全身性感染及感染性休克

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,全身性感染与感染性休克What is New?,北京协和医院,杜斌,全身性感染(sepsis): 定义,确证或可疑的感染, 以及,某些下列指标,一般指标,炎症指标,血流动力学指标,器官功能不全指标,组织灌注指标,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 定义,一般指标,发热(核心体温 38.3,C),体温过低(核心体温 90 bpm或超过按年龄校正的正常值 2SD,呼吸频数,神志改变,明显水肿或液体正平衡( 20 ml/kg/24 hr),无糖尿病患者出现高血糖( 120 mg/dl),炎症指标,白细胞增加( 12 x 10,9,/L),白细胞缺乏(10%,血浆CRP超过正常值 2SD,血浆PCT超过正常值 2SD,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 定义,血流动力学指标,低血压(SBP 40 mmHg),SvO,2, 3.5 L/min/m,2,器官功能不全指标,低氧血症(PaO,2,/FiO,2, 300),急性少尿( 0.5 mg/dl,凝血障碍(INR 1.5或aPTT 60 sec),肠梗阻(无肠鸣音),血小板缺乏( 4 mg/dl或70 mmol/L),组织灌注指标,高乳酸血症( 1 mmol/L),毛细血管充盈差或皮肤花斑,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 改变定义的原因,诊断标准应当,普遍适用于临床医疗及临床试验,具有较高的敏感性和特异性,避免过于复杂以至难以记忆或应用,采用普遍应用的试验指标,适用于成人, 儿童和新生儿,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 流行病学,Martin GS, Mannino DM, Stephanie Eaton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,全身性感染(sepsis): 流行病学,致病菌,革兰阳性菌,平均每年增加26.3%,真菌,1979年5,231例,2000年16,042例,增加207%,Martin GS, Mannino DM, Stephanie Eaton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,全身性感染(sepsis): 流行病学,Martin GS, Mannino DM, Stephanie Eaton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,全身性感染流行病学: USA 1979 2000,ICD-9有关全身性感染的编码,500家急性病医院,750,000,000住院患者,10,319,418例全身性感染/22年,全身性感染发病率的推算,平均每年增加1.5%; 相当于年增新发病例约22,875例,Angus DC, et al. The epidemiology of severe sepsis in the United States: Analysis of incidence, outcome and associated costs of care.,全身性感染临床试验对照组的病死率,全身性感染与严重全身性感染,国家,年份,发病率,死亡率,病死率,费用,全身性感染,USA,1979,82.7,21.9,26.5%,USA,2000,240.4,43.9,18.3%,严重全身性感染,USA,1995,300,0.86,28.6%,22100,UK,1997,51,24,47%,3801 17963,Australia,2003,77,37.5%,严重全身性感染: 与常见病的比较,National Center for Health Statistics, 2001.,American Cancer Society, 2001.,*American Heart Association. 2000.,Angus DC et al.,Crit Care Med.,2001 (In Press).,严重全身性感染与其他死因,2001年死亡人数,心血管疾病,931,108,恶性肿瘤,553,768,严重全身性感染,215,000,意外,101,537,Alzeimer氏病,53,852,HIV/AIDS,14,175,全身性感染的医疗费用,2000年,ICU医疗费用的40%,欧洲每年花费7,600,000,000,1,美国每年花费$16,700,000,000,2,Davies A et al. Abstract 581. 14th Annual Congress of the European Society of Intensive Care Medicine, Geneva, Switzerland, 30 September-3 October 2001,Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:13031310,Surviving Sepsis Campaign: Why?,过去5年间阳性结果的干预措施,严重全身性感染与感染性休克,EGDT,激素,APC,小潮气量通气策略,危重病患者的一般治疗,镇静,严格血糖控制,脱机方案,严重全身性感染 循证医学指南,干预措施,NNT,小潮气量通气策略,11,早期目标指导治疗,6 8,活化蛋白C,16 (whole trial),8 (APACHE II 25),强化胰岛素治疗,29,ACTH刺激试验无反应者小剂量激素治疗,7,Surviving Sepsis Campaign (SSC) Guidelines for Management of Severe Sepsis and Septic Shock,Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM and the SSC Management Guidelines Committee,Crit Care Med 2004; 32: 858-873,Intensive Care Med 2004; 30: 536-555,available online at,The guidelines were published in both Critical Care Medicine and in,Intensive care Medicine, and are available on-line,Surviving Sepsis CampaignGuidelines For Management OfSevere Sepsis / Septic Shock,The First Revision,A Preliminary Report,Surviving Sepsis Campaign Guideline,最初复苏(initial resuscitation),诊断(diagnosis),抗生素治疗(antibiotic therapy),感染源控制(source control),液体治疗(fluid therapy),升压药物(vasopressors),强心药物(inotropic therapy),激素(steroids),活化蛋白C (recombinant human activated protein C),血液制品(blood product administration),ARDS机械通气(mechanical ventilation of sepsis-induced ALI/ARDS),镇静(sedation, analgesia, and NMB in sepsis),血糖控制(glucose control),肾脏替代(renal replacement),碳酸氢钠(bicarbonate therapy),DVT预防(DVT prophylaxis),应激性溃疡预防(stress ulcer prophylaxis),考虑限制支持治疗水平(consideration for limitation of support),Surviving Sepsis Campaign Guideline,最初复苏(initial resuscitation),诊断(diagnosis),抗生素治疗(antibiotic therapy),感染源控制(source control),液体治疗(fluid therapy),升压药物(vasopressors),强心药物(inotropic therapy),激素(steroids),活化蛋白C (recombinant human activated protein C),血液制品(blood product administration),ARDS机械通气(mechanical ventilation of sepsis-induced ALI/ARDS),镇静(sedation, analgesia, and NMB in sepsis),血糖控制(glucose control),肾脏替代(renal replacement),碳酸氢钠(bicarbonate therapy),DVT预防(DVT prophylaxis),应激性溃疡预防(stress ulcer prophylaxis),考虑限制支持治疗水平(consideration for limitation of support),推荐意见的评级系统,推荐级别,至少两项I级研究支持,一项I级研究支持,仅有II级研究支持,至少一项III级研究支持,IV或V级研究支持,证据级别,结果明确的大规模随机临床试验; 假阳性或假阴性错误危险小,结果不确定的小规模随机临床试验; 假阳性或假阴性错误危险中等,非随机同期对照,非随机历史对照及专家意见,病例报告, 非对照研究及专家意见,Sackett DL. Chest 1989; 95: 2S-4S,Sprung CL, Bernard GR, Dellinger RP. Intensive Care Med 2001; 27(Suppl): S1-S2,推荐意见的评级系统 GRADE,证据的质量,评估指标,试验设计,一致性,直接性(对所研究的问题),偏倚的报告,评估级别,A 高质量,B 中等质量,C 低质量,D 极低质量,推荐的强度,1: 强烈推荐,方法学缺陷较少,作用较大,副作用较少,2: 一般推荐,方法学缺陷较多,评价不确切,作用较小,明显增加危害, 工作负担, 医疗费用,Surviving Sepsis Campaign Guideline推荐意见(n = 46),最初的复苏治疗,发生全身性感染诱发的低血压时,低血压,乳酸酸中毒,乳酸清除率与感染性休克预后,乳酸清除率 =,(乳酸,ED Presentation, 乳酸,Hour 6,) x 100,乳酸,ED Presentation,严重全身感染与感染性休克预后的独立危险因素,乳酸清除率OR 0.989,95%CI 0.978 0.999,p = .04,Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004; 32:1637-1642.,隐性低灌注与创伤预后,The Golden Hour and the Silver Day,入选标准:,成年创伤患者,存活时间 24小时,ISS, 20,血流动力学稳定,SBP 100,HR 1 mL/kg/h,乳酸 2.5 mmol/L或其他灌注不足表现,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,隐性低灌注与创伤预后,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,严重创伤患者两次LA 2.5,输注液体或血液制品,重复LA 2.5,Swan-Ganz, 动脉插管, 肾脏剂量多巴胺,将PCWP提高到12 15,将Hct提高到30%,重复LA 2.5,升压药物(多巴酚丁胺),心脏超声检查,若LA仍 2.5,隐性低灌注与创伤预后,Blow O, Magliore L, Claridge J, Butler K, Young J.,The Golden Hour and the Silver Day: Detection and Correction of Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. J Trauma 1999; 47(5): 964,全身性感染的诊断,适当的培养,至少留取2个血培养,1个外周血培养,每个留置, 48 h的血管通路留取1个血培养,(Grade D),抗生素治疗前后血培养的阳性率,139名患者,抗生素治疗前,抗生素治疗过程中,开始抗生素治疗,83名患者(60%)血培养阴性或分离出污染菌,0/83 (0%)分离到致病菌,56名患者(40%)分离到致病菌,26/56 (45%)分离到致病菌,25名患者(45%)分离到致病的葡萄球菌,19/25 (76%)分离到葡萄球菌,14名患者(25%)分离到致病的链球菌,5/14 (36%)分离到链球菌,17名患者(30%)分离到革兰阴性杆菌,2/17 (12%)分离到革兰阴性杆菌,1/139 (0.72%)分离到新的致病菌,Grace CJ, Lieberman J, Pierce K, et al. Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy. Clin Infect Dis 2001; 32: 1651-5,临床意义,应用抗生素前进行血培养分离到致病菌的可能性增加2.2倍,在开始抗生素治疗最初72小时内, 连续进行血培养的结果, 可以根据应用抗生素前血培养的结果预测,极少分离到新的致病菌,医生可以等待应用抗生素前的血培养结果回报后, 再进行新的血培养,Grace CJ, Lieberman J, Pierce K, et al. Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy. Clin Infect Dis 2001; 32: 1651-5,抗生素治疗,确诊严重全身性感染后1小时内开始静脉抗生素治疗,1C,(Grade E),早期应用抗生素与感染患者病死率,Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596,早期应用抗生素与感染患者病死率,Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596,持续低血压或乳酸, 4 mmol/L,最初的复苏治疗,最初6小时内达到的目标,CVP 8 12 mmHg,MAP, 65 mmHg,UO 0.5 ml/kg/hr,ScvO,2, 70%,1B,(Grade B),感染性休克: 灌注压与组织灌注,MAP 65,MAP 75,MAP 85,F/LT,尿量(ml),49,18,56,21,43,13,.60/.71,毛细血管血流(ml/min/100 g),6.0,1.6,5.8,1.1,5.3,0.9,.59/.55,红细胞速度(au),0.42,0.06,0.44,0.16,0.42,0.06,.74/.97,PiCO,2,(mmHg),41,2,47,2,46,2,.11/.12,Pa PiCO,2,(mmHg),13,3,17,3,16,3,.27/.40,LeDoux, Astiz ME, Carpati CM, Rackow ED. Effects of perfusion pressure on tissue perfusion in septic shock.,Crit Care Med,2000; 28:2729-2732,影响感染性休克预后的循环指标,目的: 确定与预后相关的血流动力学指标的适当阈值,设计: 回顾性队列研究,1999 2002年, 治疗的最初48小时, 分析6和48小时,结果:,病死率33%,单因素分析及逻辑回归分析,入院时的MAP和乳酸水平,48小时的MAP, SvO,2, 70%以及CVP平均值,MAP 65 mmHg, SvO,2,70%,AUC最大,Varpula M, Tallgren M, Saukkonen K, et al. Hemodynamic variables related to outcome in septic shock. Intensive Care Med 2005; 31(8): 1066-1071,影响感染性休克预后的循环指标,逻辑回归,ROC分析,p,Exp(B),AUC,95%CI,MAP,0.013,1.156,0.841,0.761 0.921,AUC SvO,2, 34,g/dl或上升, 9 ,g/dl,血浆皮质醇 15,g/dl或上升 9,g/dl,全身性感染: 相对性肾上腺皮质功能不全(RAI),相对性肾上腺皮质功能不全的患病率(%),全身性感染或ALI-ARDS,16.3 55.0,感染性休克,39.4 66.7,CORTICUS,50,相对性肾上腺皮质功能不全与病死率,T0时血浆皮质醇(,g/dl),max (g/dl),病死率, 9,26%,= 34, 34, 9,67%, 34, 9,82%,Annane D, Sbille V, Troch G, et al.: A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000, 283:1038-1045,感染性休克的激素替代治疗,入选标准,明确的感染灶,休克发生 38.3,C或 90 bpm,SBP 5 g/kg/min)或NE或Epi,UO 0.5 ml/kg/hr x 1 hr或PaO,2,/FiO,2, 2 mmol/L,机械通气,治疗,治疗组,氢化可的松50 mg iv q6h,9-,-氟氢可的松50 g qd,安慰剂组,疗程7天,Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71.,感染性休克的激素替代治疗,No. (%),指标,安慰剂,激素,校正OR (95%CI),P值,无反应者,患者数,115,114,28天病死率,73 (63),60 (53),0.54 (0.31 0.97),.04,ICU病死率,81 (70),66 (58),0.50 (0.28 0.89),.02,住院病死率,83 (72),70 (61),0.53 (0.29 0.96),.04,1年病死率,88 (77),77 (68),0.57 (0.31 1.04),.07,反应者,患者数,34,36,28天病死率,18 (53),22 (61),0.97 (0.32 2.99),.96,ICU病死率,20 (59),24 (67),0.99 (0.31 3.16),.99,住院病死率,20 (59),25 (69),1.20 (0.38 3.76),.75,1年病死率,24 (71),25 (69),0.70 (0.20 2.40),.57,Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71.,感染性休克的激素替代治疗,病例数 (%),指标,安慰剂,激素,校正OR (95%CI),P值,所有患者,患者数,150,149,28天病死率,91 (61),82 (55),0.65 (0.39 1.07),.09,ICU病死率,101 (68),90 (60),0.61 (0.37 1.02),.06,住院病死率,103 (69),95 (63),0.67 (0.40 1.12),.12,1年病死率,112 (75),102 (68),0.62 (0.36 1.05),.08,Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71.,感染性休克的激素替代治疗,Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288: 862-71.,激素与感染: 尚待阐明的问题,患者选择,严重感染 vs. 感染性休克,用药时机,发病 8小时 vs. 72小时,激素疗程,是否减量,预后指标,休克逆转 vs. 病死率,激素骤停可使细胞因子增加,Keh D, Boehnke T, Weber-Cartens S, et al. Immunologic and hemodynamic effects of low-dose hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med. 2003;167:512-520,重组人活化蛋白C,死亡高危,APACHE II, 25,感染诱发的多器官功能衰竭,感染性休克,感染诱发的ARDS,无绝对禁忌症,权衡相对禁忌症,(Grade B),全身性感染: 活化蛋白C,Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.,安慰剂,(n = 840),活化蛋白C,(n = 850),绝对病死率下降6.1%,主要分析结果,双尾P值,0.005,校正后的相对危险度降低,19.4%,存活比数增加,38.1%,全身性感染: 活化蛋白C,Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.,APACHE II四分位与病死率,Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.,26:33,57:49,58:48,118:80,衰竭脏器数目与病死率,Bernard GR, Vincent JL, Laterre PF, et al. Drotrecogin alfa (activated) (recombinant human activated protein C) for the treatment of severe sepsis. Crit Care Med 2003; 31Suppl: S85-S90.,全身性感染: 活化蛋白C,PROWESS,Randomized, double-blinded, placebo-controlled,Known or suspected infection, SIRS criteria,3; organ dysfunction,1,28-day mortality rate: 30.8% vs.24.7% (p = 0.005),ADDRESS,Randomized, double-blinded, placebo-controlled,Severe sepsis, APACHE II 25, or single-organ failure,28-day mortality rate: 17.0% vs. 18.5% (p = 0.34),ENHANCE,Single-arm, open-label,Known or suspected infection, SIRS criteria,3; organ dysfunction,1,28-day mortality rate: 25.3%,全身性感染: 活化蛋白C,Wiedermann CJ, Kaneider NC.,A meta-analysis of controlled trials of recombinant human activated protein C therapy in patients with sepsis.,BMC Emergency Medicine 2005;,5,: 7,全身性感染: 活化蛋白C,Eichacker PQ, Danner RL, Suffredini AF, Cui X, Natanson C. Reassessing recombinant human activated protein C for sepsis: Time for a new randomized controlled trial. Crit Care Med 2005; 33(10): 2426-2428,全身性感染: 活化蛋白C,Eichacker PQ, Danner RL, Suffredini AF, Cui X, Natanson C. Reassessing recombinant human activated protein C for sepsis: Time for a new randomized controlled trial. Crit Care Med 2005; 33(10): 2426-2428,血糖控制,病情稳定后,血糖 150 mg/dL,持续输注胰岛素和葡萄糖,监测,最初每30 60分钟,稳定后q4h,(Grade D),血糖控制,血糖控制非常重要,最初病情稳定后,静脉输注胰岛素,1B,目标范围?,血糖 150 mg/dL,2C,血糖控制方案,2C,葡萄糖热卡及监测,1B,外科患者的强化胰岛素治疗,高血糖与胰岛素抵抗现象十分普遍,伴有AMI的糖尿病患者, 控制血糖水平 215 mg/L, 长期预后得以显著改善,1, 2,van den Berghe等人对1548名危重病患者进行了随机对照试验, 以评价强化胰岛素治疗及传统血糖控制方法对危重病患者的影响,3,Malmberg K. BMJ1997; 314: 1512-5,Malmberg K. Circulation 1999; 99: 2626-2632,Van den Berghe G, et al. N Engl J Med 2001; 345: 1359-1367,外科患者的强化胰岛素治疗,试验设计,入住外科ICU的机械通气患者,所有患者接受200 300 g葡萄糖/天,入ICU当日TPN总热卡的60 80%为葡萄糖提供,对照组: 控制血糖180 200 mg/dl,治疗组: 控制血糖80 110 mg/dl,Van Den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345:1359-1367,外科患者的强化胰岛素治疗,至随访第12个月, 强化胰岛素治疗可以降低病死率3.4% (p 0.04),强化胰岛素治疗还可以,住院病死率, 34%,血行性感染率 46%,需要肾脏替代治疗的急性肾功能衰竭 41%,输血的中位数 50%,Van Den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345:1359-1367,危重病患者的强化胰岛素治疗,平均血糖水平下降,152.3 vs. 130.7 mg/dL (P 2501.62 (1.01 2.60),Krinsley,持续肾脏替代治疗14,Pittas,胰岛素治疗3.4 (1.9 6.3),糖尿病史,全身性感染,Sepsis Resuscitation Bundle,(应在最初6小时内达到),测定血清乳酸水平,应用抗生素前留取血培养,入急诊室3小时或入ICU1小时内应用抗生素,低血压和(或)乳酸 4 mmol/L (36 mg/dl)时:,最初应用晶体液至少20 ml/kg(或等量的胶体液),最初液体复苏无效时应用升压药物以维持MAP 65 mmHg,经过液体复苏后仍持续低血压(感染性休克)和(或)乳酸 4 mmol/L (36 mg/dl):,使CVP 8 mmHg,使ScvO,2, 70%,Sepsis Resuscitation Bundle,(应在最初6小时内达到),B.,测定血清乳酸水平,D.,应用抗生素前留取血培养,E.,入急诊室3小时或入ICU1小时内应用抗生素,E.,低血压和(或)乳酸 4 mmol/L (36 mg/dl)时:,最初应用晶体液至少20 ml/kg(或等量的胶体液),最初液体复苏无效时应用升压药物以维持MAP 65 mm Hg,B.,经过液体复苏后仍持续低血压(感染性休克)和(或)乳酸 4 mmol/L (36 mg/dl):,使CVP 8 mm Hg,使ScvO,2, 70%,Sepsis Management Bundle,(应在最初24小时内达到),对感染性休克患者根据ICU标准化规定应用小剂量激素,根据ICU标准化规定应用活化蛋白C,控制血糖水平,正常值下限, 且 150 mg/dl (8.3 mmol/L),维持机械通气患者吸气平台压力 30 cmH,2,O,Sepsis Management Bundle,(应在最初24小时内达到),C.,对感染性休克患者根据ICU标准化规定应用小剂量激素,B.,根据ICU标准化规定应用活化蛋白C,D.,控制血糖水平,正常值下限, 且 150 mg/dl (8.3 mmol/L),B.维持机械通气患者吸气平台压力 30 cmH,2,O,Surviving Sepsis Campaign Initial ResultsReporting the Gap betweenPerception and Practice,What We,Think,We Do,vs.,What We,Actually,Do,ARDS保护性通气策略 ARDSnet,小潮气量,传统潮气量,P值,患者数,387,405,NA,Vt (ml/kg),6.2,0.9,11.8,0.8, .05,Pplat (cmH,2,O),25, 7,33, 9, .05,PIP (cmH,2,O),32, 8,39, 10, .05,RR (bpm),29, 7,16, 6, .05,MV (lpm),12.9, 3.6,12.6, 4.5,NS,PEEP (cmH,2,O),9.4, 3.6,8.6, 3.6, .05,PaO,2,/ FiO,2,158, 73,176, 76, .05,PaO,2,(mmHg),76, 23,77, 19,NS,PaCO,2,(mmHg),40, 10,35, 8, .05,pH,7.38,0.08,7.41, 0.07, .05,The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.,N Engl J Med,2000; 342:1301-1308,ARDS保护性通气策略 ARDSnet,The Acute Respiratory Distress Syndrome Network: Ventilation with low