全身性感染與感染性休克PPT

全身性感染與感染性休克全身性感染(sepsis):流行病學(xué)MartinGS,ManninoDM,StephanieEatonS,etal.TheEpidemiologyofSepsisintheUnitedStatesfrom1979through2000.NEnglJMed2003;348:1546-54.全身性感染發(fā)病率的推算平均每年增加1.5%;相當(dāng)于年增新發(fā)病例約22,875例AngusDC,etal.TheepidemiologyofseveresepsisintheUnitedStates:Analysisofincidence,outcomeandassociatedcostsofcare.全身性感染臨床試驗對照組的病死率全身性感染的醫(yī)療費用2000年ICU醫(yī)療費用的40%歐洲每年花費 €7,600,000,0001美國每年花費 $16,700,000,0002DaviesAetal.Abstract581.14thAnnualCongressoftheEuropeanSocietyofIntensiveCareMedicine,Geneva,Switzerland,30September-3October2001AngusDC,Linde-ZwirbleWT,LidickerJ,etal.EpidemiologyofseveresepsisintheUnitedStates:Analysisofincidence,outcome,andassociatedcostsofcare.CritCareMed2001;29:1303–1310SurvivingSepsisCampaign:Why?過去5年間陽性結(jié)果的干預(yù)措施嚴(yán)重全身性感染與感染性休克EGDT激素APC小潮氣量通氣策略危重病患者的一般治療鎮(zhèn)靜嚴(yán)格血糖控制脫機(jī)方案SurvivingSepsisCampaign(SSC)GuidelinesforManagementofSevereSepsisandSepticShockDellingerRP,CarletJM,MasurH,GerlachH,CalandraT,CohenJ,Gea-BanaclocheJ,KehD,MarshallJC,ParkerMM,RamsayG,ZimmermanJL,VincentJL,LevyMMandtheSSCManagementGuidelinesCommitteeCritCareMed2004;32:858-873IntensiveCareMed2004;30:536-555availableonlineatspringerlinksepsisforumTheguidelineswerepublishedinbothCriticalCareMedicineandinIntensivecareMedicine,andareavailableon-lineSurvivingSepsisCampaignGuideline最初復(fù)蘇(initialresuscitation)診斷(diagnosis)抗生素治療(antibiotictherapy)感染源控制(sourcecontrol)液體治療(fluidtherapy)升壓藥物(vasopressors)強(qiáng)心藥物(inotropictherapy)激素(steroids)活化蛋白C(recombinanthumanactivatedproteinC)血液制品(bloodproductadministration)ARDS機(jī)械通氣(mechanicalventilationofsepsis-inducedALI/ARDS)鎮(zhèn)靜(sedation,analgesia,andNMBinsepsis)血糖控制(glucosecontrol)腎臟替代(renalreplacement)碳酸氫鈉(bicarbonatetherapy)DVT預(yù)防(DVTprophylaxis)應(yīng)激性潰瘍預(yù)防(stressulcerprophylaxis)考慮限制支持治療水平(considerationforlimitationofsupport)SurvivingSepsisCampaignGuideline最初復(fù)蘇(initialresuscitation)診斷(diagnosis)抗生素治療(antibiotictherapy)感染源控制(sourcecontrol)液體治療(fluidtherapy)升壓藥物(vasopressors)強(qiáng)心藥物(inotropictherapy)激素(steroids)活化蛋白C(recombinanthumanactivatedproteinC)血液制品(bloodproductadministration)ARDS機(jī)械通氣(mechanicalventilationofsepsis-inducedALI/ARDS)鎮(zhèn)靜(sedation,analgesia,andNMBinsepsis)血糖控制(glucosecontrol)腎臟替代(renalreplacement)碳酸氫鈉(bicarbonatetherapy)DVT預(yù)防(DVTprophylaxis)應(yīng)激性潰瘍預(yù)防(stressulcerprophylaxis)考慮限制支持治療水平(considerationforlimitationofsupport)嚴(yán)重全身性感染與感染性休克的治療SIRSSepsisSevereSepsisSepticShock血糖控制非常重要: 最初病情穩(wěn)定后 靜脈輸注胰島素1B目標(biāo)范圍? 血糖<150mg/dL2C

血糖控制方案2C

葡萄糖熱卡及監(jiān)測1B強(qiáng)化胰島素治療嚴(yán)格控制血糖外科患者的強(qiáng)化胰島素治療隨機(jī)分組對照組強(qiáng)化胰島素組開始輸注胰島素時的葡萄糖水平>215mg/dL>110mg/dL胰島素治療維持葡萄糖水平180–200mg/dL(10.0–11.1mmol/L)80–110mg/dL(4.4–6.1mmol/L)39%應(yīng)用胰島素99%應(yīng)用胰島素VanDenBergheG,WoutersP,WeekersF,etal.:Intensiveinsulintherapyinthecriticallyillpatients.NEnglJMed2001,345:1359-1367外科患者的強(qiáng)化胰島素治療至隨訪第12個月,強(qiáng)化胰島素治療可以降低病死率3.4%(p<0.04)強(qiáng)化胰島素治療還可以住院病死率

34%血行性感染率46%需要腎臟替代治療的急性腎功能衰竭41%輸血的中位數(shù)50%VanDenBergheG,WoutersP,WeekersF,etal.:Intensiveinsulintherapyinthecriticallyillpatients.NEnglJMed2001,345:1359-1367最初的復(fù)蘇治療發(fā)生全身性感染誘發(fā)的低血壓時低血壓乳酸酸中毒隱性低灌注與創(chuàng)傷預(yù)后TheGoldenHourandtheSilverDay入選標(biāo)準(zhǔn):成年創(chuàng)傷患者存活時間>24小時ISS20血流動力學(xué)穩(wěn)定SBP>100HR<120UO>1mL/kg/h乳酸>2.5mmol/L或其他灌注不足表現(xiàn)BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964隱性低灌注與創(chuàng)傷預(yù)后BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964嚴(yán)重創(chuàng)傷患者兩次LA>2.5輸注液體或血液制品重復(fù)LA>2.5Swan-Ganz,動脈插管,腎臟劑量多巴胺將PCWP提高到12–15將Hct提高到30%重復(fù)LA>2.5升壓藥物(多巴酚丁胺)心臟超聲檢查若LA仍>2.5隱性低灌注與創(chuàng)傷預(yù)后BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.JTrauma1999;47(5):964全身性感染的診斷適當(dāng)?shù)呐囵B(yǎng)至少留取2個血培養(yǎng)1個外周血培養(yǎng)每個留置

48h的血管通路留取1個血培養(yǎng)(GradeD)抗生素治療前后血培養(yǎng)的陽性率139名患者抗生素治療前抗生素治療過程中開始抗生素治療83名患者(60%)血培養(yǎng)陰性或分離出污染菌0/83(0%)分離到致病菌56名患者(40%)分離到致病菌26/56(45%)分離到致病菌25名患者(45%)分離到致病的葡萄球菌19/25(76%)分離到葡萄球菌14名患者(25%)分離到致病的鏈球菌5/14(36%)分離到鏈球菌17名患者(30%)分離到革蘭陰性桿菌2/17(12%)分離到革蘭陰性桿菌1/139(0.72%)分離到新的致病菌GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5臨床意義應(yīng)用抗生素前進(jìn)行血培養(yǎng)分離到致病菌的可能性增加2.2倍在開始抗生素治療最初72小時內(nèi),連續(xù)進(jìn)行血培養(yǎng)的結(jié)果,可以根據(jù)應(yīng)用抗生素前血培養(yǎng)的結(jié)果預(yù)測極少分離到新的致病菌醫(yī)生可以等待應(yīng)用抗生素前的血培養(yǎng)結(jié)果回報后,再進(jìn)行新的血培養(yǎng)GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5嚴(yán)重全身性感染與感染性休克的治療SIRSSepsisSevereSepsisSepticShock抗生素治療與感染灶控制確診嚴(yán)重全身性感染后1小時內(nèi)開始靜脈抗生素治療1C強(qiáng)化胰島素治療嚴(yán)格控制血糖早期應(yīng)用抗生素與感染患者病死率KumarA,RobertsD,WoodKE,etal.Durationofhypotensionbeforeinitiationofeffectiveantimicrobialtherapyisthecriticaldeterminantofsurvivalinhumansepticshock.CritCareMed2006;34:1589-1596嚴(yán)重全身性感染與感染性休克的治療SIRSSepsisSevereSepsisSepticShock抗生素治療與感染灶控制早期目標(biāo)指導(dǎo)治療持續(xù)低血壓或乳酸

4mmol/L

最初6小時內(nèi)達(dá)到的目標(biāo)CVP8–12mmHgMAP65mmHgUO0.5ml/kg/hrScvO270%1B強(qiáng)化胰島素治療嚴(yán)格控制血糖全身性感染:早期目標(biāo)指導(dǎo)治療RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377全身性感染:早期目標(biāo)指導(dǎo)治療RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377EGDT組患者輸液更多RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377EGDT組輸血及應(yīng)用多巴酚丁胺更多RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377EGDT與感染性休克的預(yù)后RiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377心血管猝死 21%vs.10%P=0.02MODS 22%vs.16%P=0.27嚴(yán)重全身性感染與感染性休克的治療SIRSSepsisSevereSepsisSepticShock抗生素治療與感染灶控制早期目標(biāo)指導(dǎo)治療死亡高危: APACHEII25

感染誘發(fā)的MOF

感染性休克 感染誘發(fā)的ARDS無絕對禁忌癥權(quán)衡相對禁忌癥B活化蛋白C治療強(qiáng)化胰島素治療嚴(yán)格控制血糖全身性感染:活化蛋白CBernardGR,VincentJL,LaterrePF,etal.EfficacyandsafetyofrecombinanthumanactivatedproteinCforseveresepsis.NEnglJMed2001;344:699-709.安慰劑(n=840)活化蛋白C(n=850)絕對病死率下降6.1%主要分析結(jié)果雙尾P值0.005校正后的相對危險度降低19.4%存活比數(shù)增加38.1%嚴(yán)重全身性感染與感染性休克的治療SIRSSepsisSevereSepsisSepticShock抗生素治療與感染灶控制早期目標(biāo)指導(dǎo)治療應(yīng)用氫化可的松200–300mg/d,分為3–4次給藥或持續(xù)靜脈輸注,療程7天經(jīng)過液體復(fù)蘇和升壓藥物治療低血壓持續(xù)1小時1B充分液體復(fù)蘇后仍需升壓藥物至少1小時2C活化蛋白C治療激素替代治療強(qiáng)化胰島素治療嚴(yán)格控制血糖感染性休克的激素替代治療AnnaneD,SebilleV,CharpentierC,etal.Effectoftreatmentwithlowdosesofhydrocortisoneandfludrocortisoneonmortalityinpatientswithsepticshock.JAMA2002;288:862-71.ACTHtest8hoursSEPTICSHOCKplaceboHC50mg/6hours+FC50mcg/dayp.o.N=150N=14928-daymortality7days感染性休克的激素替代治療AnnaneD,SebilleV,CharpentierC,etal.Effectoftreatmentwithlowdosesofhydrocortisoneandfludrocortisoneonmortalityinpatientswithsepticshock.JAMA2002;288:862-71.P=0.04P=0.96嚴(yán)重全身性感染–循證醫(yī)學(xué)指南干預(yù)措施NNT小潮氣量通氣策略11早期目標(biāo)指導(dǎo)治療6–8活化蛋白C16(wholetrial)8(APACHEII>25)強(qiáng)化胰島素治療29ACTH刺激試驗無反應(yīng)者小劑量激素治療7SepsisResuscitationBundle

(應(yīng)在最初6小時內(nèi)達(dá)到)測定血清乳酸水平應(yīng)用抗生素前留取血培養(yǎng)入急診室3小時或入ICU1小時內(nèi)應(yīng)用抗生素低血壓和(或)乳酸>4mmol/L(36mg/dl)時:最初應(yīng)用晶體液至少20ml/kg(或等量的膠體液)最初液體復(fù)蘇無效時應(yīng)用升壓藥物以維持MAP>65mmHg經(jīng)過液體復(fù)蘇后仍持續(xù)低血壓(感染性休克)和(或)乳酸>4mmol/L(36mg/dl):使CVP>8mmHg使ScvO2>70%SepsisManagementBundle

(應(yīng)在最初24小時內(nèi)達(dá)到)對感染性休克患者根據(jù)ICU標(biāo)準(zhǔn)化規(guī)定應(yīng)用小劑量激素根據(jù)ICU標(biāo)準(zhǔn)化規(guī)定應(yīng)用活化蛋白C控制血糖水平正常值下限,且<150mg/dl(8.3mmol/L)維持機(jī)械通氣患者吸氣平臺壓力<30cmH2OARDS機(jī)械通氣(mechanicalventilationofsepsis-inducedALI/ARDS)胰島素治療維持葡萄糖水平availableonlineatCritCareMed2006(inpress)1186/cc3909)WhatWeActuallyDo外科患者的強(qiáng)化胰島素治療經(jīng)過液體復(fù)蘇后仍持續(xù)低血壓(感染性休克)和(或)乳酸>4mmol/L(36mg/dl):對照組(n=30)Theimpactofcompliancewith6-hourand24-hoursepsisbundlesonhospitalmortalityinpatientswithseveresepsis:aprospectiveobservationalstudy.:Intensiveinsulintherapyinthecriticallyillpatients.SepticShockSurvivingSepsisCampaignInitialResults

ReportingtheGapbetween

PerceptionandPracticeEarlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.CritCareMed2006;34:1589-1596醫(yī)療費用報銷的限制,繁忙的工作安排研究結(jié)果的發(fā)表對日常工作并無影響SevereSepsisSurvivingSepsisCampaignInitialResults

ReportingtheGapbetween

PerceptionandPracticeWhatWeThinkWeDovs.WhatWeActuallyDoARDS保護(hù)性通氣策略–ARDSnetTheAcuteRespiratoryDistressSyndromeNetwork:Ventilationwithlowertidalvolumesascomparedwithtraditionaltidalvolumesforacutelunginjuryandtheacuterespiratorydistresssyndrome.NEnglJMed2000;342:1301-1308P=0.007研究結(jié)果的發(fā)表對日常工作并無影響RubenfeldGD,etal.AmJRespirCritCareMed2001;163:A295P=0.11P=0.02Adhereto“BestPractice”?Doyouuselungprotectivestrategyinventilatingacutelunginjurypatients?BrunkhorstFM,etal,fortheGermanCompetenceNetworkSepsis[SepNet].Thegapbetweenperceptionandpracticeofsepsistherapy.(submitted)Adhereto“BestPractice”?ResultsofNon-ScriptedCareProcessesBrunkhorstFM,etal,fortheGermanCompetenceNetworkSepsis[SepNet].Thegapbetweenperceptionandpracticeofsepsistherapy.(submitted)SupportiveandAdjunctiveTherapies

ResultsoftheGerman“Prevalence”StudyBrunkhorstFM,etal,fortheGermanCompetenceNetworkSepsis[SepNet].Thegapbetweenperceptionandpracticeofsepsistherapy.(submitted)為何循證治療在ICU中應(yīng)用并不普遍缺乏相關(guān)知識醫(yī)療費用報銷的限制,繁忙的工作安排ICU醫(yī)生的懷疑危重病領(lǐng)域眾多的陰性試驗結(jié)果對證據(jù)的主觀選擇臨床惰性不能正確鑒別患者醫(yī)療資源的配置VHA19-ICUSepsisBundles69%Reduction(p<0.001)36%Reduction(NS)PronovostP,2005EGDTinEDMean

SDMedianRangeCentrallineinserted2.1

1.71.51–8CVPgoalachieved6.3

3.86.01–14MAPgoalachieved5.6

3.24.02–13ScvO2measured2.4

1.82.01–8ScvO2goalachieved6.4

4.05.02–16TrzeciakS,DellingerRP,AbateNL,CowanRM,StaussM,KilgannonJH,ZanottiS,ParrilloJE.TranslatingResearchtoClinicalPractice:A1-YearExperienceWithImplementingEarlyGoal-DirectedTherapyforSepticShockintheEmergencyDepartment.Chest2006;129:225-232EGDTinEDBeforeEGDTEGDTPvalue輸注晶體液ED35092312568530210.02ICU第一個24小時55484878275217310.03PAC應(yīng)用7(43.8)2(9.1)0.01ICU住院日(d)4.2(0.5–14.3)1.8(0.0–34.9)0.12住院病死率7(43.8)4(18.2)0.09住院費用(USD)135,19982,2330.14TrzeciakS,DellingerRP,AbateNL,CowanRM,StaussM,KilgannonJH,ZanottiS,ParrilloJE.TranslatingResearchtoClinicalPractice:A1-YearExperienceWithImplementingEarlyGoal-DirectedTherapyforSepticShockintheEmergencyDepartment.Chest2006;129:225-232SepsisBundle101名嚴(yán)重全身性感染患者符合6小時Bundle普通病房:90(89%) 急診科:11(11%)71名收入ICU符合24小時Bundle:69(98%)43(61%)轉(zhuǎn)出ICU28(39%)死于ICU35(81%)存活8(19%)死亡65(64%)存活36(36%)死亡GaoF,MelodyT,DanielsDF,GilesS,FoxS.Theimpactofcompliancewith6-hourand24-hoursepsisbundlesonhospitalmortalityinpatientswithseveresepsis:aprospectiveobservationalstudy.CriticalCare2005,9:R764-R770(DOI10.1186/cc3909)SepsisBundle符合6小時Bundle(n=101)符合24小時Bundle(n=69)52%(52/101)30%(21/69)依從率GaoF,MelodyT,DanielsDF,GilesS,FoxS.Theimpactofcompliancewith6-hourand24-hoursepsisbundlesonhospitalmortalityinpatientswithseveresepsis:aprospectiveobservationalstudy.CriticalCare2005,9:R764-R770(DOI10.1186/cc3909)SevereSepsisSurvivingSepsisCampaign(SSC)GuidelinesforManagementofSevereSepsisandSepticShockUsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.Thegapbetweenperceptionandpracticeofsepsistherapy.充分液體復(fù)蘇后仍需升壓藥物至少1小時Theimpactofcompliancewith6-hourand24-hoursepsisbundlesonhospitalmortalityinpatientswithseveresepsis:aprospectiveobservationalstudy.BlowO,MaglioreL,ClaridgeJ,ButlerK,YoungJ.SupportiveandAdjunctiveTherapies

ResultsoftheGerman“Prevalence”StudySurvivingSepsisCampaignInitialResults

ReportingtheGapbetween

PerceptionandPractice17名患者(30%)分離到革蘭陰性桿菌TheGoldenHourandtheSilverDay:DetectionandCorrectionofOccultHypoperfusionwithin24HoursImprovesOutcomefromMajorTrauma.GaoF,MelodyT,DanielsDF,GilesS,FoxS.sepsisforum