感染性休克指南解读

2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016中国急诊感染性休克临床实践指南Speaker:CaiHanThe1stAffiliatedHospitalofFujianMedicalUniversity1整理pptIndexcaseName:SunZuYuAge:63yearsSex:femaleID:0680716admission

time:2015.06.29—2015.07.06主诉:：

repeatedfatigue13years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。2整理pptIndexcase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3整理pptBaseline（6.29）（7.3）WBC6.104.54N%51.449.5Lac//PH//TB67.2↑56.5↑ALB24.5↓30.4↑ALT29↓35↓CHE1197↓1281↓Cr74.675GRR56.8358.11CRP9.26↑14.22↑PCT<0.05/IL-6117.4↑/Pro-BNP168/INR1.53↑1.53↑肺部CT上腹部MRI+增强4整理ppt6.296.307.17.27.37.47.57.65整理pptBaseline（6.29）（7.3）SIRS（7.5）sepsis/Septicshock（7.6）WBC6.104.542.05↓5.65N%51.449.565.777.7↑Lac//9.04↑>12↑PH///7.25↓TB67.2↑56.5↑46.9↑ALB24.5↓30.4↑25.7↑ALT293531CHE1197↓1281↓772↓Cr74.675121.1↑212.6↑GRR56.8358.11CRP9.26↑14.22↑13.28↑22.92↑PCT<0.05/2.04↑39.5↑IL-6117.4↑/317↑>5000↑Pro-BNP168/4100↑INR1.53↑1.53↑2.19↑culturesEscherichiacoli(+)*26整理pptIndexcaseName:ChenYiMingAge:75yearsSex:maleID:Madmission

time:2016.02.14—2016.02.17主诉：suddenfeverandshiver6hours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WBC

12.44×109/L，N

11.30×109/L，N％

90.8％，急诊生化：AST

123U/L，糖

9.73mmol/L；肺部CT：双肺炎症7整理pptIndexcase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。8整理ppt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整理ppt门诊（2.14）变症（2.14）WBC12.44↑11.89↑N11.30↑10.86↑N%90.8↑91.4↑Cr83.3CRP120↑PCT10↑Pro-BNP4800↑INR1.43↑2.1419:00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。10整理ppt11整理ppt12整理pptProblemlist:Inessence,at

different

stages

of

theonesamedisease13整理pptSIRSsystemicinflammatoryresponsesyndrome

GeneralvariablesFever(>38.3°C)，Hypothermia低体温(coretemperature<36°C)Heartrate>90/min–1ormorethantwosdabovethenormalvalueforageTachypnea呼吸急促

（>20次/min,PaCO2<32mmHg)Inflammatoryvariables炎症反应参数Leukocytosis(WBCcount>12,000/μL)Leukopenia(WBCcount<4000/μL)NormalWBCcountwithgreaterthan10%immatureforms

Definition14整理pptSIRS⑤Alteredmentalstatus⑥Significantedemaorpositivefluidbalance(>20ml/kgover24hr)⑦Hyperglycemia高血糖症(plasmaglucose>140mg/dlor7.7mmol/L)intheabsenceofdiabetes

Definition15整理pptSepsisSIRSissecondarytodocumentedorsuspectedinfection.Sepsis-inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput<0.5mL/kg/hrCreatinine>176.8μmol/LAcutelunginjurywithPao2/Fio2（OI）<250mmHgBilirubin胆红素>34.2μmol/LPLT<100,000μLCoagulopathy凝血障碍(INR>1.5)

Definition16整理pptDefinitionSepticshockisdefinedassepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitation.17整理pptDiagnostic1.Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay(>

45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厌氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(<48hrs)inserted(grade1C).18整理ppt2.diagnosisoffungus真菌infection--Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).葡聚糖试验、半乳甘露聚糖试验3.Imagingstudies、PlasmaC-reactiveprotein（CRP）、Plasmaprocalcitonin（PCT）Contributetoconfirmapotentialsourceofinfection(UG).Diagnostic19整理pptRecommendations:SourceControlAntimicrobialTherapyVasopressorsCorticosteroids

AdjunctiveTherapyBloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis

Evidence-based

medicine20整理pptSourceControl1）recommendcrystalloids晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock(grade1B).2）addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids(grade2C).3）recommendagainsttheuseofhydroxyethylstarches(羟乙基淀粉）forfluidresuscitationofseveresepsisandsepticshock(grade1B).21整理pptSourceControl；achieve≥30mL/kgofcrystalloidsadministrationQuantity量MAP、SVV、CO、SBP、HRmonitoring

Index监测指标CVP8-12mmH2O，MAP≥65mmHg，Urineoutput≥0.5ml/kg/h，ScvO2≥70%或SvO2≥65%GoalsforInitialResuscitation(6hrs)复苏目标22整理pptAntimicrobialTherapy

1.Administrationofeffectiveintravenousantimicrobialswithin1sthour2a.Initialempiricanti-infectivetherapyofoneormoredrugs，

haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)2b.Antimicrobialregimen抗菌药物组合

shouldbereassesseddailyforpotentialde-escalation降阶梯(grade1B)23整理pptAntimicrobialTherapy

3.UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C)24整理ppt4.durationoftherapy:7to10days

AntimicrobialTherapy

※Neutropenic

patients粒缺※multidrug-resistantAcinetobacter多重耐药菌不动杆菌※Pseudomonasspp铜绿假单胞菌(grade2B)combinationempirictherapy※haveaslowclinicalresponse※undrainableociofinfection感染灶无法很好的引流※bacteremiawithS.aureus金葡;※somefungalandviralinfections※immunologicdeficiencies(grade2C)longercourses25整理ppt5.Antiviraltherapy抗病毒治疗

initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin(grade2C).AntimicrobialTherapy

26整理pptiftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).血管活性药物VasopressorsNorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidenceOutcomesAssumedriskCorrespondingriskRelativeeffectNo.ofparticipantsDANE0.91(0.83to0.99)2043(6studies)Short-termmortality530/1000482/1000(440to524)supraventriculararrhythmias229/100082/1000(34to195)0.47(0.38to0.58)1931(2studies)ventriculararrhythmias39/100015/1000(8to27)0.35(0.19to0.66)1931(2studies)27整理ppt1.Norepinephrine（NE）asthefirstchoiceofvasopressor(grade1B).2.Epinephrine(addedtoandsubstitutedfornorepinephrine)(grade2B)whenanadditionalagentisneededtomaintainadequatebloodpressure.3.Vasopressin（0.03IU/min）---tobeaddedtoNE.intent:raiseMAP;decreaseNEdosage;protectrenalfunction(UG).

Vasopressors血管活性药物28整理ppt4.Dopamine（DA)---analternativevasopressoragenttoNE.(2C)onlyinhighlyselectedpatients(eg.patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心动过缓)Low-dosedopamineshouldnotbeusedrenalprotection(grade1A).

Vasopressors血管活性药物29整理pptAtrialofdobutamine多巴酚丁胺infusionupto20micrograms/kg/minbeadministeredoraddedtovasopressor(ifinuse)Inthepresenceof:(a)myocardialdysfunction--elevatecardiacfillingpressure,andlowcardiacoutput,(b)hypoperfusion低灌注,despiteachievingadequateintravascularvolumeandadequateMAP(grade1C).Vasopressors血管活性药物30整理pptCorticosteroids

类固醇激素(1)Notusingintravenoushydrocortisone氢化可的松totreatadultsepticshockpatientsifadequatefluidresuscitationandvasopressortherapyareabletorestorehemodynamicstability.Incase,notachievable：hydrocortisone氢化可的松

200mgqd.intravenous(grade2A).Whengiven,usecontinuousinfusion(grade2C).iv-p.优于iv.31整理ppt（2）NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone(grade2B).（3）reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired(grade2D).（4）Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock(grade1D).Corticosteroids

类固醇激素32整理pptAdjunctiveTherapy

Emphasizes!BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis33整理pptBloodProductAdministration

血制品的输注（1）recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration(HGB)decreasesto<70g/L(grade1B).

totargetaHGBof70-90g/L,

in

merger

of

extenuatingcircumstances:(a)myocardialischemia(b)severehypoxemia顽固性低氧血症(c)acutehemorrhageorischemiccoronaryarterydisease34整理ppt（2）usefreshfrozenplasma新鲜冰冻血浆.Notonlytobecorrectedlaboratoryclottingabnormalitiesbutalsotobeusedinbleedingorplannedinvasiveprocedures(grade2D)；（3）recommendagainstantithrombin凝血酶administration(grade2D).（4）

prophylacticallyPlateletsAdministration(grade2D)PLT≤(10,000/μL)intheabsenceofapparentbleeding;PLT≤(20,000/μL)ifthepatienthasasignificantriskofbleeding.（5）notusingEPOasaspecifictreatmentofanemia.BloodProductAdministration

血制品的输注35整理pptnotusingintravenousimmunoglobulins(grade2B).HistoryofRecommendationsRegardingUseofRecombinantActivatedProteinC(rhAPC)---nolongeravailable.重组人活性蛋白CNotusingintravenousselenium硒收益<风险Immunoglobulins

免疫球蛋白36整理pptBicarbonateTherapy碳酸氢盐recommendagainsttheuseofsodiumbicarbonatetherapyforthepurposeofimprovinghemodynamicsorreducingvasopressorrequirementsinpatientswithhypoperfusion-inducedlacticacidemiawithpH>7.15(grade2B).5%NaHCO3（ml）=(24-HCO3-)*weight/337整理pptStressUlcerProphylaxis

应激性溃疡预防

Stressulcerprophylaxisusingprotonpumpinhibitors(PPI)(grade1B)ratherthanH2receptorantagonists(H2RA)(grade2C).PPI优于H2RAwithoutriskfactorsshouldnotreceiveprophylaxis(grade2B).38整理pptContinuousRenalReplacementTherapy(CRRT)suggestthatCRRTandIntermittentHemodialysis间断血透

areequivalent

inpatientswithseveresepsisandacuterenalfailure(grade2B).

CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients(grade2D).

39整理pptGlucoseControl

血糖控制Startinsulin胰岛素

dosing

whentwoconsecutivebloodglucoselevelsare>180mg/dL.(grade1A).Target：110-180mg/dlMonitorbloodglucosevaluesq1h~q2h→q4h(grade1C).

40整理pptDeepVeinThrombosisProphylaxis

深静脉血栓的预防dailysubcutaneouslow-molecularweightheparin(LMWH)grade1BversusUFHtwicedaily.grade2CversusUFHgiventhricedaily.Ifcreatinineclearanceis<30mL/min,werecommenduseofUFH(grade1A).patientswhohaveacontraindication禁忌症

toheparinreceivemechanicalprophylactictreatment充气性机械装置(eg,thrombocytopenia血小板减少症,activebleeding,recentintracerebralhemorrhage脑内出血)41整理pptNutrition

营养支持suggestadministeringoralorenteralfeedings肠内营养,astolerated,ratherthaneithercompletefasting禁食orgiveonlyintravenous

glucosewithinthefirst48hrs(grade2C).suggestusingintravenousglucoseandenteralnutritionratherthantotalparenteralnutrition(TPN)inthefirst7days(grade2B).Avoid

full

caloric

feeding

in

the

first

week,suggest

low

dose

feeding

(eg,

up

to

500

calories

per

day),advancing

only

as

tolerated

(grade

2B).42整理pptMechanicalVentilation机械通气ofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（1）Targetatidalvolume(潮气量)of6mL/kgpredictedbodyweight（2）initialupperlimitgoalforPlateaupressures(平台压)≤30cmH2O(grade1B)；（3）Positiveend-expiratorypressure(最低PEEP)beappliedtoavoidalveolarcollapse肺泡塌陷atendexpiration(grade1B).（4）Pronepositioning(俯卧位通气)beusedinsepsis-inducedARDSpatientswithaPao2/Fio2ratio≤100mmHg(grade2B)；（5）Recruitmentmaneuvers(肺复张)beusedinsepsispatientswithsevererefractoryhypoxemia顽固性低氧血症(grade2C).43整理pptMechanicalVentilationofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（6）bemaintainedwiththeheadofthebedelevatedto30-45degreestolimitaspirationrisk误吸andventilator-associatedpneumonia呼吸机相关肺炎(grade1B)；（7）noninvasivemaskventilation无创面罩beusedinthatminorityofpatientsinwhomthebenefitsofNIVhavebeencarefullysonsideredandarethoughttooutweighttherisks(grade2B)；（8）Againsttheroutineuseofthepulmonaryarterycatheter(肺动脉导管)；44整理pptSettingGoalsofCare

确立治疗目标（1）Discussgoalsofcareandprognosiswithpatientsandfamilies(grade1B).将诊断及进一步治疗方案与患者家属沟通（2）Incorporategoalsofcareintotreatmentandend-of-lifecareplanning,utilizingpalliativecareprincipleswhereappropriate(grade1B).包括预后，终止生命的方式以及姑息治疗措施（3）Addressgoalsofcareasearlyasfeasible,butnolaterthanwithin72hoursofICUadmission(grade2C).45整理pptEnhancethe

earlierrecognitionofsepsis.Resuscitationassoonaspossible.CareofEvidence-based

medicineEmphasizesthesignificanceofadjuvanttherapy集束化（BUNDLE）治疗策略update46整理pptSepsis