感染性休克指南解读-文档

1、Index case,Name: Sun Zu Yu Age: 63years Sex: female ID:0680716 admissiontime:2015.06.292015.07.06 主诉:：repeated fatigue 13 years 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,Index case,查体：T37.5，

2、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,Index case,Name: Chen Yi Ming Age: 75years Sex: male ID:M admissiontime:2016

3、.02.142016.02.17 主诉：sudden fever and shiver 6 hours 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WBC12.44109/L，N11.30109/L，N90.8，急诊生化：AST123U/L，糖9.73mmol/L；肺部CT：双肺炎症,Index case,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

4、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

5、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,2.14 19:00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,Problem list,In essence,

6、 atdifferentstagesofthe one same disease,SIRS,systemic inflammatory response syndrome General variables Fever( 38.3C)，Hypothermia低体温 (core temperature 90/min1 or more than two sd above the normal value for age Tachypnea呼吸急促 （20次/min, PaCO2 12,000/ L) Leukopenia (WBC count 4000/L) Normal WBC count wi

7、th greater than 10% immature forms,Definition,SIRS,Altered mental status Significant edema or positive fluid balance(20ml/kg over 24hr) Hyperglycemia高血糖症(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes,Definition,Sepsis,SIRS is secondary to documented or suspected infection. Sepsis

8、-induced hypotension Lactate乳酸 above upper limits laboratory normal Urine output 176.8 mol/L Acute lung injury with Pao2/Fio2（OI） 34.2 mol/L PLT 1.5,Definition,Definition,Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation,Diagnostic,1. Cultures as c

9、linically 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厌氧 bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously经皮地 and 1 drawn t

10、hrough 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).葡聚糖试验、半乳甘露聚糖试验 3. Imaging studies、Plasma C-reactive protein（CRP）、 Plasma procalci

11、tonin（PCT） Contribute to confirm a potential source of infection (UG,Diagnostic,Recommendations,Source Control Antimicrobial Therapy Vasopressors Corticosteroids,Adjunctive Therapy,Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDs Glucose Control Stress Ulcer Prophylaxis Deep

12、 Vein Thrombosis Prophylaxis Nutrition Renal Replacement Therapy Sedation, Analgesia, and Neuromuscular Blockade in Sepsis,Evidence-basedmedicine,Source Control,1）recommend crystalloids晶体液 be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B). 2）add

13、 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 (羟乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (grade 1B,Source Control,Antimicrobial Therapy,1.Administration

14、 of effective intravenous antimicrobials within 1st hour 2a. 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抗菌药物组合 should be reassessed daily for potential de-escalation降阶梯

15、 (grade 1B,Antimicrobial Therapy,3. Use of low PCT 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 T

16、herapy,5.Antiviral therapy抗病毒治疗 initiated as 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,血管活性药物V

17、asopressors,Norepinephrine Compared With Dopamine in Severe Sepsis Summary of Evidence,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.

18、Vasopressin（ 0.03 IU/min） -to be added to NE. intent: raise MAP ; decrease NE dosage; protect renal function (UG,Vasopressors 血管活性药物,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 b

19、radycardia心动过缓) Low-dose dopamine should not be used renal protection (grade 1A,Vasopressors 血管活性药物,A trial of dobutamine多巴酚丁胺 infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) In the presence of: (a) myocardial dysfunction- elevate cardiac filling pressure, and

20、 low cardiac output, (b) hypoperfusion低灌注, despite achieving adequate intravascular volume and adequate MAP (grade 1C,Vasopressors 血管活性药物,Corticosteroids类固醇激素,1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are

21、able to restore hemodynamic stability. In case,not achievable：hydrocortisone氢化可的松 200 mg qd. intravenous (grade 2A). When given, use continuous infusion (grade 2C). iv-p.优于iv,2） Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade 2B). （3）

22、reduce the treated patient 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类固醇激素,Adjunctive TherapyEmphasizes,Blood Product Administratio Mechanical Ventilati

23、on of Sepsis-Induced ARDs Glucose Control Stress Ulcer Prophylaxis Deep Vein Thrombosis Prophylaxis Nutrition Renal Replacement Therapy Sedation, Analgesia, and Neuromuscular Blockade in Sepsis,Blood Product Administration血制品的输注,1）recommend red blood cell transfusion occur only when the hemoglobin c

24、oncentration(HGB) decreases to 70 g/L (grade 1B). to target a HGB of 70-90 g/L,inmergerof extenuating circumstances: (a) myocardial ischemia (b) severe hypoxemia顽固性低氧血症 (c) acute hemorrhage or ischemic coronary artery disease,2） use fresh frozen plasma新鲜冰冻血浆. Not only to be corrected laboratory clot

25、ting abnormalities but also to 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

26、 has a significant risk of bleeding. （5） not using EPO as a specific treatment of anemia,Blood Product Administration血制品的输注,not using intravenous immunoglobulins (grade 2B). History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)-no longer available. 重组人活性蛋白C Not using in

27、travenous selenium硒 收益风险,Immunoglobulins 免疫球蛋白,Bicarbonate Therapy碳酸氢盐,recommend against the use of sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH 7.15 (grade 2B). 5%NaHCO3（ml）=(

28、24-HCO3-)*weight/3,Stress Ulcer Prophylaxis应激性溃疡预防,Stress ulcer prophylaxis using proton pump inhibitors (PPI) (grade 1B) rather than H2 receptor antagonists (H2RA) (grade 2C). PPI优于H2RA without risk factors should not receive prophylaxis (grade 2B,Continuous Renal Replacement Therapy(CRRT,suggest t

29、hat CRRT and Intermittent Hemodialysis间断血透 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胰岛素 dosing when two consecutive blood gl

30、ucose levels are 180 mg/dL.(grade 1A). Target：110-180mg/dl Monitor blood glucose values q1hq2hq4h(grade 1C,Deep Vein Thrombosis Prophylaxis深静脉血栓的预防,daily subcutaneous low-molecular weight heparin (LMWH) grade 1B versus UFH twice daily. grade 2C versus UFH given thrice daily. If creatinine clearance

31、is 30 mL/min, we recommend use of UFH (grade 1A). patients who have a contraindication禁忌症 to heparin receive mechanical prophylactic treatment充气性机械装置 (eg, thrombocytopenia血小板减少症, active bleeding, recent intracerebral hemorrhage脑内出血,Nutrition营养支持,suggest administering oral or enteral feedings肠内营养,as

32、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,suggestlowdo

33、sefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B,Mechanical Ventilation机械通气 of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS,1）Target a tidal volume(潮气量)of 6 mL/kg predicted body weight （2）initial upper limit goal for Plateau pressures(平台压)30 cm H2O (grade 1B)； （3）Pos

34、itive end-expiratory pressure (最低PEEP) be applied to avoid alveolar collapse肺泡塌陷 at end expiration (grade 1B). （4）Prone positioning(俯卧位通气)be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm Hg (grade 2B)； （5）Recruitment maneuvers(肺复张)be used in sepsis patients with severe refractor

35、y hypoxemia顽固性低氧血症 (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误吸 and ventilator-associated pneumonia呼吸机相关肺炎 (grade 1B)； （7）noninvasive mask ventilation无创面罩 be

36、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(肺动脉导管,Setting Goals of Care确立治疗目标,1）Discuss goals of care and prognosis with patients and familie

37、s (grade 1B).将诊断及进一步治疗方案与患者家属沟通 （2）Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate (grade 1B).包括预后，终止生命的方式以及姑息治疗措施 （3）Address goals of care as early as feasible, but no later than within 72 hours of ICU admission (grade 2

38、C,Enhance theearlier recognition of sepsis. Resuscitation as soon as possible. Care of Evidence-basedmedicine Emphasizes the significance of adjuvant therapy 集束化（BUNDLE）治疗策略,update,Sepsis resucitation bundle初始复苏,1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectr