感染性克指南解讀課件

1、2013 SSC International Guidelines for Management of Severe Sepsis and Septic Shock2016中國(guó)急診感染性休克臨床實(shí)踐指南Speaker: Cai HanThe 1st Affiliated Hospital of Fujian Medical UniversityIndex caseName: Sun Zu Yu Age: 63years Sex: female ID:0680716 admissiontime:2015.06.292015.07.06主訴:：repeated fatigue 13 years現(xiàn)病

2、史：入院前13年無(wú)明顯誘因出現(xiàn)乏力、納差，食欲減退為原來(lái)的1/2，就診福州市傳染病院，查轉(zhuǎn)氨酶增高（未見(jiàn)單），行肝穿檢查，肝穿病理示：慢性膽汁性肝硬化（輕度），予保肝處理后，好轉(zhuǎn)出院。出院后未定期復(fù)查，1月余前無(wú)明顯誘因再次出現(xiàn)乏力、納差，伴眼黃、尿黃、皮膚瘙癢，就診我院，門(mén)診擬“肝硬化”收住入院。Index case查體：T37.5，P88次/分，R19次/分，BP125/68mmHg。神志清楚，全身皮膚、鞏膜黃染，雙側(cè)肝掌，未見(jiàn)蜘蛛痣，淺表淋巴結(jié)未觸及，雙肺未聞及干濕性啰音，心律齊，各瓣膜區(qū)未聞及雜音，腹無(wú)壓痛、反跳痛，肝脾肋下未觸及，墨菲氏征陰性，移動(dòng)性濁音陰性，腸鳴音3次/分，雙下肢輕

3、度浮腫。初步診斷：1.肝硬化失代償期(膽汁淤積性)2.高血壓病3.慢性膽囊炎治療方案：思美泰、易善復(fù)、天晴甘美 保肝 前列地爾改善肝內(nèi)循環(huán) 螺內(nèi)酯利尿Baseline（6.29）（7.3）WBC6.104.54N%51.449.5Lac/PH/TB67.256.5ALB24.530.4ALT2935CHE11971281Cr74.675GRR56.8358.11CRP9.2614.22PCT12PH/7.25TB67.256.546.9ALB24.530.425.7ALT293531CHE11971281772Cr74.675121.1212.6GRR56.8358.11CRP9.2614.2

4、213.2822.92PCT5000Pro-BNP168/4100INR1.531.532.19culturesEscherichia coli(+)*2Index caseName: Chen Yi Ming Age: 75years Sex: male ID:M admissiontime:2016.02.142016.02.17主訴：sudden fever and shiver 6 hours現(xiàn)病史：入院前6小時(shí)無(wú)明顯誘因出現(xiàn)畏冷、發(fā)熱，體溫最高39.1，伴寒戰(zhàn)、右側(cè)胸痛，偶有咳嗽、咳痰，急診我院，查血常規(guī)提示W(wǎng)BC12.44109/L，N11.30109/L，N90.8，急診生化：A

5、ST123U/L，糖9.73mmol/L；肺部CT：雙肺炎癥Index case既往史：有高血壓病10余年，不規(guī)則服用 “安內(nèi)真、氯沙坦、雙克”等藥物，未監(jiān)測(cè)血壓；6年前出現(xiàn)反酸、噯氣，就診我院行胃鏡后診斷“反流性食管炎（1級(jí)），慢性淺表性胃炎（2級(jí)）”，間斷服用保胃藥，現(xiàn)仍偶有反酸；4年前因進(jìn)行性排尿困難，就診我院，診斷“前列腺增生癥，膀胱多發(fā)結(jié)石，雙腎囊腫”，行“經(jīng)尿道前列腺切除術(shù)膀胱切開(kāi)取石術(shù)”，術(shù)后無(wú)再出現(xiàn)排尿困難。3月前因反復(fù)腹痛20天就診我院，診斷“膽囊穿孔、膽囊結(jié)石并膽囊炎”，予保肝、解痙止痛等保守治療后癥狀好轉(zhuǎn)。查體： T36.5，P88次/分，R20次/分，BP110/65m

6、mHg。神清，精神疲乏，鎖骨上等淺表淋巴結(jié)未觸及腫大，雙肺呼吸音粗，雙下肺有聞及少許濕性啰音。心律齊，各瓣膜聽(tīng)診區(qū)未聞及雜音，腹平軟，全腹部無(wú)壓痛，無(wú)反跳痛，Murphy征陰性，肝脾未觸及，移動(dòng)性濁音陰性，腸鳴音3次/分，雙下肢無(wú)水腫。 初步診斷：1.肺炎2.高血壓病3.脂肪肝4.膽囊結(jié)石伴慢性膽囊炎5.反流性食管炎6.慢性胃炎7.單純性腎囊腫8.前列腺增生9.頸動(dòng)脈硬化10. 手術(shù)后狀態(tài)(經(jīng)尿道前列腺電切術(shù)+膀胱切開(kāi)取石術(shù))治療方案：考慮患者為社區(qū)獲得性肺炎，予頭孢美唑抗感染，沐舒坦祛痰，薄芝糖肽提高免疫力，易善復(fù)保肝及補(bǔ)液營(yíng)養(yǎng)支持門(mén)診（2.14）變癥（2.14）WBC12.4411.89N

7、11.3010.86N%90.891.4Cr83.3CRP120PCT10Pro-BNP4800INR1.432.14 19:00患者突發(fā)四肢抽搐，伴發(fā)熱、畏冷、寒戰(zhàn)。查體：T38.5，P100次/分，R22次/分，BP88/50mmHg。神志欠清，雙下肢皮膚花斑樣改變，右側(cè)乳頭至臍水平廣泛壓痛，雙肺呼吸音粗，雙下肺有聞及少許濕性啰音。心律齊，無(wú)雜音，Morphy征可疑陽(yáng)性，腸鳴音3次/分，雙下肢無(wú)水腫。Problem list:In essence, atdifferentstagesofthe one same diseaseSIRSsystemic inflammatory respon

8、se syndrome General variablesFever( 38.3C)，Hypothermia低體溫 (core temperature 90/min1 or more than two sd above the normal value for ageTachypnea呼吸急促 （20次/min, PaCO2 12,000/ L) Leukopenia (WBC count 20ml/kg over 24hr) Hyperglycemia高血糖癥(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes

9、DefinitionSepsisSIRS is secondary to documented or suspected infection.Sepsis-induced hypotensionLactate乳酸 above upper limits laboratory normalUrine output 176.8 mol/LAcute lung injury with Pao2/Fio2（OI） 34.2 mol/LPLT 1.5) DefinitionDefinitionSeptic shock is defined as sepsis-induced hypotension per

10、sisting despite adequate fluid resuscitation.Diagnostic1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay ( 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic需氧 and anaerobic厭氧 bottles) be obtained before anti

11、microbial therapy with at least 1 drawn percutaneously經(jīng)皮地 and 1 drawn through each vascular access device，unless the device was recently (48hrs) inserted (grade 1C).2. diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C).葡聚糖試驗(yàn)、半乳甘

12、露聚糖試驗(yàn)3. Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection (UG).DiagnosticRecommendations:Source ControlAntimicrobial TherapyVasopressorsCorticosteroidsAdjunctive TherapyBlood Product Administratio Mechanical Ventilation of S

13、epsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in SepsisEvidence-basedmedicineSource Control1）recommend crystalloids晶體液 be used as the initial fluid of choice in the resuscita

14、tion of severe sepsis and septic shock (grade 1B).2）add to use of albumin白蛋白 in the fluid resuscitation when patients require substantial amounts of crystalloids (grade 2C).3）recommend against the use of hydroxyethyl starches (羥乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (grade 1B

15、). Source Control；achieve 30 mL/kg of crystalloids administrationQuantity量MAP、SVV、CO、SBP、HRmonitoringIndex監(jiān)測(cè)指標(biāo)CVP 8-12mmH2O，MAP65 mmHg，Urine output 0.5ml/kg/h，ScvO270%或SvO265%Goals for Initial Resuscitation(6hrs)復(fù)蘇目標(biāo)Antimicrobial Therapy 1.Administration of effective intravenous antimicrobials withi

16、n 1st hour2a. Initial empiric anti-infective therapy of one or more drugs， have activity against all likely pathogens (bacterial and/or fungal or viral) (grade 1B)2b. Antimicrobial regimen抗菌藥物組合 should be reassessed daily for potential de-escalation降階梯 (grade 1B)Antimicrobial Therapy 3. Use of low P

17、CT levels or similar biomarkers to assist the clinicians in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C)4.duration of therapy :7 to 10 days Antimicrobial Therapy Neutropenic patients粒缺 multidrug-resistan

18、t Acinetobacter多重耐藥菌不動(dòng)桿菌Pseudomonas spp銅綠假單胞菌 (grade 2B)combination empiric therapy have a slow clinical response undrainable oci of infection感染灶無(wú)法很好的引流 bacteremia with S. aureus金葡; some fungal and viral infections immunologic deficiencies (grade 2C)longer courses5.Antiviral therapy抗病毒治療 initiated a

19、s early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).Antimicrobial Therapy if the Initial fluid resuscitation did not target a mean arterial pressure (MAP) of 65 mmHg，Vasopressor therapy can be added (grade 1C).血管活性藥物VasopressorsNorepinephrine Compared With D

20、opamine in Severe Sepsis Summary of EvidenceOutcomesAssumed riskCorresponding riskRelative effectNo. of participantsDANE0.91(0.83 to 0.99)2043(6 studies)Short-term mortality530/1000482 /1000(440 to 524)supraventricular arrhythmias229 /100082/1000(34 to 195)0.47(0.38 to 0.58)1931(2 studies)ventricula

21、r arrhythmias39 /100015/1000(8 to 27)0.35(0.19 to 0.66)1931(2 studies)1.Norepinephrine（NE） as the first choice of vasopressor (grade 1B).2.Epinephrine (added to and substituted for norepinephrine) (grade 2B) when an additional agent is needed to maintain adequate blood pressure.3.Vasopressin（ 0.03 I

22、U/min） -to be added to NE. intent: raise MAP ; decrease NE dosage; protect renal function (UG). Vasopressors血管活性藥物4.Dopamine（DA)- an alternative vasopressor agent to NE. (2C) only in highly selected patients (eg.patients with low risk of tachyarrhythmias and absolute or relative bradycardia心動(dòng)過(guò)緩) Low

23、-dose dopamine should not be used renal protection (grade 1A). Vasopressors血管活性藥物A trial of dobutamine多巴酚丁胺 infusion up to 20 micrograms/kg/minbe administered or added to vasopressor (if in use)In the presence of: (a) myocardial dysfunction- elevate cardiac filling pressure, and low cardiac output,

24、(b) hypoperfusion低灌注, despite achieving adequate intravascular volume and adequate MAP (grade 1C).Vasopressors血管活性藥物Corticosteroids類(lèi)固醇激素(1)Not using intravenous hydrocortisone氫化可的松 to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemody

25、namic stability.In case,not achievable：hydrocortisone氫化可的松 200 mg qd. intravenous (grade 2A). When given, use continuous infusion (grade 2C). iv-p.優(yōu)于iv.（2） Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B).（3）reduce the treated pati

26、ent from steroid therapy when vasopressors are no longer required (grade 2D).（4）Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).Corticosteroids類(lèi)固醇激素Adjunctive TherapyEmphasizes!Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARD

27、sGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in SepsisBlood Product Administration血制品的輸注（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB) decreases to

28、 70 g/L (grade 1B). to target a HGB of 70-90 g/L,inmergerofextenuating circumstances: (a) myocardial ischemia (b) severe hypoxemia頑固性低氧血癥 (c) acute hemorrhage or ischemic coronary artery disease（2） use fresh frozen plasma新鮮冰凍血漿. Not only to be corrected laboratory clotting abnormalities but also to

29、be used in bleeding or planned invasive procedures (grade 2D) ；（3） recommend against antithrombin凝血酶 administration(grade 2D).（4） prophylactically Platelets Administration (grade 2D) PLT(1 0,000 / L) in the absence of apparent bleeding; PLT(2 0,000/ L) if the patient has a significant risk of bleedi

30、ng.（5） not using EPO as a specific treatment of anemia .Blood Product Administration血制品的輸注not using intravenous immunoglobulins (grade 2B).History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)-no longer available. 重組人活性蛋白CNot using intravenous selenium硒收益7.15 (grade 2B)

31、.5%NaHCO3（ml）=(24-HCO3-)*weight/3 Stress Ulcer Prophylaxis應(yīng)激性潰瘍預(yù)防 Stress ulcer prophylaxis using proton pump inhibitors (PPI) (grade 1B) rather than H2 receptor antagonists (H2RA) (grade 2C). PPI優(yōu)于H2RAwithout risk factors should not receive prophylaxis (grade 2B).Continuous Renal Replacement Therapy

32、(CRRT)suggest that CRRT and Intermittent Hemodialysis間斷血透 are equivalent in patients with severe sepsis and acute renal failure (grade 2B) . CRRT to facilitate management of fluid balance in hemodynamically unstable septic patients (grade 2D). Glucose Control血糖控制Start insulin胰島素 dosing when two cons

33、ecutive blood glucose levels are 180 mg/dL.(grade 1A).Target：110-180mg/dlMonitor blood glucose values q1hq2hq4h(grade 1C). Deep Vein Thrombosis Prophylaxis深靜脈血栓的預(yù)防daily subcutaneous low-molecular weight heparin (LMWH) grade 1B versus UFH twice daily. grade 2C versus UFH given thrice daily. If creati

34、nine clearance is 30 mL/min, we recommend use of UFH (grade 1A).patients who have a contraindication禁忌癥 to heparin receive mechanical prophylactic treatment充氣性機(jī)械裝置 (eg, thrombocytopenia血小板減少癥, active bleeding, recent intracerebral hemorrhage腦內(nèi)出血)Nutrition營(yíng)養(yǎng)支持suggest administering oral or enteral fee

35、dings腸內(nèi)營(yíng)養(yǎng),as tolerated, rather than either complete fasting禁食 or give only intravenous glucose within the first 48hrs (grade 2C). suggest using intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) in the first 7 days (grade 2B).Avoidfullcaloricfeedinginthefirstweek,

36、suggestlowdosefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B).Mechanical Ventilation機(jī)械通氣 of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（1）Target a tidal volume(潮氣量)of 6 mL/kg predicted body weight（2）initial upper limit goal for Plateau pressures(平臺(tái)壓)30 cm H2O (grad

37、e 1B)；（3）Positive end-expiratory pressure (最低PEEP) be applied to avoid alveolar collapse肺泡塌陷 at end expiration (grade 1B).（4）Prone positioning(俯臥位通氣)be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm Hg (grade 2B)；（5）Recruitment maneuvers(肺復(fù)張)be used in sepsis patients with severe

38、 refractory hypoxemia頑固性低氧血癥 (grade 2C).Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（6）be maintained with the head of the bed elevated to 30-45 degrees to limit aspiration risk誤吸 and ventilator-associated pneumonia呼吸機(jī)相關(guān)肺炎 (grade 1B)；（7）noninvasive mask ventilat

39、ion無(wú)創(chuàng)面罩 be used in that minority of patients in whom the benefits of NIV have been carefully sonsidered and are thought to outweight the risks(grade 2B)；（8）Against the routine use of the pulmonary artery catheter(肺動(dòng)脈導(dǎo)管)；Setting Goals of Care確立治療目標(biāo)（1）Discuss goals of care and prognosis with patients

40、and families (grade 1B).將診斷及進(jìn)一步治療方案與患者家屬溝通（2）Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate (grade 1B).包括預(yù)后，終止生命的方式以及姑息治療措施（3）Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2C).Enhance theearlier recognition of sepsis.Resuscitation as soon as possible.Care of Evidence-basedmedicineEmphasizes the significance of adjuvant therapy集束化（BUNDLE）治療策略u(píng)pdateSepsis resucitatio