the blood culture drawn,Antibiotic Therapy,MANAGEMENT OF SEVERE SEPSIS,Antibiotic TherapyMANAGEMENT O,Initial empiricbroadspectrum antimicrobial therapy(selected to coverall suspectedorganism) within1 hour,after recognition of septic shockand severe sepsis withoutseptic shock,Mortality rises everyhour withoutantimicrobials,MANAGEMENT OF SEVERE SEPSIS,Antibiotic Therapy,Initial empiricbroadspectru,We recommend that intravenous antibiotic therapy be started as early as possible and within the rst hour of recognition of septic shock (1B) and severe sepsis without septic shock (1D).,Appropriate cultures should be obtained before initiating antibiotic therapy but should not prevent prompt administration of antimicrobial therapy (grade 1D).,MANAGEMENT OF SEVERE SEPSIS,Antibiotic Therapy,We recommend that intravenous,We recommend that initial empirical anti-infective therapy include one or more drugs that have activity against all likely pathogens (bacterial and/or fungal) and that penetrate in adequate concentrations into the presumed source of sepsis (grade 1B).,We recommend that the antimicrobial regimen be reassessed daily to optimize activity,