感染性休克指南解讀

2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016中國急診感染性休克臨床實踐指南Speaker:CaiHanThe1stAffiliatedHospitalofFujianMedicalUniversity1整理pptIndexcaseName:SunZuYuAge:63yearsSex:femaleID:0680716admission

time:2015.06.29—2015.07.06主訴:：

repeatedfatigue13years現病史：入院前13年無明顯誘因出現乏力、納差，食欲減退為原來的1/2，就診福州市傳染病院，查轉氨酶增高（未見單），行肝穿檢查，肝穿病理示：慢性膽汁性肝硬化（輕度），予保肝處理后，好轉出院。出院后未定期復查，1月余前無明顯誘因再次出現乏力、納差，伴眼黃、尿黃、皮膚瘙癢，就診我院，門診擬“肝硬化”收住入院。2整理pptIndexcase查體：T37.5℃，P88次/分，R19次/分，BP125/68mmHg。神志清楚，全身皮膚、鞏膜黃染，雙側肝掌，未見蜘蛛痣，淺表淋巴結未觸及，雙肺未聞及干濕性啰音，心律齊，各瓣膜區(qū)未聞及雜音，腹無壓痛、反跳痛，肝脾肋下未觸及，墨菲氏征陰性，移動性濁音陰性，腸鳴音3次/分，雙下肢輕度浮腫。初步診斷：1.肝硬化失代償期(膽汁淤積性)

2.高血壓病

3.慢性膽囊炎治療方案：思美泰、易善復、天晴甘美——保肝

前列地爾——改善肝內循環(huán)

螺內酯——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+增強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主訴：suddenfeverandshiver6hours現病史：入院前6小時無明顯誘因出現畏冷、發(fā)熱，體溫最高39.1℃，伴寒戰(zhàn)、右側胸痛，偶有咳嗽、咳痰，急診我院，查血常規(guī)提示WBC

12.44×109/L，N

11.30×109/L，N％

90.8％，急診生化：AST

123U/L，糖

9.73mmol/L；肺部CT：雙肺炎癥7整理pptIndexcase既往史：有高血壓病10余年，不規(guī)則服用“安內真、氯沙坦、雙克”等藥物，未監(jiān)測血壓；6年前出現反酸、噯氣，就診我院行胃鏡后診斷“反流性食管炎（1級），慢性淺表性胃炎（2級）”，間斷服用保胃藥，現仍偶有反酸；4年前因進行性排尿困難，就診我院，診斷“前列腺增生癥，膀胱多發(fā)結石，雙腎囊腫”，行“經尿道前列腺切除術＋膀胱切開取石術”，術后無再出現排尿困難。3月前因反復腹痛20天就診我院，診斷“膽囊穿孔、膽囊結石并膽囊炎”，予保肝、解痙止痛等保守治療后癥狀好轉。8整理ppt查體：T36.5℃，P88次/分，R20次/分，BP110/65mmHg。神清，精神疲乏，鎖骨上等淺表淋巴結未觸及腫大，雙肺呼吸音粗，雙下肺有聞及少許濕性啰音。心律齊，各瓣膜聽診區(qū)未聞及雜音，腹平軟，全腹部無壓痛，無反跳痛，Murphy征陰性，肝脾未觸及，移動性濁音陰性，腸鳴音3次/分，雙下肢無水腫。初步診斷：1.肺炎

2.高血壓病

3.脂肪肝

4.膽囊結石伴慢性膽囊炎

5.反流性食管炎

6.慢性胃炎

7.單純性腎囊腫

8.前列腺增生

9.頸動脈硬化

10.手術后狀態(tài)(經尿道前列腺電切術+膀胱切開取石術)治療方案：考慮患者為社區(qū)獲得性肺炎，予頭孢美唑抗感染，沐舒坦祛痰，薄芝糖肽提高免疫力，易善復保肝及補液營養(yǎng)支持9整理ppt門診（2.14）變癥（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患者突發(fā)四肢抽搐，伴發(fā)熱、畏冷、寒戰(zhàn)。查體：T38.5℃，P100次/分，R22次/分，BP88/50mmHg。神志欠清，雙下肢皮膚花斑樣改變，右側乳頭至臍水平廣泛壓痛，雙肺呼吸音粗，雙下肺有聞及少許濕性啰音。心律齊，無雜音，Morphy征可疑陽性，腸鳴音3次/分，雙下肢無水腫。10整理ppt11整理ppt12整理pptProblemlist:Inessence,at

different

stages

of

theonesamedisease13整理pptSIRSsystemicinflammatoryresponsesyndrome

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

（>20次/min,PaCO2<32mmHg)Inflammatoryvariables炎癥反應參數Leukocytosis(WBCcount>12,000/μL)Leukopenia(WBCcount<4000/μL)NormalWBCcountwithgreaterthan10%immatureforms

Definition14整理pptSIRS⑤Alteredmentalstatus⑥Significantedemaorpositivefluidbalance(>20ml/kgover24hr)⑦Hyperglycemia高血糖癥(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膽紅素>34.2μmol/LPLT<100,000μLCoagulopathy凝血障礙(INR>1.5)

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

45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厭氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously經皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(<48hrs)inserted(grade1C).18整理ppt2.diagnosisoffungus真菌infection--Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).葡聚糖試驗、半乳甘露聚糖試驗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晶體液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock(grade1B).2）addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids(grade2C).3）recommendagainsttheuseofhydroxyethylstarches(羥乙基淀粉）forfluidresuscitationofseveresepsisandsepticshock(grade1B).21整理pptSourceControl；achieve≥30mL/kgofcrystalloidsadministrationQuantity量MAP、SVV、CO、SBP、HRmonitoring

Index監(jiān)測指標CVP8-12mmH2O，MAP≥65mmHg，Urineoutput≥0.5ml/kg/h，ScvO2≥70%或SvO2≥65%GoalsforInitialResuscitation(6hrs)復蘇目標22整理pptAntimicrobialTherapy

1.Administrationofeffectiveintravenousantimicrobialswithin1sthour2a.Initialempiricanti-infectivetherapyofoneormoredrugs，

haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)2b.Antimicrobialregimen抗菌藥物組合

shouldbereassesseddailyforpotentialde-escalation降階梯(grade1B)23整理pptAntimicrobialTherapy

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

AntimicrobialTherapy

※Neutropenic

patients粒缺※multidrug-resistantAcinetobacter多重耐藥菌不動桿菌※Pseudomonasspp銅綠假單胞菌(grade2B)combinationempirictherapy※haveaslowclinicalresponse※undrainableociofinfection感染灶無法很好的引流※bacteremiawithS.aureus金葡;※somefungalandviralinfections※immunologicdeficiencies(grade2C)longercourses25整理ppt5.Antiviraltherapy抗病毒治療

initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin(grade2C).AntimicrobialTherapy

26整理pptiftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).血管活性藥物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血管活性藥物28整理ppt4.Dopamine（DA)---analternativevasopressoragenttoNE.(2C)onlyinhighlyselectedpatients(eg.patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心動過緩)Low-dosedopamineshouldnotbeusedrenalprotection(grade1A).

Vasopressors血管活性藥物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血管活性藥物30整理pptCorticosteroids

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

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

類固醇激素32整理pptAdjunctiveTherapy

Emphasizes!BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis33整理pptBloodProductAdministration

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

totargetaHGBof70-90g/L,

in

merger

of

extenuatingcircumstances:(a)myocardialischemia(b)severehypoxemia頑固性低氧血癥(c)acutehemorrhageorischemiccoronaryarterydisease34整理ppt（2）usefreshfrozenplasma新鮮冰凍血漿.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

血制品的輸注35整理pptnotusingintravenousimmunoglobulins(grade2B).HistoryofRecommendationsRegardingUseofRecombinantActivatedProteinC(rhAPC)---nolongeravailable.重組人活性蛋白CNotusingintravenousselenium硒收益<風險Immunoglobulins

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

應激性潰瘍預防

Stressulcerprophylaxisusingprotonpumpinhibitors(PPI)(grade1B)ratherthanH2receptorantagonists(H2RA)(grade2C).PPI優(yōu)于H2RAwithoutriskfactorsshouldnotreceiveprophylaxis(grade2B).38整理pptContinuousRenalReplacementTherapy(CRRT)suggestthatCRRTandIntermittentHemodialysis間斷血透

areequivalent

inpatientswithseveresepsisandacuterenalfailure(grade2B).

CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients(grade2D).

39整理pptGlucoseControl

血糖控制Startinsulin胰島素

dosing

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

40整理pptDeepVeinThrombosisProphylaxis

深靜脈血栓的預防dailysubcutaneouslow-molecularweightheparin(LMWH)grade1BversusUFHtwicedaily.grade2CversusUFHgiventhricedaily.Ifcreatinineclearanceis<30mL/min,werecommenduseofUFH(grade1A).patientswhohaveacontraindication禁忌癥

toheparinreceivemechanicalprophylactictreatment充氣性機械裝置(eg,thrombocytopenia血小板減少癥,activebleeding,recentintracerebralhemorrhage腦內出血)41整理pptNutrition

營養(yǎng)支持suggestadministeringoralorenteralfeedings腸內營養(yǎng),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機械通氣ofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（1）Targetatidalvolume(潮氣量)of6mL/kgpredictedbodyweight（2）initialupperlimitgoalforPlateaupressures(平臺壓)≤30cmH2O(grade1B)；（3）Positiveend-expiratorypressure(最低PEEP)beappliedtoavoidalveolarcollapse肺泡塌陷atendexpiration(grade1B).（4）Pronepositioning(俯臥位通氣)beusedinsepsis-inducedARDSpatientswithaPao2/Fio2ratio≤100mmHg(grade2B)；（5）Recruitmentmaneuvers(肺復張)beusedinsepsispatientswithsevererefractoryhypoxemia頑固性低氧血癥(grade2C).43整理pptMechanicalVentilationofSepsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（6）bemaintainedwiththeheadofthebedelevatedto30-45degreestolimitaspirationrisk誤吸andventilator-associatedpneumonia呼吸機相關肺炎(grade1B)；（7）noninvasivemaskventilation無創(chuàng)面罩beusedinthatminorityofpatientsinwhomthebenefitsofNIVhavebeencarefullysonsideredandarethoughttooutweighttherisks(grade2B)；（8）Againsttheroutineuseofthepulmonaryarterycatheter(肺動脈導管)；44整理pptSettingGoalsofCare

確立治療目標（1）Discussgoalsofcareandprognosiswithpatientsandfamilies(grade1B).將診斷及進一步治療方案與患者家屬溝通（2）Incorporategoalsofcareintotreatmentandend-of-lifecareplanning,utilizingpalliativecareprincipleswhereappropriate(grade1B).包括預后，終止生命的方式以及姑息治療措施（3）Addressgoalsofcareasearlyasfeasible,butnolaterthanwithin72hoursofICUadmission(grade2C).45整理pptEnhancethe

earlierrecognitionofsepsis.Resuscitationassoonaspossible.CareofEvidence-based

medicineEmphasizesthesignificanceofadjuvanttherapy集束化（BUNDLE）治療策略update46整理pptSepsis