全身炎症反应综合症与脓毒血症(中).ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,全身炎症反应综合症 与脓毒血症,（中）,XXXX,医院,六脓毒血症治疗,1,。原发病治疗,2,。寻找感染源，控制感染,3,。器官功能支持,4,。针对炎症反应的治疗（酶抑制剂。,CRRT,清除炎性介质，糖皮质激素等）,5,。控制血糖,早期液体复苏,早期治疗目标的多中心研究表明，,6h,内,SVO2,必须,70,，通过积极的液体复苏、输血及应用血管活性药物治疗。,采用这种目标治疗的死亡率为,30.5%,，而传统的治疗方法的死亡率为,46.5%,。,对脓毒症患者早期积极的容量复苏能显著改善预后。,脓毒血症液体复苏,Sepsis Resuscitation Bundle,低血压事件或血乳酸,4mmol/L,1,。晶体液至少,20ml/kg,补液试验（胶体）等同：,B1,；,2,。经液体复苏后，血压持续低应给与血管升压药，维持平均动脉血压（,MAP,）,65mmHg,：,C1,脓毒血症液体复苏,Sepsis Resuscitation Bundle,经液体复苏后持续低血压（脓毒性休克）或血乳酸,4mmol/L,1,。建议放置,CVP,（中心静脉插管）,2,。维持,CVP 8-12mmHg,（在肺顺应性增加或胸腔内压增高可以高于此）,3,。达到,ScvO2 70%,SvO265%,：,1C,脓毒血症液体复苏,Sepsis Resuscitation Bundle,液体复苏后仍,SvO230%,。,2C,Fluid Therapy,Crystalloids,Lactated Ringer,s solution,Normal saline,Colloids,Hetastarch,Albumin,Gelatins,Packed red blood cells,Infuse to physiologic endpoints,Fluid Therapy,Correct hypotension first,Decrease heart rate,Correct,hypoperfusion,abnormalities,Monitor for deterioration of oxygenation,Inotropic,/,Vasopressor,Agents,Dopamine,Low dose(2-3,g/kg/min),mild,inotrope,plus renal effect,Intermediate dose(4-10,g/kg/min),inotropic,effect,High dose(10,g/kg/min),vasoconstriction,Chronotropic,effect,Inotropic,Agents,Dobutamine,5-20,g/kg/min,Inotropic,and variable,chronotropic,effects,Decrease in systemic vascular resistance,Inotropic,/,Vasopressor,Agents,Norepinephrine,0.05,g/kg/min and titrate to effect,Inotropic,and,vasopressor,effects,Potent,vasopressor,at high doses,Inotropic,/,Vasopressor,Agents,Epinephrine,Both,and,actions for,inotropic,and,vasopressor,effects,0.1,g/kg/min and titrate,Increases myocardial O,2,consumption,Therapeutic Goals in Shock,Increase O,2,delivery,Optimize O,2,content of blood,Improve cardiac output and blood pressure,Match systemic O,2,needs with O,2,delivery,Reverse/prevent organ,hypoperfusion,严重脓毒症诊断,DIAGNOSIS OF SEVERE SEPSIS,在应用抗生素治疗之前，作各种培养获取病原微生物,对于插管,48,小时，应该至少做两个血培养，一个经皮抽取血，另一个经导管取血。,1C,抗生素治疗,Antimicrobial Therapy,考虑严重感染获取培养标本后，立即静脉抗生素治疗。,1B,开始经验治疗应用抗生素至少,1,种或几种抗生素，具有广谱抗病源菌的活力（覆盖细菌和真菌）和具有穿透组织能力抗生素。,2B,抗生素方案每日需要评估最优活性，防止耐药菌的形成，降低药物的毒性，及降低医疗费用。,1C,感染源控制,Source Control,控制技术 举例,引流 腹腔脓肿，,脓胸,清创术 坏死性筋膜炎，,感染胰腺坏死,拔除管路 感染静脉插管，,导尿尿管,权威处理 胆囊切除术，,乙状结肠切除术,液体和血管活性药物治疗,液体即可以自然或人工的晶体或胶体,1B,怀疑低血容量时，补液试验,1000ml,晶体或,300-500ml,胶体超过,30,分钟输液。,1D,当心脏充盈压（,CVP,或,PAOP,）增加或血液动力学无改善时，输液速度应该降低。,1D,血管收缩药物应用,在脓毒血症中纠正低血压建议应用去甲肾上腺素或多巴胺等血管收缩药。,1C,低剂量的多巴胺不用于肾功能保护治疗。,1A,肾上腺素（,2B,）或血管加压素（,0.03u/min,）（,2C,）可以治疗经液体复苏和高剂量常规血管收缩药无效的难治性休克,SSC Guidelines,Crit,Care Med 2008,强心药物治疗,当心脏充盈压增加和低心输出量时，存在心功能被抑制时，推荐应用多巴酚丁胺。,1C,避免使用增加心指数以增加超出正常水平状态。,1B,SSC Guidelines,Crit,Care Med 2008,皮质醇激素治疗,静脉注射氢化可的松应用于成人伴有脓毒性休克，虽经液体复苏和 血管收缩剂治疗无效者。,2C,如果有氢化可的松时，应该不用地塞米松。,2B,如果应用氢化可的松后，可考虑应用氟氢可的松。,1C,脓毒血症患者氢化可的松 每天剂量不超过,300mg,。,1A,SSC Guidelines,Crit,Care Med 2008,重组人活化蛋白,-C,的应用,推荐成人伴有脓度血症诱导器官功能障碍伴高死亡率（,APACHE-,25,）或多器官功能衰竭并且无出血相关的禁忌症。,2B,成人伴有严重脓度血症和低死亡率（,APACHE-20,）或一器官功能衰竭者不接受,rhAPC,。,1A,脓毒血症诱导,ALI/ARDS,的机械通气,目标潮气量,6ml/kg 1B,维持平台压,30cmH2O 1C,允许性高碳酸血症被接受维持最低的平台压和潮气量,1C,PEEP,设置避免在呼气时广泛的肺塌陷,1C,在严重的,ARDS,可以腹卧位,2C,降低,VAP,需要头抬高,30-45,2C,建议不常规行,PA,检测,1A,建议保守液体疗法减少机械通气时间和在,ICU,的时间。,1C,血糖的控制,推荐病人伴有脓毒血症和高血糖者进入,ICU,应静脉应用胰岛素降低血糖。,1B,应用胰岛素维持血糖,1000 ml of crystalloids or 300-500 ml of colloids over 30,mins,.,Grade 1D,Rate of fluid administration should be reduced substantially when cardiac filling pressures(CVP or PAOP)increase without concurrent,hemodynamic,improvement,Grade 1D,液体及血管活性药物应用,FLUID AND VASOPRESSOR THERAPY,Fluid resuscitation with either natural or artificial colloids or crystalloids.,Grade 1B,Fluid challenge in patients with suspected,hypovolemia,may start with,1000 ml of crystalloids or 300-500 ml of colloids over 30,mins,.,Grade 1D,Rate of fluid administration should be reduced substantially when cardiac filling pressures(CVP or PAOP)increase without concurrent,hemodynamic,improvement,Grade 1D,Albumin and Saline for Fluid Resuscitation in the ICU(SAFE Trial),RCT 7,000 pts in 16 Australian/NZ ICUs,Excluded pts after cardiac surgery,liver transplant and burns,4%albumin or NS,No significant difference:,28-day mortality,New organ failure,duration of CRRT,or mechanical ventilation,ICU and,Hospital LOS,NEJM 2004;350:2247-2256,Vasopressor Therapy,Either,norepinephrine,or dopamine is the first choice,vasopressor,agent to correct hypotension in septic shock.,Grade 1C,Low-dose dopamine should not be used for renal protection.,Grade 1A,Epinephrine,(2B),or Vasopressin(0.03 U/min),(2C),may be added in pts with refractory shock despite adequate fluids and high-dose conventional,vasopressors,.,SSC Guidelines,Crit,Care Med 2008,Inotropic Therapy,Dobutamine,infusion is recommended in the presence of myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output.,Grade 1C,Avoid use of strategy to increase cardiac index to predetermined,supranormal,levels.,Grade 1B,SSC Guidelines,Crit,Care Med 2008,Corticosteroid Therapy,IV hydrocortisone should be given,only,to adult septic shock patients after it has been confirmed that their BP is poorly responsive to fluid resuscitation and,vasopressor,therapy.,Grade 2C,Crit,Care Med 2008 SSC Update,Rapid ACTH Test Can Identify Septic Patients at High Risk of Death,Relative adrenal insufficiency,Failure to increase,cortisol,by 9,g/dl,at 30-or 60-min following 250,g ACTH stimulation test,Annane,D,et al.JAMA 2000;283:1038-45,Clinical Practice Guidelines for the Diagnosis and Management of Corticosteroid Insufficiency in Critical Illness:Recommendations from an International Task Force,Marik,PE,Pastores,SM,Annane,D,Meduri,GU,Sprung C,et al.,Crit,Care Med(under review,),Consensus Statement,At this time,CIRCI is best diagnosed by a delta cortisol(following 250,g,cosyntropin)of 9,g/dl or a random cortisol of 300 mg of hydrocortisone daily not be used in septic shock,(1A),Marik PE,Pastores SM,Annane D,Meduri GU,Sprung C,et al.Crit Care Med 2008(under review);SCC 2008 Update 2008,Recombinant Human Activated Protein C,Recommended in adult pts with sepsis-induced organ dysfunction associated with a high risk of death(APACHE II,25)or multiple organ failure and with no contraindications related to bleeding,Grade 2B,Adult patients with severe sepsis and low risk of death(APACHE II 750,000 new cases per year in the U.S.,Mortality rates range from 28%to 50%,Approximately 500 to 1,000 Americans die daily of severe sepsis,Angus DC,et al.Crit Care Med 2001;29:1303-10,Murphy SL.National Center for Health Statistics,2000.DHHS.,Severe Sepsis:Comparative Incidence and Mortality,Angus DC,et al.Crit Care Med 2001;American Cancer Society,Incidence,Cases/100,000,Mortality,Deaths/Year,Mortality of Severe Sepsis by Age in the United States,Angus DC,et al.Crit Care Med 2001,.,0%,5%,10%,15%,20%,25%,30%,35%,40%,45%,0,1,5,10,15,20,25,30,35,40,45,50,55,60,65,70,75,80,85,Age,Mortality,Without Co-morbidity,With Co-morbidity,Overall,Severe Sepsis:Primary Source,Pulmonary:50%,Abdomen/Pelvis:25%,Primary bacteremia:15%,Urosepsis:10%,Skin:5%,Vascular:5%,Other:15%,Martin GS,et al.NEJM 2003;348:1546,Microbiology of Sepsis,Martin GS,et al.NEJM 2003;348:1546,Sepsis Battlefield:Cells and Mediators,Hotchkiss RS,Karl IE,NEJM 2003;348:138,Surviving Sepsis Campaign2008 Update,International effort to increase awareness and improve outcomes in severe sepsis,Endorsed by various organizations including SCCM,ACCP,ACEP,SHM,AACCN,and ESICM,Crit Care Med 2008;36:296-327,Surviving Sepsis Campaign,Partial funding by unrestricted educational industry grants from:,Edwards Life-Sciences,Eli Lilly and Company,Philips Medical Systems,Coalition for Critical Care Excellence of SCCM,No industry funding was used in the guidelines revision process,Crit Care Med 2008;36:296-327,Modified GRADE System,Grading of Evidence,1A:Strong recommendation,high quality evidence,1B:Strong recommendation,moderate quality of evidence,1C:Strong recommendation,low quality or very low quality evidence,2A:Weak recommendation,high quality evidence,2B:Weak recommendation,moderate quality evidence,2C:Weak recommendation,low quality or very low quality of evidence,Guyatt G,et al.Chest 2006;129:174-81,Severe Sepsis:nitial Resuscitation(,1,st,6 hours,),Should begin as soon as the syndrome is recognized and should not be delayed pending ICU admission.,Elevated serum lactate concentration identifies tissue hypoperfusion in patients at risk who are not hypotensive.,Resuscitation Goals,Goals in the first 6 hours:,CVP:8-12 mm Hg,MAP,65 mm Hg,Urine output,0.5 ml/kg/hr,Central venous(SVC)or mixed venous oxygen(SvO2)saturation,70%,GRADE 1C,EARLY GOAL DIRECTED THERAPY,EGDT for Severe Sepsis and Septic Shock,Rivers,E et al.NEJM 2001;345:1368,EGDT in Severe Sepsis and Septic Shock,Rivers et al,NEJM 2001;345:1368,EGDT in the Treatment of Severe Sepsis and Septic Shock,Rivers et al,NEJM 2001;345:1368,Sepsis Resuscitation Bundle,In the event of hypotension and/or lactate 4 mmol/L:,Administer a minimum of 20 ml/kg of crystalloid(or colloid equivalent):1B,Use vasopressors for hypotension not responding to initial fluid resuscitation to maintain MAP,65 mmHg:1C,SSC Guidelines-IHI,Sepsis Resuscitation Bundle,If persistent arterial hypotension despite volume resuscitation(septic shock)and/or initial lactate 4 mmol/L:,Recommend insertion of central venous catheter,Achieve CVP of 8-12 mmHg,Higher with altered ventricular compliance or increased intrathoracic pressure,Achieve ScvO2 of,70%or SvO2 65%,SSC Guidelines-IHI,Grade 1C,Sepsis Resuscitation Bundle,If ScvO2 remains 70%after fluid resuscitation goals are met,Dobutamine up to 20,g/kg/min,Transfusion to maintain Hct 30%,Grade 2C,SSC Guidelines,Crit Care Med 2008,DIAGNOSIS OF SEVERE SEPSIS,Diagnosis of Severe Sepsis,Appropriate cultures should always be obtained before antimicrobial therapy is initiated.,At least 2 blood cultures with at least one drawn percutaneously and one drawn through each vascular access device,unless the device was recently(,1000 ml of crystalloids or 300-500 ml of colloids over 30 mins.,Grade 1D,Rate of fluid administration should be reduced substantially when cardiac filling pressures(CVP or PAOP)increase without concurrent hemodynamic improvement,Grade 1D,SSC Guidelines,Crit Care Med 2008,Albumin and Saline for Fluid Resuscitation in the ICU(SAFE Trial),RCT 7,000 pts in 16 Australian/NZ ICUs,Excluded pts after cardiac surgery,liver transplant and burns,4%albumin or NS,No significant difference:,28-day mortality,New organ failure,duration of CRRT,or mechanical ventilation,ICU and,Hospital LOS,NEJM 2004;350:2247-2256,Vasopressor Therapy,Either norepinephrine or dopamine is the first choice vasopressor agent to correct hypotension in septic shock.,Grade 1C,Low-dose dopamine should not be used for renal protection.,Grade 1A,Epinephrine,(2B),or Vasopressin(0.03 U/min),(2C),may be added in pts with refractory shock despite adequate fluids and high-dose conventional vasopressors.,SSC Guidelines,Crit Care Med 2008,Inotropic Therapy,Dobutamine infusion is recommended in the presence of myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output.,Grade 1C,Avoid use of strategy to increase cardiac index to predetermined supranormal levels.,Grade 1B,SSC Guidelines,Crit Care Med 2008,STEROIDS,Corticosteroid Therapy,IV hydrocortisone should be given,only,to adult septic shock patients after it has been confirmed that their BP is poorly responsive to fluid resuscitation and vasopressor therapy.,Grade 2C,Crit Care Med 2008 SSC Update,Rapid ACTH Test Can Identify Septic Patients at High Risk of Death,Relative adrenal insufficiency,Failure to increase cortisol by 9,g/dl,at 30-or 60-min following 250,g ACTH stimulation test,Annane D,et al.JAMA 2000;283:1038-45,Low Dose Steroids in Septic Shock Study Design,Time 0,Onset of shock,Randomization,At 8 Hours,Hydrocortisone IV 50-mg,every 6 hours x 7 days,+,Fludrocortisone 50 mcg NG,daily x 7 days,Placebo,X 7 days,0,Eligibility,and,ACTH test,Main Outcome:,28-day survival,Annane,D.,JAMA,2002;288(7):863,Low Dose Steroids in Septic Shock:28 Day Mortality All Patients,Low-dose Steroids,Placebo,P=0.09,28-day Mortality,Annane,D.,JAMA,2002;288(7):868,N=150,N=149,Annane et al.JAMA 2002;288:862,Annane et al.JAMA 2002;288:862,