感染性休克指南解讀宣講培訓(xùn)課件

1、感染性休克指南解讀宣講感染性休克指南解讀宣講Index case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(cè)肝掌，未見(jiàn)蜘蛛痣，淺表淋巴結(jié)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(wú)壓痛、反跳痛，肝脾肋下未觸及，墨菲氏征陰性，移動(dòng)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(fù)、天晴甘美 保肝 前列地爾改善肝內(nèi)循環(huán) 螺內(nèi)酯利尿2感染性休克指南解讀宣講Index case查體：T37.5，P88次/分，R19Baseline（6.2

2、9）（7.3）WBC6.104.54N%51.449.5Lac/PH/TB67.256.5ALB24.530.4ALT2935CHE11971281Cr74.675GRR56.8358.11CRP9.2614.22PCT12PH/7.25TB67.256.546.9ALB24.530.425.7ALT293531CHE11971281772Cr74.675121.1212.6GRR56.8358.11CRP9.2614.2213.2822.92PCT5000Pro-BNP168/4100INR1.531.532.19culturesEscherichia coli(+)*25感染性休克指南解讀

3、宣講WBC6.104.542.055.65N%51.449.5Index caseName: Chen Yi Ming Age: 75years Sex: male ID:M admissiontime:2016.02.142016.02.17主訴：sudden fever and shiver 6 hours現(xiàn)病史：入院前6小時(shí)無(wú)明顯誘因出現(xiàn)畏冷、發(fā)熱，體溫最高39.1，伴寒戰(zhàn)、右側(cè)胸痛，偶有咳嗽、咳痰，急診我院，查血常規(guī)提示W(wǎng)BC12.44109/L，N11.30109/L，N90.8，急診生化：AST123U/L，糖9.73mmol/L；肺部CT：雙肺炎癥6感染性休克指南解讀宣講Inde

4、x caseName: Chen Yi Ming Index case既往史：有高血壓病10余年，不規(guī)則服用 “安內(nèi)真、氯沙坦、雙克”等藥物，未監(jiān)測(cè)血壓；6年前出現(xiàn)反酸、噯氣，就診我院行胃鏡后診斷“反流性食管炎（1級(jí)），慢性淺表性胃炎（2級(jí)）”，間斷服用保胃藥，現(xiàn)仍偶有反酸；4年前因進(jìn)行性排尿困難，就診我院，診斷“前列腺增生癥，膀胱多發(fā)結(jié)石，雙腎囊腫”，行“經(jīng)尿道前列腺切除術(shù)膀胱切開(kāi)取石術(shù)”，術(shù)后無(wú)再出現(xiàn)排尿困難。3月前因反復(fù)腹痛20天就診我院，診斷“膽囊穿孔、膽囊結(jié)石并膽囊炎”，予保肝、解痙止痛等保守治療后癥狀好轉(zhuǎn)。7感染性休克指南解讀宣講Index case既往史：有高血壓病10余年，不規(guī)

5、則服用 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(jié)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(tīng)診區(qū)未聞及雜音，腹平軟，全腹部無(wú)壓痛，無(wú)反跳痛，Murphy征陰性，肝脾未觸及，移動(dòng)性濁音陰性，腸鳴音3次/分，雙下肢無(wú)水腫。 初步診斷：1.肺炎2.高血壓病3.脂肪肝4.膽囊結(jié)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(dòng)脈硬化10. 手術(shù)后狀態(tài)(經(jīng)尿道前列腺電切術(shù)+膀胱切開(kāi)取石術(shù))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(fù)保肝

6、及補(bǔ)液營(yíng)養(yǎng)支持8感染性休克指南解讀宣講查體： T36.5，P88次/分，R20次/分，BP110門(mén)診（2.14）變癥（2.14）WBC12.4411.89N11.3010.86N%90.891.4Cr83.3CRP120PCT10Pro-BNP4800INR1.432.14 19:00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(cè)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(wú)雜音，Morphy征可疑陽(yáng)性，腸鳴音3次/分，雙下肢無(wú)水腫。9感染性休克指南解讀宣講WBC12.

7、4411.89N11.3010.86N%10感染性休克指南解讀宣講10感染性休克指南解讀宣講11感染性休克指南解讀宣講11感染性休克指南解讀宣講Problem list:In essence, atdifferentstagesofthe one same disease12感染性休克指南解讀宣講Problem list:In essence, atdiSIRSsystemic inflammatory response syndrome General variablesFever( 38.3C)，Hypothermia低體溫 (core temperature 90/min1 or mor

8、e than two sd above the normal value for ageTachypnea呼吸急促 （20次/min, PaCO2 12,000/ L) Leukopenia (WBC count 20ml/kg over 24hr) Hyperglycemia高血糖癥(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes Definition14感染性休克指南解讀宣講SIRS Altered mental statusDefSepsisSIRS is secondary to documented

9、or suspected infection.Sepsis-induced hypotensionLactate乳酸 above upper limits laboratory normalUrine output 176.8 mol/LAcute lung injury with Pao2/Fio2（OI） 34.2 mol/LPLT 1.5) Definition15感染性休克指南解讀宣講SepsisSIRS is secondary to docDefinitionSeptic shock is defined as sepsis-induced hypotension persisti

10、ng despite adequate fluid resuscitation.16感染性休克指南解讀宣講DefinitionSeptic shock is defiDiagnostic1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay ( 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic需氧 and anaero

11、bic厭氧 bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously經(jīng)皮地 and 1 drawn through each vascular access device，unless the device was recently (48hrs) inserted (grade 1C).17感染性休克指南解讀宣講Diagnostic1. Cultures as cli2. diagnosis of fungus真菌 infection-Use of the 1,3 beta-D

12、-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C).葡聚糖試驗(yàn)、半乳甘露聚糖試驗(yàn)3. Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection (UG).Diagnostic18感染性休克指南解讀宣講2. diagnosis of fungus真菌 infeRecommendations:Source Control

13、Antimicrobial TherapyVasopressorsCorticosteroidsAdjunctive TherapyBlood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in Seps

14、isEvidence-basedmedicine19感染性休克指南解讀宣講Recommendations:Source ControlSource Control1）recommend crystalloids晶體液 be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).2）add to use of albumin白蛋白 in the fluid resuscitation when patients require substantia

15、l amounts of crystalloids (grade 2C).3）recommend against the use of hydroxyethyl starches (羥乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (grade 1B). 20感染性休克指南解讀宣講Source Control1）recommend crysSource Control；achieve 30 mL/kg of crystalloids administrationQuantity量MAP、SVV、CO、SBP、HRmo

16、nitoringIndex監(jiān)測(cè)指標(biāo)CVP 8-12mmH2O，MAP65 mmHg，Urine output 0.5ml/kg/h，ScvO270%或SvO265%Goals for Initial Resuscitation(6hrs)復(fù)蘇目標(biāo)21感染性休克指南解讀宣講Source Control；achieve 30 mLAntimicrobial Therapy 1.Administration of effective intravenous antimicrobials within 1st hour2a. Initial empiric anti-infective therapy

17、 of one or more drugs， have activity against all likely pathogens (bacterial and/or fungal or viral) (grade 1B)2b. Antimicrobial regimen抗菌藥物組合 should be reassessed daily for potential de-escalation降階梯 (grade 1B)22感染性休克指南解讀宣講Antimicrobial Therapy 1.AdminiAntimicrobial Therapy 3. Use of low PCT levels

18、 or similar biomarkers to assist the clinicians in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C)23感染性休克指南解讀宣講Antimicrobial Therapy 3. Use o4.duration of therapy :7 to 10 days Antimicrobial Therapy Neutrop

19、enic patients粒缺 multidrug-resistant Acinetobacter多重耐藥菌不動(dòng)桿菌Pseudomonas spp銅綠假單胞菌 (grade 2B)combination empiric therapy have a slow clinical response undrainable oci of infection感染灶無(wú)法很好的引流 bacteremia with S. aureus金葡; some fungal and viral infections immunologic deficiencies (grade 2C)longer courses24

20、感染性休克指南解讀宣講Antimicrobial Therapy Neutro5.Antiviral therapy抗病毒治療 initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).Antimicrobial Therapy 25感染性休克指南解讀宣講Antimicrobial Therapy 25感染性休克指if the Initial fluid resuscitation did not target a mean arterial

21、pressure (MAP) of 65 mmHg，Vasopressor therapy can be added (grade 1C).血管活性藥物VasopressorsNorepinephrine Compared With Dopamine in Severe Sepsis Summary of EvidenceOutcomesAssumed riskCorresponding riskRelative effectNo. of participantsDANE0.91(0.83 to 0.99)2043(6 studies)Short-term mortality530/10004

22、82 /1000(440 to 524)supraventricular arrhythmias229 /100082/1000(34 to 195)0.47(0.38 to 0.58)1931(2 studies)ventricular arrhythmias39 /100015/1000(8 to 27)0.35(0.19 to 0.66)1931(2 studies)26感染性休克指南解讀宣講if the Initial fluid resuscita1.Norepinephrine（NE） as the first choice of vasopressor (grade 1B).2.

23、Epinephrine (added to and substituted for norepinephrine) (grade 2B) when an additional agent is needed to maintain adequate blood pressure.3.Vasopressin（ 0.03 IU/min） -to be added to NE. intent: raise MAP ; decrease NE dosage; protect renal function (UG). Vasopressors血管活性藥物27感染性休克指南解讀宣講1.Norepineph

24、rine（NE） as the fi4.Dopamine（DA)- an alternative vasopressor agent to NE. (2C) only in highly selected patients (eg.patients with low risk of tachyarrhythmias and absolute or relative bradycardia心動(dòng)過(guò)緩) Low-dose dopamine should not be used renal protection (grade 1A). Vasopressors血管活性藥物28感染性休克指南解讀宣講4.

25、Dopamine（DA)- an alternatiA trial of dobutamine多巴酚丁胺 infusion up to 20 micrograms/kg/minbe administered or added to vasopressor (if in use)In the presence of: (a) myocardial dysfunction- elevate cardiac filling pressure, and low cardiac output, (b) hypoperfusion低灌注, despite achieving adequate intrav

26、ascular volume and adequate MAP (grade 1C).Vasopressors血管活性藥物29感染性休克指南解讀宣講A trial of dobutamine多巴酚丁胺 infCorticosteroids類固醇激素(1)Not using intravenous hydrocortisone氫化可的松 to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stabil

27、ity.In case,not achievable：hydrocortisone氫化可的松 200 mg qd. intravenous (grade 2A). When given, use continuous infusion (grade 2C). iv-p.優(yōu)于iv.30感染性休克指南解讀宣講Corticosteroids類固醇激素(1)Not us（2） Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone (grade

28、2B).（3）reduce the treated patient from steroid therapy when vasopressors are no longer required (grade 2D).（4）Corticosteroids not be administered for the treatment of sepsis in the absence of shock (grade 1D).Corticosteroids類固醇激素31感染性休克指南解讀宣講（2） Not using the ACTH stimulaAdjunctive TherapyEmphasizes

29、!Blood Product Administratio Mechanical Ventilation of Sepsis-Induced ARDsGlucose ControlStress Ulcer ProphylaxisDeep Vein Thrombosis Prophylaxis NutritionRenal Replacement TherapySedation, Analgesia, and Neuromuscular Blockade in Sepsis32感染性休克指南解讀宣講Adjunctive TherapyEmphasizesBlood Product Administ

30、ration血制品的輸注（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB) decreases to 70 g/L (grade 1B). to target a HGB of 70-90 g/L,inmergerofextenuating circumstances: (a) myocardial ischemia (b) severe hypoxemia頑固性低氧血癥 (c) acute hemorrhage or ischemic coronary artery

31、 disease33感染性休克指南解讀宣講Blood Product Administration（2） use fresh frozen plasma新鮮冰凍血漿. Not only to be corrected laboratory clotting abnormalities but also to be used in bleeding or planned invasive procedures (grade 2D) ；（3） recommend against antithrombin凝血酶 administration(grade 2D).（4） prophylacticall

32、y Platelets Administration (grade 2D) PLT(1 0,000 / L) in the absence of apparent bleeding; PLT(2 0,000/ L) if the patient has a significant risk of bleeding.（5） not using EPO as a specific treatment of anemia .Blood Product Administration血制品的輸注34感染性休克指南解讀宣講（2） use fresh frozen plasma新鮮冰not using in

33、travenous immunoglobulins (grade 2B).History of Recommendations Regarding Use of Recombinant Activated Protein C (rhAPC)-no longer available. 重組人活性蛋白CNot using intravenous selenium硒收益7.15 (grade 2B).5%NaHCO3（ml）=(24-HCO3-)*weight/3 36感染性休克指南解讀宣講Bicarbonate Therapy碳酸氫鹽recommeStress Ulcer Prophylaxis應(yīng)

34、激性潰瘍預(yù)防 Stress ulcer prophylaxis using proton pump inhibitors (PPI) (grade 1B) rather than H2 receptor antagonists (H2RA) (grade 2C). PPI優(yōu)于H2RAwithout risk factors should not receive prophylaxis (grade 2B).37感染性休克指南解讀宣講Stress Ulcer Prophylaxis應(yīng)激性潰瘍Continuous Renal Replacement Therapy(CRRT)suggest tha

35、t CRRT and Intermittent Hemodialysis間斷血透 are equivalent in patients with severe sepsis and acute renal failure (grade 2B) . CRRT to facilitate management of fluid balance in hemodynamically unstable septic patients (grade 2D). 38感染性休克指南解讀宣講Continuous Renal Replacement T感染性休克指南解讀宣講培訓(xùn)課件Deep Vein Throm

36、bosis Prophylaxis深靜脈血栓的預(yù)防daily subcutaneous low-molecular weight heparin (LMWH) grade 1B versus UFH twice daily. grade 2C versus UFH given thrice daily. If creatinine clearance is 30 mL/min, we recommend use of UFH (grade 1A).patients who have a contraindication禁忌癥 to heparin receive mechanical prop

37、hylactic treatment充氣性機(jī)械裝置 (eg, thrombocytopenia血小板減少癥, active bleeding, recent intracerebral hemorrhage腦內(nèi)出血)40感染性休克指南解讀宣講Deep Vein Thrombosis ProphylaxNutrition營(yíng)養(yǎng)支持suggest administering oral or enteral feedings腸內(nèi)營(yíng)養(yǎng),as tolerated, rather than either complete fasting禁食 or give only intravenous glucose

38、within the first 48hrs (grade 2C). suggest using intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) in the first 7 days (grade 2B).Avoidfullcaloricfeedinginthefirstweek,suggestlowdosefeeding(eg,upto500caloriesperday),advancing onlyastolerated(grade2B).41感染性休克指南解讀宣

39、講Nutrition營(yíng)養(yǎng)支持suggest administMechanical Ventilation機(jī)械通氣 of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（1）Target a tidal volume(潮氣量)of 6 mL/kg predicted body weight（2）initial upper limit goal for Plateau pressures(平臺(tái)壓)30 cm H2O (grade 1B)；（3）Positive end-expiratory pressure (最低PEEP) be

40、 applied to avoid alveolar collapse肺泡塌陷 at end expiration (grade 1B).（4）Prone positioning(俯臥位通氣)be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm Hg (grade 2B)；（5）Recruitment maneuvers(肺復(fù)張)be used in sepsis patients with severe refractory hypoxemia頑固性低氧血癥 (grade 2C).42感染性休克指南解讀宣講

41、Mechanical Ventilation機(jī)械通氣 of Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)（6）be maintained with the head of the bed elevated to 30-45 degrees to limit aspiration risk誤吸 and ventilator-associated pneumonia呼吸機(jī)相關(guān)肺炎 (grade 1B)；（7）noninvasive mask ventilation無(wú)創(chuàng)面罩 be

42、 used in that minority of patients in whom the benefits of NIV have been carefully sonsidered and are thought to outweight the risks(grade 2B)；（8）Against the routine use of the pulmonary artery catheter(肺動(dòng)脈導(dǎo)管)；43感染性休克指南解讀宣講Mechanical Ventilation of SepsSetting Goals of Care確立治療目標(biāo)（1）Discuss goals of

43、care and prognosis with patients and families (grade 1B).將診斷及進(jìn)一步治療方案與患者家屬溝通（2）Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate (grade 1B).包括預(yù)后，終止生命的方式以及姑息治療措施（3）Address goals of care as early as feasible, but no later than

44、 within 72 hours of ICU admission (grade 2C).44感染性休克指南解讀宣講Setting Goals of Care確立治療目標(biāo)（1Enhance theearlier recognition of sepsis.Resuscitation as soon as possible.Care of Evidence-basedmedicineEmphasizes the significance of adjuvant therapy集束化（BUNDLE）治療策略u(píng)pdate45感染性休克指南解讀宣講Enhance theearlier recognitioSepsis resucitation bundle初始復(fù)蘇1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics廣譜抗生素 4) Administer 30 mL/kg crystalloid for hypotension or l