新光医院感染科败血症标准作业流程

新光醫院感染科敗血症標準作業流程

severesepsisandsepticshock新光醫院感染科黃建賢SEPSISDEFINITIONSmicrobes

involvesarapidlyamplifyingpolyphonyofsignalsandresponsesthatmayspread

beyondtheinvadedtissue.

1.敗血症的定義敗血症的定義1.1宿主因微生物感染大量繁殖並造而造成全身性症狀，臨床上可表現出發燒，低體溫，寒顫，呼吸加速，心搏加速，宿主因為微生物的侵犯而表現出”系統性發炎反應症候群”(systemicinflammatoryresponsesyndrome，SIRS)1.2”系統性發炎反應症候群”定義為包函下列或兩者以上1.2.1體溫38度C以上或36度C以下1.2.2心跳速度超越每分鐘90下1.2.3呼吸速率超越每分鐘20下1.2.4血液中白血球大於每毫升12000或小於每毫升4000或含百分之10以上之不成熟白血球(bands)ETIOLOGYgram-negativeandgram-positivebacteriafungi,mycobacteria,rickettsiae,viruses,orprotozoans…Positivebloodcultures:30to60%ofpatientswithsepsis

60to80%ofpatientswithsepticshockSepsisDefinitionsUsedtoDescribetheConditionofSepticPatientsBacteremiaSystemicinflammatoryresponsesyndrome(SIRS)SepsisSeveresepsisSepticshockMultiple-organdysfunctionsyndrome(MODS)PresenceofbacteriainbloodFever,tachypnea,tachycardia,leukocytosis/leukopeniaSIRShasaprovenorsuspectedmicrobialetiologySepsiswith≥1signsoforgandysfunctionSepsiswithhypotensionorneedforvasopressorDysfunctionof≥1organEpidemiologyofSepsisintheUnitedStatesfrom1979-2000NEnglJMed2003;348:1546-54.EPIDEMIOLOGY

2/3:inhospitalizedpatients.RiskFactorstoGNBbacteremiadiabetesmellituslymphoproliferativediseasescirrhosisoftheliverburnsinvasiveproceduresordevicesdrugsthatcauseneutropeniaEPIDEMIOLOGY

RiskfactorsforGPCbacteremia

vascularcatheters,indwellingmechanicaldevices,burns,intravenousdruginjection.Fungemia

:immunosuppressedpatientsneutropeniabroad-spectrumantimicrobialtherapyTPNIntestinalperforationPATHOPHYSIOLOGYEndotoxinGramnegativebacilliLipopolysaccharide(LPS,alsocalledendotoxin)PATHOPHYSIOLOGYMicrobialsignalsGrampositivecoccipeptidoglycanandlipoteichoicacidsextracellularenzymes敗血症的症症狀Feverorhypothermia(lowbodytemperature)HyperventilationChillsShakingWarmskinSkinrashRapidheartbeatConfusionordeliriumDecreasedurineoutputCLINICALMANIFESTATIONSS/S:fever,chills,tachycardia,tachypnea,alteredmentalstatus,andhypotension.afebrilecommoninneonates,inelderlypatientsandinpersonswithuremiaoralcoholism.CLINICALMANIFESTATIONSLlaboratoryfinding:C-reactiveproteinfibrinogencomplementcomponentstransferrininhibitsalbuminsynthesisLeukocytosis,leftshiftLABORATORYFINDINGSEarlysepsisleukocytosiswithaleftshiftRespiratoryalkalosisThrombocytopeniaHyperbilirubinemiaproteinuria.neutrophilsmaycontaintoxicgranulations,Dohlebodies,orcytoplasmicvacuolesLABORATORYFINDINGSProgressingofsepsis:thrombocytopeniaworsensprolongationofthethrombintimedecreasedfibrinogenpresenceofD-dimers,suggestingDIC)Azotemia,hyperbilirubinemiabecomeprominentElevatedGOTGPTLABORATORYFINDINGSProgressingsepsis:hyperventilationinducesrespiratoryalkalosis.accumulationoflactate,metabolicacidosis(withincreasedaniongap)hyperglycemia,severeinfectionmayprecipitatediabeticketoacidosis(DKA)MultipleorgandysfunctionsyndromeMOF:Dysfunctionorfailureofmultipleorgansreflectingwidespreadvascularendothelialinjuryassociatedwithhighfatalityrates.Mortalityandmorbiditycorrelatewiththenumberoforgansaffected.DIAGNOSISS/S--Progressingsepsistachypnea,tachycardia,alteredmentalstatus,ThesepticresponsecanbequitevariablesystemicinflammatoryresponsesyndromeSIRSDIAGNOSISDefinitivediagnosisisolationofthemicroorganismfrombloodoralocalinfectedsiteGram'sstaincultureoftheprimarysiteofinfection.TREATMENTSepsismaybefatalquickly.Successfulmanagementurgentmeasurestotreatthelocalsiteofinfection,hemodynamicandrespiratorysupporteliminatetheoffendingmicroorganismTherapyofacidosisandDIC,othercomplicationsTREATMENTOutcomeinfluencedbythepatient'sunderlyingdiseaseaggressivelytreated.AntimicrobialagentsPROGNOSISMortality:Morethan25%1/3withinthefirst48hmortalitycanoccur14ormoredayslater.Latedeathspoorlycontrolledinfectioncomplicationsofintensivecaremultipleorgansfailure2.敗血症症初期之緊緊急處理2.1敗敗血症最初初七小時之之緊急處理理措施著眼眼於恢復因因敗血症所所引起的低低血流灌注注，恢復組組織功能，，應包含以以下所有之之緊急處理理2.1.1中心靜靜脈壓維持持8-12mmHg2.1.2平均動動脈壓維持持大於等於於65mmHg2.1.3小便量量維持大於於等於每小小時每公斤斤體重0.5毫升2.1.4中心靜靜脈氧飽含含量維持大大於等於70﹪2.敗血症症初期之緊緊急處理2.2臨臨床檢驗2.2.1由周邊靜靜脈至少抽抽取2至3套血液培培養後盡快快給予抗生生素治療2.2.2盡快找尋尋可能之感感染部位並並取得檢體體，如導管管相關之感感染，呼吸吸器相關之之肺炎等2.2.3在抗生素素使用前須須取得可能能感染部位位之培養檢檢體，如尿尿液，腦脊脊髓液，傷傷口，呼吸吸道檢體或或其他部位位之組織液液2.2.4必要時可可作血清學學檢查、檢檢測抗體及及抗原或檢檢測尿液中中退伍軍人人菌抗體2.敗血症症初期之緊緊急處理2.2臨臨床檢驗2.2.5如有液狀狀檢體，可可作染色鏡鏡檢如葛蘭蘭氏染色，，抗酸菌染染色等2.2.6軟組織感感染時，除除了做血液液培養外，，盡可能取取得檢體做做染色鏡檢檢2.2.7必要時可可在主治醫醫師同意下下對病灶施施行超音波波檢查，電電腦斷層或或核磁共振檢查查以確立病病灶及嚴重重程度2.2.8必要時可可對病灶做做抽吸或切切片檢查以以取得檢體體2.2.9如病灶有有明顯積液液、必要時時可施以抽抽吸引流或或外科治療療3.抗生素素療法3.1抗生生素治療必必須在取得得適當檢體體後盡快給給予3.2當病病患有嚴重重敗血症或或敗血性休休克時，要要盡速給予予體液補充充，除非有有相當禁忌忌症(如急急性肺水腫腫等)3.3抗生生素經驗療療法必須依依社區或院院內感染，，感染部位位、菌種、抗生素穿透透能力及疾疾病人實際際狀況來給給予(參考考本院每半半年出版之之菌種及抗抗生素敏感感試驗表)3.3.1抗生素治治療以一種種抗生素為為原則3.3.2必要時可可以合併抗抗生素使用用以治療混混合型感染染或加強抗抗生素療效效3.3.3抗生素之之選擇依病病人過去病病史，過敏敏史，合併併疾病，合合併症及臨臨床抗生素素敏感性做做選擇3.抗生素素療法3.4抗生生素治療必必須在使用用48小時時至72小小時後重新新評估3.4.1依細菌培培養及抗生生素敏感性性試驗之結結果做調整整3.4.2以窄效性性抗生素為為原則3.4.3為避免抗抗藥性產生生，抗生素素之選擇以以低毒性及及同類藥中中價廉為原原則3.4.4治療以7-10天天為原則，，必要時可可延長之3.4.5抗生素之之使用及停停用以培養養結果及臨臨床醫師判判定為原則則4控制病病源4.1臨床床上所有敗敗血症病患患均盡量查查出並除去去感染源4.1.1必要時以以引流、清清創或外科科手術行之之4.1.2病患有外外科手術需需求時，必必須在完成成初步急救救並解釋病病情之後、、在家屬同同意下、盡盡速施行之之5輸液治治療5.1輸液液治療包括括自然血漿漿，人工血血漿及一般般輸液5.1.1人工輸液液較血漿易易出現水份份積蓄及水水腫5.1.2輸液速度度以每30分鐘輸人人工輸液300至1000毫毫升、或血血漿以每30分鐘300至500毫升升為主5.1.3輸液速度度及輸液量量以臨床反反應、血壓壓及尿液量量做調整5.1.4密切監視視病患以避避免出現肺肺水腫及其其他併發症症5.2個人人體液需求量量依個體及疾疾病狀況不同同依臨床狀況況做調整6血管收縮縮劑6.1當病病患經輸液治治療後仍無法法維持適當的的血壓及組織織灌流時得使使用血管收縮縮劑治療6.2當低低血壓足以危危及生命時，，血管收縮劑劑得以和輸液液治療同時給給予6.3Nor-epinephrine或dopamine須以中中心靜脈脈方式給給予6.4使使用血血管收縮縮劑病患患得施行行動脈血血壓監測測6.5Nor-epinephrine起始劑劑量以0.01至0.04units/分為原原則6.6Cardiacindex在2.5L.min-1.m2以下下者不宜宜使用血血管收縮縮劑7升壓壓劑(Dobutamine)7.1病病患在在經適當當輸液治治療後仍仍無法維維持正常常之輸出出量時得得以使用用升壓劑劑，必要要時得合合併血管管收縮劑劑使用8類固固醇8.1休休克病病患在適適當補充充輸液，，使用血血管升壓壓劑後，，仍無法法維持正正常血壓壓時得以以使用類類固醇8.2劑劑量以以每天hydrocortisone200至300毫毫克，分分3至4次給予予，使用用7天為為原則、必要時得得延長之之8.3病病患在在檢測ATCH前得以以使用dexamethasone取代hydrocortisone以免免影響血血中cortisol濃度檢檢測值8.4敗敗血症症病患未未合併休休克時，，不建議議使用類類固醇9人類類活性C蛋白使使用9.1高高死亡亡率之多多重器官官衰竭、敗血性休休克、成人呼吸吸窘迫症症病患，，無出血血傾向時時、APACHEIIscore>=25、在主治醫醫師同意意下得以以使用人人類活性性C蛋白白(rhAPC)10血血類製劑劑10.1無特特殊禁忌忌症之敗敗血症病病患在血血色素7.0g/dl以下時時得以輸輸血10.2輸血血目標值值為血色色素7.0至9.0g/dl10.3病患患無明顯顯出血時時、不建議以以冷凍新新鮮血漿漿來改善善血液中中之凝血血值10.4不論有有無出血血現象，，嚴重敗敗血症病病患得以以輸用血血小板以以維持血血小板值值在5000/mm3以上(5×10-9/L)11呼呼吸器使使用11.1呼吸吸器使用用依本院院呼吸器器使用原原則，及及成人呼呼吸窘迫迫症呼吸吸器使用用原則行行之12鎮鎮靜劑麻麻醉藥品品及肌肉肉鬆弛劑劑使用12.1嚴重重敗血症症病患合合併呼吸吸衰竭及及呼吸器器使用時時、得依本院院藥物使使用規範範使用鎮鎮靜劑麻麻醉藥物物及肌肉肉鬆弛劑劑12.2必要要時得以以會診麻麻醉科、以進行藥藥物調整整及避免免藥物副副作用13血血中葡萄萄糖控制制13.1敗血血症病患患須嚴密密監測並並控制血血糖13.2血中中葡萄糖糖控制以以200mg/dl以下為為原則(有嚴格格監測時時得控制制在140mg/dl以下下)13.3必要要時得以以使用胰胰島素取取代口服服降血糖糖藥控制制血糖14碳碳酸鹽治治療14.1碳酸酸鹽治療療得以使使用於敗敗血症合合併血流流灌注所所引起之之酸中毒毒14.2碳酸酸鹽治療療酸中毒毒以pH值7.3以下下為原則則14.3嚴重重敗血症症病患得得使用低低劑量肝肝素或低低分子量量肝素預預防深部部靜脈血血栓形成成14.4病患患有出血血傾向或或其他禁禁忌症時時應避免免使用肝肝素15預預防壓力力性腸胃胃道潰瘍瘍15.1所有有敗血症症病患均均應預防防壓力性性潰瘍之之產生15.2以使使用H2receptor抑制劑劑為原則則，有禁禁忌症或或不適用用者除外外16褥褥瘡之預預防16.1敗血血症合併併活動能能力降低低之病患患、應預防褥褥瘡之產產生16.2臨床床上依預預防褥瘡瘡形成臨臨床技術術手冊行行之16.3褥瘡瘡之治療療、必要時可可給予抗抗生素及及施行清清創手術術EpidemiologyofSepsisintheUnitedStatesfrom1979-2000NEnglJMed2003;348:1546-54.CausativeOrganismsGram-positivebacteria52.1%Gram-negativebacteria37.6%polymicrobialinfections4.7%anaerobes1.0%fungi4.6%Specificorganismscausingsepsiswererecordedin51%ofalldischargerecordsoverthe22-yearperiod.AntimicrobialAgentsintheManagementofSepsisCritCareMed2004;32:858-73.Twobloodcultureonepercutaneousonefromeachvascularaccess>48hrsmicrobialandclinicaldatanarrow-spectrumantibioticsnon-infectiouscauseidentifiedpreventresistance,reducetoxicityandreducecostoneormoredrugsactiveagainstlikelybacterialorfungalpathogensconsidermicrobialsusceptibilitypatternsEvaluatepatientforafocusedinfectionReassessantimicrobialregimenat48-72hrsBeginIVantibioticswithinthefirsthrofrecognitionofseveresepsisNorepinephrine4mg/4ml/amp(dilutedbyD5W)-0.03~3.3μg/kg/min(2~200μg/kg/hr)Epinephrine1mg/1ml/amp-0.06~0.47μg/kg/min(3.6~30μμg/kg/hr)Dopamine200mg/5ml/amp2~55μg/kg/min(0.12~3.3mg/kg/hr)Dobutamine250mg/20ml/amp2~28μg/kg/min(0.12~1.68mg/kg/hr)Vasopressin20U/1ml/amp0.01~0.04U/min(0.6~2.4U/hr)CritCareMed2004;32:1928-48.VasopressorandInotropicsRoleofCorticosteroidintheManagementofSepticShockCritCareMed2004;32:858-73.Treatpatientswhostillrequirevasopressorsdespitefluidreplacementwithhydrocortisone200-300mg/dayfor7daysdividedin3-4dosesorbycontinuousinfusion(GradeC)Highdoseofcorticosteroids(>300mg/day)shouldNOTbeusedinseveresepsisorsepticshock.(GradeA)CritCareMed2004;32:858-73.RoleofCorticosteroidintheManagementofSepticShockIntheabsenceofshock,corticosteroidsshouldNOTbeadministratedforthetreatmentofsepsis(GradeE)TheuseofACTHstimulationtesttoidentifyresponders(>9μg/mlincreaseincortisol30-60minspost-ACTHadministration)andtocontinuetherapyisoptional.ShouldNOTwaitforACTHstimulationresultstoadministercorticosteroids(GradeE)MechanicalVentilationofSepsis-inducedALI/ARDSCritCareMed2004;32:858-73.HightidalvolumethatarecoupledwithhighplateaupressuresshouldbeavoidedinALI/ARDS.reducetidalvolumeover1-2hrsto6ml/kgpredictedbodyweightmaintaininspiratoryplateaupressure<30cmH2OmaintainSaO2/SpO288-95%anticipatedPEEPsettingsatvariousFiO2requirementsFiO0.91.0PEEP55888101012141414161820-24(GradeB)IntensiveInsulininCriticalIllPatientsCritCareMed2004;32:858-73.Afterinitialstabilizationofpatientswithseveresepsismaintainglucose<150mg/dlbycontinuousinfusionofinsulinmonitorbloodglucoseevery30-60minsandthenq4h(GradeD)Inpatientswithseveresepsis,astrategyofglycemiccontrolshouldincludeanutritionprotocolwiththepreferentialuseoftheenteralroute.(GradeE)IntensiveInsulininCriticalIllPatientsNEnglJMed2006;354:449-61.prospective,randomized,controlledtrialadultsadmittedtoSICU(N=1,548)whowerereceivingMVadultsadmittedtoMICU(N=1,200)whowereconsideredtoneedICUcareforatleast3days50IUactrapidHM/50mlNSinfusedbypump(max.dose50IU/hr)intensiveinsulin(blo