2012+2016感染性休克指南解读.ppt

2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016中国急诊感染性休克临床实践指南 Speaker CaiHanThe1stAffiliatedHospitalofFujianMedicalUniversity Indexcase Name SunZuYuAge 63yearsSex femaleID 0680716admissiontime 2015 06 29 2015 07 06主诉 repeatedfatigue13years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 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 1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 肝硬化 收住入院 Indexcase 查体 T37 5 P88次 分 R19次 分 BP125 68mmHg 神志清楚 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 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3次 分 双下肢轻度浮肿 初步诊断 1 肝硬化失代偿期 胆汁淤积性 2 高血压病3 慢性胆囊炎治疗方案 思美泰 易善复 天晴甘美 保肝前列地尔 改善肝内循环螺内酯 利尿 肺部CT 上腹部MRI 增强 Indexcase Name ChenYiMingAge 75yearsSex maleID Madmissiontime 2016 02 14 2016 02 17主诉 suddenfeverandshiver6hours现病史 入院前6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 查血常规提示WBC12 44 109 L N11 30 109 L N 90 8 急诊生化 AST123U L 糖9 73mmol L 肺部CT 双肺炎症 Indexcase 既往史 有高血压病10余年 不规则服用 安内真 氯沙坦 双克 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 反流性食管炎 1级 慢性浅表性胃炎 2级 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 前列腺增生症 膀胱多发结石 双肾囊肿 行 经尿道前列腺切除术 膀胱切开取石术 术后无再出现排尿困难 3月前因反复腹痛20天就诊我院 诊断 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 查体 T36 5 P88次 分 R20次 分 BP110 65mmHg 神清 精神疲乏 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 全腹部无压痛 无反跳痛 Murphy征阴性 肝脾未触及 移动性浊音阴性 肠鸣音3次 分 双下肢无水肿 初步诊断 1 肺炎2 高血压病3 脂肪肝4 胆囊结石伴慢性胆囊炎5 反流性食管炎6 慢性胃炎7 单纯性肾囊肿8 前列腺增生9 颈动脉硬化10 手术后状态 经尿道前列腺电切术 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 沐舒坦祛痰 薄芝糖肽提高免疫力 易善复保肝及补液营养支持 2 1419 00患者突发四肢抽搐 伴发热 畏冷 寒战 查体 T38 5 P100次 分 R22次 分 BP88 50mmHg 神志欠清 双下肢皮肤花斑样改变 右侧乳头至脐水平广泛压痛 双肺呼吸音粗 双下肺有闻及少许湿性啰音 心律齐 无杂音 Morphy征可疑阳性 肠鸣音3次 分 双下肢无水肿 Problemlist Inessence atdifferentstagesoftheonesamedisease SIRS systemicinflammatoryresponsesyndromeGeneralvariablesFever 38 3 C Hypothermia低体温 coretemperature90 min 1ormorethantwosdabovethenormalvalueforageTachypnea呼吸急促 20次 min PaCO212 000 L Leukopenia WBCcount 4000 L NormalWBCcountwithgreaterthan10 immatureforms Definition SIRS Alteredmentalstatus Significantedemaorpositivefluidbalance 20ml kgover24hr Hyperglycemia高血糖症 plasmaglucose 140mg dlor7 7mmol L intheabsenceofdiabetes Definition Sepsis SIRSissecondarytodocumentedorsuspectedinfection Sepsis inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput176 8 mol LAcutelunginjurywithPao2 Fio2 OI 34 2 mol LPLT1 5 Definition Definition Septicshockisdefinedassepsis inducedhypotensionpersistingdespiteadequatefluidresuscitation Diagnostic 1 Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay 45mins inthestartofantimicrobial s grade1C Atleast2setsofbloodcultures bothaerobic需氧andanaerobic厌氧bottles beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice unlessthedevicewasrecently 48hrs inserted grade1C 2 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 Diagnostic Recommendations SourceControlAntimicrobialTherapyVasopressorsCorticosteroids AdjunctiveTherapy BloodProductAdministratioMechanicalVentilationofSepsis InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation Analgesia andNeuromuscularBlockadeinSepsis Evidence basedmedicine SourceControl 1 recommendcrystalloids晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock grade1B 2 addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids grade2C 3 recommendagainsttheuseofhydroxyethylstarches 羟乙基淀粉 forfluidresuscitationofseveresepsisandsepticshock grade1B SourceControl AntimicrobialTherapy 1 Administrationofeffectiveintravenousantimicrobialswithin1sthour2a Initialempiricanti infectivetherapyofoneormoredrugs haveactivityagainstalllikelypathogens bacterialand orfungalorviral grade1B 2b Antimicrobialregimen抗菌药物组合shouldbereassesseddailyforpotentialde escalation降阶梯 grade1B AntimicrobialTherapy 3 UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic buthavenosubsequentevidenceofinfection grade2C 4 durationoftherapy 7to10days AntimicrobialTherapy 5 Antiviraltherapy抗病毒治疗initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin grade2C AntimicrobialTherapy iftheInitialfluidresuscitationdidnottargetameanarterialpressure MAP of65mmHg Vasopressortherapycanbeadded grade1C 血管活性药物Vasopressors NorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidence 1 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 4 Dopamine DA analternativevasopressoragenttoNE 2C onlyinhighlyselectedpatients eg patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心动过缓 Low dosedopamineshouldnotbeusedrenalprotection grade1A Vasopressors血管活性药物 Atrialofdobutamine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 Corticosteroids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 2 NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone grade2B 3 reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired grade2D 4 Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock grade1D Corticosteroids类固醇激素 AdjunctiveTherapyEmphasizes BloodProductAdministratioMechanicalVentilationofSepsis InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation Analgesia andNeuromuscularBlockadeinSepsis BloodProductAdministration血制品的输注 1 recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration HGB decreasesto 70g L grade1B totargetaHGBof70 90g L inmergerofextenuatingcircumstances a myocardialischemia b severehypoxemia顽固性低氧血症 c acutehemorrhageorischemiccoronaryarterydisease 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 notusingintravenousimmunoglobulins grade2B HistoryofRecommendationsRegardingUseofRecombinantActivatedProteinC rhAPC nolongeravailable 重组人活性蛋白CNotusingintravenousselenium硒收益 风险 Immunoglobulins免疫球蛋白 BicarbonateTherapy碳酸氢盐 recommendagainsttheuseofsodiumbicarbonatetherapyforthepurposeofimprovinghemodynamicsorreducingvasopressorrequirementsinpatientswithhypoperfusion inducedlacticacidemiawithpH 7 15 grade2B 5 NaHCO3 ml 24 HCO3 weight 3 StressUlcerProphylaxis应激性溃疡预防 Stressulcerprophylaxisusingprotonpumpinhibitors PPI grade1B ratherthanH2receptorantagonists H2RA grade2C PPI优于H2RAwithoutriskfactorsshouldnotreceiveprophylaxis grade2B ContinuousRenalReplacementTherapy CRRT suggestthatCRRTandIntermittentHemodialysis间断血透areequivalentinpatientswithseveresepsisandacuterenalfailure grade2B CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients grade2D GlucoseControl血糖控制 Startinsulin胰岛素dosingwhentwoconsecutivebloodglucoselevelsare 180mg dL grade1A Target 110 180mg dlMonitorbloodglucosevaluesq1h q2h q4h grade1C DeepVeinThrombosisProphylaxis深静脉血栓的预防 dailysubcutaneouslow molecularweightheparin LMWH grade1BversusUFHtwicedaily grade2CversusUFHgiventhricedaily Ifcreatinineclearanceis 30mL 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 Nutrition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 MechanicalVentilation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 Fio2ratio 100mmHg grade2B 5 Recruitmentmaneuvers 肺复张 beusedinsepsispatientswithsevererefractoryhypoxemia顽固性低氧血症 grade2C MechanicalVentilationofSepsis 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 SettingGoalsofCare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 Enhancetheearlierrecognitionofsepsis Resuscitationassoonaspossible CareofEvidence basedmedicineEmphasizesthesignificanceofadjuvanttherapy集束化 BUNDLE 治疗策略 update Sepsisresucitationbundle初始复苏 1 Measurelactatelevel2 Obtainbloodculturespriortoadministrationofantibiotics3 Administerbroadspectrumantibiotics广谱抗生素4 Administer30mL kgcrystalloidforhypotensionorlactate4mmol L1h内使用抗菌药物 3h内启动监测和体液复苏 TOBECOMPLETEDWITHIN3HOURS Septicshockbundle感染性休克 1 vasopressorstomaintainMAP 65mmHg2 Intheeventofpersistentarterialhypotension顽固性低血压despitevolumeresuscitation septicshock orinitiallactate4mmol L 36mg dL MeasureCVP MeasureSCVO2 Remeasurelactateifinitiallactatewaselevated TargetsforquantitativeresuscitationincludedintheguidelinesareCVPof 8mmH2O SCVO2 70 andnormalizationoflactate 6h内达成治疗目标及再次评估 TOBECOMPLETEDWITHIN6HOURS 2016中国急诊感染性休克临床实践指南update 2016中国急诊感染性休克临床实践指南update 2016中国急诊感染性休克临床实践指南update 容量反应评估方法 CVP指导的补液试验PAWP导向的补液试验功能性血流动力学参数 SVV PPV SPV超声 SV CO SVR被动抬腿试验 2016中国急诊感染性休克临床实践指南update ExpoundphysiopathologicmechanismOpportunityofSteroidsandimmunomodulatorydrugs 病原体 免疫细胞 细胞因子炎症介质 级联反应 SIRS 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 细菌和毒素仅起到触发急性全身感染的作用 其发展与否及轻重程度完全取决于机体的反应性 因此在治疗感染性休克时 应正确评价个体的免疫状态 MODS 2016中国急诊感染性休克临床实践指南update 在SIRS反应初期 激素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保护血管内皮乌司他丁抑制炎症介质的产生和释放改善微循环 ExpondphysiopathologicmechanismOpportunityofSteroidsandimmunomodulatorydrugs SIRS CARS Thankyou 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 EN