脓毒症之前世今生.ppt

Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,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,*,*,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,Nantong Third Peoples Hospital,南通市第三人民医院,南通大学附属南通第三医院,脓毒症,之,前世今生,南通市第三人民医院 重症医学科,田李均,危重,症专科护士理论,培训,2018-07-06,1,脓毒症辞源及演变,2,脓毒症,3.0,3,脓,毒,症,治疗,进展,4,脓毒,症未来展望,目录,CONTENTS,脓毒症,辞源,Sepsis,腐烂，和疾病、死亡有关。,希波克拉底,前,460,年,-,前,370,年,脓毒症,辞源,Sepsis 1.0=infection+SIRS,Chest 1992 Jun;101(6):1644-55,创伤,烧伤,胰腺炎,缺血,SIRS,sepsis,SEVERE,SEPSIS,细菌,其他,病毒,原虫,真菌,其他,INFECTION,S,epsis,1.0,Sepsis 1.0,SIRS,Sepsis,Severe Sepsis,Septic Shock,非特异性损伤引起的临床反应，,满足,2,条标准,:,体温：,T 38,C or 90,bpm,呼吸：,20,bpm,白细胞计数：,12,000/mm,3,或,10%,重症脓毒症,:,脓毒症患者出现器官功能障碍,脓毒症,:,SIRS,及可疑或明确的感染,脓毒性休克,:,严重感染导致的循环衰竭，表现为经充分液体复苏仍不能纠正的组织低灌注和低血压。,Sepsis,2.0,Intensive Care Med.2003 Apr;29(4):530-8.,Epub,2003 Mar 28.,Sepsis 2.0=,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,Sepsis 2.0,。,创伤,烧伤,胰腺炎,缺血,SIRS,sepsis,SEVERE,SEPSIS,细菌,其他,病毒,原虫,真菌,其他,INFECTION,Sepsis 2.0,明确或怀疑的感染，加上以下部分指标,一般指标,发热,(38.3,),低体温,(,体内核心温度,90,次,/,分或超过年龄校正后正常值的,2,个标准差以上,呼吸急促,意识改变,严重水肿或液体正平衡,(24 h,内,20 ml/kg),高血糖,血糖,7.7,mmol,/L(140 mg/dl,，无糖尿病,),炎症指标,白细胞增多,白细胞计数,(WBC)12,10,9,/L,白细胞减少,(WBC10,C-,反应蛋白超过正常值,2,倍标准差以上,血浆降钙素原超过正常值,2,倍标准差以上,血流动力学指标,低血压,收缩压,(SBP)90 mm Hg,，,MAP70 mm Hg,，或,SBP,下降超过年龄校正后正常值的,2,倍标准差以上,器官功能障碍指标,动脉低氧血症,氧合指数,(PaO,2,/FiO,2,)300 mmHg,急性少尿,(,足量液体复苏，但尿量,44.2,mol,/L(0.5 mg/,dL,),凝血功能异常,国际标准化比值,(INR)1.5,或活化部分凝血活酶时间,(APTT)60 s,肠梗阻,(,肠鸣音消失,),血小板减少,血小板计数,(PLT)70,mol,/L(4mg/,dL,),组织灌注指标,高乳酸血症,(,血乳酸,1,mmol,/L),毛细血管充盈受损或皮肤花斑,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！,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。,N,Engl,J Med,2015,372(17):1629-1638.,脓毒症诊断标准的,“,争议,”,Do we need a new definition of sepsis?,the,definition of septic shock currently revolves around variable blood pressure and/or lactate levels,with loosely termed or undefined adequacy of fluid resuscitation and persistent hypotension.Defining sepsis must,however,be an ongoing iterative process requiring minor or major revisions as new,findings,come to light.In much the same way that software enhancements move from version 1.0 to 1.1 or to 2.0 depending on the magnitude of change,so,a new,sepsis,3.0 definition,must be refined into versions 3.1,3.2,and so on until an eventual complete overhaul generates the development of sepsis 4.0.,Intensive Care Med,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,。,Sepsis 3.0,“,应运而生,”,JAMA.2016 Feb 23;315(8):801-,10,1,脓毒症辞源及演变,2,脓毒症,3.0,3,脓,毒,症治疗进展,4,脓毒症未来展望,目录,CONTENTS,Sepsis 3.0,定义,JAMA.2016 Feb 23;315(8):801-,10,感染引起的宿主异常反应所导致的危及生命的多器官功能,障碍。,Sepsis 3.0,Infection,SOFA2,Sepsis 3.0,诊断标准,JAMA.2016 Feb 23;315(8):801-,10,Septic shock,定义及诊断标准,JAMA.2016 Feb 23;315(8):801-10,Septic shock,=Sepsis+,输液无反应低血压,+,使用缩血管药物维持,MAP65mmHg,）,+,乳酸则,2mmol/,L,。,Septic shock,is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.,快速,SOFA,（qSOFA,）,格拉斯哥评分,13,分以下,收缩压,100 mmHg,以下,(1 mmHg=0.133 kPa),呼吸频率,22,次,/,分以上,以上,3,项中符合,2,项，与完全的,SOFA,评分类似。,可床旁快速重复评价感染患者是否可能有不良预后,脓毒症筛查,脓毒症,3.0,诊断流程,JAMA.2016 Feb 23;315(8):801-10,Problem#1:Sepsis-III remains,subjective,Sepsis 3.0,的,10,个疑问（,一,）,所有定义都包含了,“,suspected infection,”,，但怎么去界定,“,suspected infection,”,却很难。,Problem,#2:,qSOFA,&SOFA are mortality predictors,not tests for,sepsis,Sepsis 3.0,的,10,个疑问（,二,）,qSOFA,&SOFA,评分多用于死亡预测，而非用于检测,sepsis,。,Problem,#3:Sepsis-III is less specific for infection than Sepsis-,II,Sepsis 3.0,的,10,个疑问（,三,）,Sepsis,3.0,对诊断感染特异性低于,Sepsis,2.0,。,Problem,#4:,qSOFA,has similar performance compared to SIRS for mortality,prediction,Sepsis 3.0,的,10,个疑问（,四,）,事实上，,qSOFA,与,SIRS,对死亡预测价值相当,。,Problem,#5:,qSOFA,may be less specific in diseases that directly cause hypotension,tachypnea,or,delirium,Sepsis 3.0,的,10,个疑问（,五,）,Sepsis 3.0,的,10,个疑问（,六,）,Problem#6:,qSOFA,is inconsistent with a validated prognostic model(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。,Sepsis 3.0,的,10,个疑问（,七,）,Problem,#7:Combining,qSOFA,and SOFA scores is not evidence-based among patients outside the ICU,SOFA,比,qSOFA,特异性更低，似乎不符合逻辑。,Sepsis 3.0,的,10,个疑问（,八,）,Problem,#8:The combined performance of,qSOFA,+SOFA for mortality is not reported.,Sepsis 3.0,的,10,个疑问（,九,）,Problem,#9:The overall sensitivity of Sepsis-III for sepsis might be 0.5ml/kg/h,、,MAP65mmHg,、,CVP,：,8,12mmHg,、,ScvO2,或,SvO270%,或,65%,。,在血流动力学监测下指导的液体复苏血流动力学监测手段包括压力监测、容量监测及组织灌注监测。,包括输注不同液体（晶体、胶体），使用血管活性药物或正性肌力药物，以及提升血液携氧能力的措施。液体复苏时应注意晶体液恢复生理需要量，微循环障碍的患者输注人工胶体有望改善微循环灌注和预后，应避免盲目使用白蛋白。,Early Goal-Directed Therapy:,A house collapsing in slow motion,殊途同归,CVP 8-12cmH20,MAP65mmHg,ScvO2,70%,尿量,0.5ml/,kg.h,前负荷,泵功能,氧供,/,氧耗,组织灌注,EGDT,是一种理念，而非目标,不应该强调数值，而应该关心目的,EGDT,让我们关心什么？,1,脓毒症辞源及演变,4,脓毒,症未来展望,2,Sepsis 3.0,3,脓毒,症治疗进展,目录,CONTENTS,What is the optimal fluid and,vasopressor,resuscitation strategy in the early phase of septic shock?,感染性休克早期阶段理想的液体与缩血管药物复苏策略？,Will lung protective ventilation in patients with sepsis reduce the development of acute respiratory distress syndrome?,肺保护通气降低,SEPSIS,患者,ARDS,发展？,Will new treatments reduce the incidence of acute kidney injury in patients with sepsis?,新疗法降低,SEPSIS,患者,AKI,发生率？,发展方向,Can rapid,inexpensive,and specific microbiologic tests for defining causative pathogens be developed using genetic and other approaches?,快速、廉价、特异的方法如基因检测等可行吗？,Will we develop new effective and safe antibiotics in an era of increasingly common drug resistant pathogens?,耐药时代的新抗菌药物？,BMJ(Clinical research ed.)2016 353:i1585.,脓毒症未来发展方向,How does the microbiome change in sepsis and how might this be leveraged therapeutically?,SEPSIS,中微生物如何变化及如何因此调整治疗？,What are the long term physical,cognitive,and psychosocial changes in patients who survive sepsis,and can we develop effective rehabilitative,techniques?,SEPSIS,存活者长期的躯体、认知、心理有何变化？有效康复技术？,Can we improve the ability of preclinical models of sepsis to predict therapeutic efficacy?,改善,SEPSIS,临床前模型能力，预测治疗效果,Can we develop a range of point-of-care biomarkers to group patients with sepsis into pathophysiologic categories?This would improve our understanding of the biology and may enhance clinical trial design,能通过生物标志物对,SEPSIS,患者进行病理生理归类，从而加深认识提高临床研究的设计？,How will the recently released definitions and clinical criteria for sepsis shape its clinical detection,treatment,and research?,新标准对诊断、治疗、研究的影响？,BMJ(Clinical research ed.)2016 353:i1585.,脓毒症未来发展方向,指南不断更新,Measure lactate level.Re-measure if initial lactate is2,mmol,/L,测定血乳酸水平。如果乳酸初始水平,2mmol/L,，应动态监测,Obtain blood cultures prior to administration of antibiotics,在应用抗生素前留取血培养,Administer broad-spectrum antibiotics,应用广谱抗生素,Rapidly administer 30 ml/kg crystalloid for hypotension or lactate4,mmol,/L,合并低血压或乳酸水平,4mmol/L,时，快速输注晶体液,30ml/kg,Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP65,mm,Hg,如果在液体复苏治疗期间或之后患者仍然低血压，应用升压药物维持,MAP65mm,Hg,The Surviving Sepsis Campaign Bundle:2018,update,（,2018-04-19,）,谢谢聆听,Thank You,