脓毒症j宣教培训课件

严重脓毒症及脓毒性休克流行病学严重脓毒症患者死亡风险为34%，脓毒性休克患者死亡风险为50%。1脓毒症j宣教9/15/2024新近流调显示脓毒性休克死亡率下降结果发现，重症感染患者的绝对死亡率从35.0%下降到了18.4%，总死亡率下降了16.6%，年绝对死亡率下降了1.3%，相对风险下降了47.5%。JAMA.

2014Apr2;311(13):1308-16.2脓毒症j宣教9/15/2024脓毒症定义变迁（1.0）Sepsis1.0=感染＋SIRSChest1992Jun;101(6):1644-55创伤烧伤胰腺炎缺血SIRSsepsisSEVERESEPSIS细菌其他病毒原虫真菌其他INFECTION3脓毒症j宣教9/15/2024脓毒症定义变迁（2.0）IntensiveCareMed.2003Apr;29(4):530-8.Epub2003Mar28.Sepsis2.0=感染＋SIRS会议提出了包括20余条临床症状和体征评估指标构成的诊断标准，即Sepsis2.0。然而该标准过于复杂，且缺乏充分的研究基础和科学研究证据支持，并未得到临床认可和应用。创伤烧伤胰腺炎缺血SIRSsepsisSEVERESEPSIS细菌其他病毒原虫真菌其他INFECTION4脓毒症j宣教9/15/2024Diagnosticcriteriaforsepsis5脓毒症j宣教9/15/2024ThePIROsystemforstagingsepsis6脓毒症j宣教9/15/20242012SSC指南发展Criticalcaremedicine2004Mar;32(3):858-73.Criticalcaremedicine2008Jan;36(1):296-327.CritCareMed.2013Feb;41(2):580-637.200820047脓毒症j宣教9/15/2024脓毒症诊断标准的“争议”方法：通过对2000年至2013年澳大利亚和新西兰172个重症加强治疗病房(ICU)近120万例患者的数据分析，根据是否满足≥2条全身炎症反应综合征(SIRS)的诊断标准将感染伴器官功能障碍的患者分为SIRS阳性和SIRS阴性两组。结果：在近11万例感染伴器官功能障碍的患者中，87.9%为SIRS阳性，12.1%为SIRS阴性，在14年内两组患者的临床特征和病死率变化相似。校正分析显示，患者病死率随着满足SIRS标准项目的增加呈线性增高。结论：该研究说明现有脓毒症标准有可能遗漏约1/8的感染伴器官功能障碍患者，且该标准不能确定病死率增加的临界点，这提示当前脓毒症的筛查标准的特异性不佳。

NEnglJMed,2015,372(17):1629-1638.8脓毒症j宣教9/15/2024Doweneedanewdefinitionofsepsis?

……thedefinitionofsepticshockcurrentlyrevolvesaroundvariablebloodpressureand/orlactatelevels,withlooselytermedorundefined‘adequacyoffluidresuscitation’and‘persistent’hypotension.Definingsepsismust,however,beanongoingiterativeprocessrequiringminorormajorrevisionsasnewfindingscometolight.Inmuchthesamewaythatsoftwareenhancementsmovefromversion1.0to1.1orto2.0dependingonthemagnitudeofchange,soanewsepsis3.0definitionmustberefinedintoversions3.1,3.2,andsoonuntilaneventualcompleteoverhaulgeneratesthedevelopmentofsepsis4.0.IntensiveCareMed,2015,41(5):909-911.脓毒症的诊断标准于1991年发布（脓毒症1.0）,但过于敏感，可能导致脓毒症的过度诊断和治疗；2001年更新版（脓毒症2.0）又过于复杂，未被广泛应用。9脓毒症j宣教9/15/2024脓毒症3.0…..2016年……10脓毒症j宣教9/15/2024

Sepsis3.0“应运而生”JAMA.2016Feb23;315(8):801-10｀11脓毒症j宣教9/15/2024Sepsis3.0定义JAMA.2016Feb23;315(8):801-10｀Mortality10%12脓毒症j宣教9/15/2024Sepsis3.0＝Infection＋SOFA≥2Sepsis3.0诊断标准JAMA.2016Feb23;315(8):801-1013脓毒症j宣教9/15/2024Septicshock定义及诊断标准JAMA.2016Feb23;315(8):801-10Mortality40%Septicshock=Sepsis+输液无反应低血压+使用缩血管药物维持MAP≥65mmHg）+乳酸则＞2mmol/L。Septicshockisasubsetofsepsisinwhichunderlyingcirculatoryandcellular/metabolicabnormalitiesareprofoundenoughtosubstantiallyincreasemortality.14脓毒症j宣教9/15/2024脓毒症3.0诊断流程JAMA.2016Feb23;315(8):801-1015脓毒症j宣教9/15/2024Sepsis

3.016脓毒症j宣教9/15/2024ACCP反对Sepsis3.01.Giventhatuseofthecurrentdefinitionsresultsinsavinglives,itseemsunwisetochangecourseinmidstreambyshiftingthedefinition.Thisisespeciallytruebecausethereisstillnoknownprecisepathophysiologicalfeaturethatdefinessepsis.2.AbandoningtheuseofSIRStofocusonfindingsthataremorehighlypredictiveofdeathcouldencouragewaiting,ratherthanearly,aggressiveintervention.Thisisamistakethatwecannotmake.3.Toabandononesystemofrecognizingsepsisbecauseitisimperfectandnotyetinuniversaluseforanothersystemthatisusedevenlessseemsunwisewithoutprospectivevalidationofthenewsystem’sutility.Chest2016Feb17脓毒症j宣教9/15/2024ACCP反对Sepsis3.04.Whatpatientsneedisthatwecontinuetobuildonthemomentumofthelasttwodecadesandthatwenotdisruptitbyconflatingchangewithprogress.

5.Ourprincipalconcernisthatthenewdefinitionde-emphasizesinterventionatearlierstagesofsepsiswhenthesyndromeisactuallyatitsmosttreatable.Webelievethatadoptingamorerestrictivedefinitionthatrequiresfurtherprogressionalongthesepsispathwaymaydelayinterventioninthishighlytime-dependentcondition,withadditionalrisktopatients.Chest2016Feb18脓毒症j宣教9/15/2024精准医学下的Sepsis3.0不足“Definition”versus“ClinicalCriteria”.(1)Sepsisresearchers,bothbenchandclinical,shouldconsiderhowtheirfindingsmightvalidateorinvalidatethenewdefinition;(2)Cliniciansshoulddetermineiftheclinicalcriteriaareusefulintheirownpracticesandconsiderwhatadditionalelementsoughttobetested;(3)soonerratherthanlater.Criticalcaremedicine2016May;44(5):857-8.19脓毒症j宣教9/15/2024“DependentandIndependentVariables”.Sepsis=ƒ[(life-threatening)(organdysfunction)(dysregulatedhostresponse)(infection)].(1)Don’tassumethatthesequenceofeventsidentifiedinthenewdefinitionreflectspathobiologicalreality,becausenoonereallyknowshowthingsareorderedandconnected;(2)Don’tassumethatthepredominantabnormalityinsepsisisimmunological–thathypothesishasdominatedbothmechanisticandtherapeuticinvestigationforovertwodecades,andhasyettobearfruit.Criticalcaremedicine2016May;44(5):857-8.精准医学下的Sepsis3.0不足20脓毒症j宣教9/15/2024精准医学下的Sepsis3.0不足“Appropriatecomparators”.(1)Weneedtoreconsiderjustwhatconstitutesanappropriatecontrolforsepsisresearch;(2)Attheveryleast,weoughttomakesurethatstudiescharacterizingsepsisinanimalmodelsandinpatientsusesimilarcontrols.“Whatcomesnext?”.

How−andhowsoon−doweinitiateSepsis-4.0?Idon’tknow−butlet’snotwaitadecadeandahalfthistime.Criticalcaremedicine2016May;44(5):857-8.21脓毒症j宣教9/15/202422脓毒症j宣教9/15/2024Problem#1:Sepsis-IIIremainssubjectiveSepsis3.0的10个疑问（一）所有定义都包含了“suspectedinfection”，但怎么去界定“suspectedinfection”却很难。23脓毒症j宣教9/15/2024Problem#2:qSOFA&SOFAaremortalitypredictors,nottestsforsepsisSepsis3.0的10个疑问（二）qSOFA&SOFA评分多用于死亡预测，而非用于检测sepsis。24脓毒症j宣教9/15/2024Problem#3:Sepsis-IIIislessspecificforinfectionthanSepsis-IISepsis3.0的10个疑问（三）Sepsis3.0对诊断感染特异性低于Sepsis2.0。25脓毒症j宣教9/15/2024Problem#4:qSOFAhassimilarperformancecomparedtoSIRSformortalitypredictionSepsis3.0的10个疑问（四）事实上，qSOFA与SIRS对死亡预测价值相当

。26脓毒症j宣教9/15/2024Problem#5:qSOFAmaybelessspecificindiseasesthatdirectlycausehypotension,tachypnea,ordeliriumSepsis3.0的10个疑问（五）27脓毒症j宣教9/15/2024Sepsis3.0的10个疑问（六）Problem#6:qSOFAisinconsistentwithavalidatedprognosticmodel(CURB65)CURB65模型被认为肺炎诊断经典模型。qSOFA与之比较，会高估肺炎的死亡率。28脓毒症j宣教9/15/2024Sepsis3.0的10个疑问（七）Problem#7:CombiningqSOFAandSOFAscoresisnotevidence-basedamongpatientsoutsidetheICUSOFA比qSOFA特异性更低，似乎不符合逻辑。29脓毒症j宣教9/15/2024Sepsis3.0的10个疑问（八）Problem#8:Thecombinedperformanceof{qSOFA+SOFA}formortalityisnotreported.30脓毒症j宣教9/15/2024Sepsis3.0的10个疑问（九）Problem#9:TheoverallsensitivityofSepsis-IIIforsepsismightbe<50%outsideoftheICU31脓毒症j宣教9/15/2024Sepsis3.0的10个疑问（十）Problem#10:Sepsis-IIIisnotaconsensusguidelineintheUnitedStates支持团体：SocietyofCriticalCareMedicinetheAmericanThoracicSocietytheAmericanAssociationofCriticalCareNurses暂未支持团体：AmericanCollegeofChestPhysicianstheInfectiousDiseaseSocietyofAmericatheEmergencyMedicinesocietiesthehospitalmedicinesocieties32脓毒症j宣教9/15/2024脓毒症未来发展机制、诊治发展……定义更新：脓毒症3.0……33脓毒症j宣教9/15/2024BMJ：Sepsis的病理生理及临床治疗

作者综述5000多篇文献（引文217篇），复习了近35年来脓毒症的流行病学，危险因素、微生物学以及病因学及其治疗的研究成果，。综述对最新的Sepsis3.0也做了介绍和归纳，根据Sepsis3.0定义规定，脓毒症是由于对感染的不适当的宿主反应而产生的危及生命的脏器功能障碍，而Sepsis1.0或2.0说的是全身炎症反应，两者的差别决定了其病理生理的机制是不一致的。BMJ(Clinicalresearched.)2016353:i1585.34脓毒症j宣教9/15/2024BMJ:当前证据下的脓毒症诊治“取舍”BMJ(Clinicalresearched.)2016353:i1585.35脓毒症j宣教9/15/2024脓毒症未来发展方向Whatistheoptimalfluidandvasopressorresuscitationstrategyintheearlyphaseofsepticshock?

感染性休克早期阶段理想的液体与缩血管药物复苏策略？Willlungprotectiveventilationinpatientswithsepsisreducethedevelopmentofacuterespiratorydistresssyndrome?肺保护通气降低SEPSIS患者ARDS发展？Willnewtreatmentsreducetheincidenceofacutekidneyinjuryinpatientswithsepsis?新疗法降低SEPSIS患者AKI发生率？发展方向Canrapid,inexpensive,andspecificmicrobiologictestsfordefiningcausativepathogensbedevelopedusinggeneticandotherapproaches?快速、廉价、特异的方法如基因检测等可行吗？Willwedevelopneweffectiveandsafeantibioticsinaneraofincreasinglycommondrugresistantpathogens?耐药时代的新抗菌药物？BMJ(Clinicalresearched.)2016353:i1585.36脓毒症j宣教9/15/2024Howdoesthemicrobiomechangeinsepsisandhowmightthisbeleveragedtherapeutically?

SEPSIS中微生物如何变化及如何因此调整治疗？Whatarethelongtermphysical,cognitive,andpsychosocialchangesinpatientswhosurvivesepsis,andcanwedevelopeffectiverehabilitativetechniques?SEPSIS存活者长期

的躯体、认知、心里有何变化？有效康复技术？Canweimprovetheabilityofpreclinicalmodelsofsepsistopredicttherapeuticefficacy?改善SEPSIS临床前模