医学课件-感染性休克指南解读课件

1、2013 SSC International Guidelines for Management of Severe Sepsis and Septic Shock2016中国急诊感染性休克临床实践指南12013 SSC International GuideliIndex caseName: 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

2、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。2Index caseName: Sun Zu Yu Index case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

3、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3Index case查体：T37.5，P88次/分，R19肺部CT上腹部MRI+增强4肺部CT上腹部MRI+增强46.296.307.17.27.37.47.57.656.296.307.17.27.37.47.57.6566Index caseName: Chen Yi Ming Age: 75years Sex: male ID:M admissiontime:2016.02.142016.02.17主诉：sudden fever and shiver 6 hours

4、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7Index caseName: Chen Yi Ming 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年前因进行性排尿困难，就诊我院，诊断“前列腺增生症，膀胱

5、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。8Index case既往史：有高血压病10余年，不规则服用 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.

6、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9查体： T36.5，P88次/分，R20次/分，BP1102.14 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

7、，双下肢无水肿。102.14 19:00患者突发四肢抽搐，伴发热、畏冷、寒战。查11111212Problem list:SIRSSepsis脓毒症Septic shock In essence, atdifferentstagesofthe one same disease13Problem list:SIRSSepsis脓毒症SeptSIRSsystemic inflammatory response syndrome General variablesFever( 38.3C)，Hypothermia低体温 (core temperature 90/min1 or more than t

8、wo 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高血糖症(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes Definition15SIRS Altered mental statusDefSepsisSIRS is secondary to documented or suspected infect

9、ion.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) Definition16SepsisSIRS is secondary to docDefinitionSeptic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resu

10、scitation.17DefinitionSeptic shock is defiDiagnostic1. 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厌氧 bottles) be obtained before antimic

11、robial therapy with at least 1 drawn percutaneously经皮地 and 1 drawn through each vascular access device，unless the device was recently (48hrs) inserted (grade 1C).18Diagnostic1. Cultures as cli2. diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan ant

12、ibody assays (2C).葡聚糖试验、半乳甘露聚糖试验3. Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection (UG).Diagnostic192. diagnosis of fungus真菌 infeRecommendations:Source ControlAntimicrobial TherapyVasopressorsCorticosteroidsAdjunctive Ther

13、apyBlood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in SepsisEvidence-basedmedicine20Recommendations:Source ControlSource

14、Control1）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 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 hydrox

15、yethyl starches (羟乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (grade 1B). 21Source Control1）recommend crysSource Control；achieve 30 mL/kg of crystalloids administrationQuantity量MAP、SVV、CO、SBP、HRmonitoringIndex监测指标CVP 8-12mmH2O，MAP65 mmHg，Urine output 0.5ml/kg/h，ScvO270%或SvO265%Goa

16、ls for Initial Resuscitation(6hrs)复苏目标22Source Control；achieve 30 mLAntimicrobial Therapy 1.Administration of effective intravenous antimicrobials within 1st hour2a. Initial empiric anti-infective therapy of one or more drugs， have activity against all likely pathogens (bacterial and/or fungal or vi

17、ral) (grade 1B)2b. Antimicrobial regimen抗菌药物组合 should be reassessed daily for potential de-escalation降阶梯 (grade 1B)23Antimicrobial Therapy 1.AdminiAntimicrobial Therapy 3. Use of low PCT levels or similar biomarkers to assist the clinicians in the discontinuation of empiric antibiotics in patients w

18、ho initially appeared septic, but have no subsequent evidence of infection (grade 2C)24Antimicrobial Therapy 3. Use o4.duration of therapy :7 to 10 days Antimicrobial Therapy Neutropenic patients粒缺 multidrug-resistant Acinetobacter多重耐药菌不动杆菌Pseudomonas spp铜绿假单胞菌 (grade 2B)combination empiric therapy

19、have a slow clinical response undrainable oci of infection感染灶无法很好的引流 bacteremia with S. aureus金葡; some fungal and viral infections immunologic deficiencies (grade 2C)longer courses25Antimicrobial Therapy Neutro5.Antiviral therapy抗病毒治疗 initiated as early as possible in patients with severe sepsis or

20、septic shock of viral origin (grade 2C).Antimicrobial Therapy 26Antimicrobial Therapy 26if 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VasopressorsNorepinephrine Compared With Dopamine in Severe Sepsis Sum

21、mary of Evidence27if the Initial fluid resuscita1.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 IU/min） -to be added to

22、 NE. intent: raise MAP ; decrease NE dosage; protect renal function (UG). Vasopressors血管活性药物281.Norepinephrine（NE） as the fi4.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 bradycardi

23、a心动过缓) Low-dose dopamine should not be used renal protection (grade 1A). Vasopressors血管活性药物294.Dopamine（DA)- an alternatiA 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 fi

24、lling pressure, and 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30A trial of dobutamine多巴酚丁胺 infCorticosteroids类固醇激素(1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic shock patients if adequat

25、e fluid resuscitation and vasopressor therapy are 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.31Corticosteroids类固醇激素(1)Not us（2） Not using the ACTH stimulation test to id

26、entify adults with septic shock who should receive hydrocortisone (grade 2B).（3）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

27、激素32（2） Not using the ACTH stimulaAdjunctive TherapyEmphasizes!Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in Sepsis3

28、3Adjunctive TherapyEmphasizesBlood Product Administration血制品的输注（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB) decreases to 70 g/L (grade 1B). to target a HGB of 70-90 g/L,inmergerofextenuating circumstances: (a) myocardial ischemia (b) severe hypoxemia顽固性低氧

29、血症 (c) acute hemorrhage or ischemic coronary artery disease34Blood Product Administration（2） use fresh frozen plasma新鲜冰冻血浆. Not only to be corrected laboratory clotting abnormalities but also to be used in bleeding or planned invasive procedures (grade 2D) ；（3） recommend against antithrombin凝血酶 admi

30、nistration(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 bleeding.（5） not using EPO as a specific treatment of anemia .Blood Product Administration血制品的输注35（2） use fresh

31、 frozen plasma新鲜冰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CNot using intravenous selenium硒收益7.15 (grade 2B).5%NaHCO3（ml）=(24-HCO3-)*weight/3 37Bicarbonate Therapy碳酸氢盐recommeStress

32、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H2RAwithout risk factors should not receive prophylaxis (grade 2B).38Stress Ulcer Prophylaxis应激性溃疡Continuous Renal Replacement Therapy(CRRT)sugg

33、est that 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). 39Continuous Renal Replacement TGlucose Control血糖控制Start insulin胰岛

34、素 dosing when two consecutive blood glucose levels are 180 mg/dL.(grade 1A).Target：110-180mg/dlMonitor blood glucose values q1hq2hq4h(grade 1C). 40Glucose Control血糖控制Start insuDeep Vein Thrombosis Prophylaxis深静脉血栓的预防daily subcutaneous low-molecular weight heparin (LMWH) grade 1B versus UFH twice dai

35、ly. grade 2C versus UFH given thrice daily. If creatinine clearance 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)4

36、1Deep Vein Thrombosis ProphylaxNutrition营养支持suggest administering oral or enteral feedings肠内营养,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

37、nutrition (TPN) in the first 7 days (grade 2B).Avoidfullcaloricfeedinginthefirstweek,suggestlowdosefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B).42Nutrition营养支持suggest administMechanical Ventilation机械通气 of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（1）Target a ti

38、dal 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）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(俯卧位通气)be used in sepsis-induced ARDS pati

39、ents with a Pao2/Fio2 ratio 100 mm Hg (grade 2B)；（5）Recruitment maneuvers(肺复张)be used in sepsis patients with severe refractory hypoxemia顽固性低氧血症 (grade 2C).43Mechanical Ventilation机械通气 of Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（6）be maintained with the hea

40、d 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 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)

41、；（8）Against the routine use of the pulmonary artery catheter(肺动脉导管)；44Mechanical Ventilation of SepsSetting Goals of Care确立治疗目标（1）Discuss goals of care and prognosis with patients and families (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, uti

42、lizing 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 2C).45Setting Goals of Care确立治疗目标（1Enhance theearlier recognition of sepsis.Resuscitation as soon as possible.Ca

43、re of Evidence-basedmedicineEmphasizes the significance of adjuvant therapy集束化（BUNDLE）治疗策略update46Enhance theearlier recognitioSepsis resucitation bundle初始复苏1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics广谱抗生素 4) Administer 30 mL/