感染性休克指南解读宣讲培训课件.ppt

1、感染性休克指南解读宣讲Index case查体：查体：T37.5，P88次次/分，分，R19次次/分，分，BP125/68mmHg。神志清。神志清楚，楚，全身皮肤、巩膜黄染，双侧肝掌，全身皮肤、巩膜黄染，双侧肝掌，未见蜘蛛痣，浅表淋巴结未触未见蜘蛛痣，浅表淋巴结未触及，双肺未闻及干湿性啰音，心律齐，各瓣膜区未闻及杂音，腹无压及，双肺未闻及干湿性啰音，心律齐，各瓣膜区未闻及杂音，腹无压痛、反跳痛，肝脾肋下未触及，墨菲氏征阴性，移动性浊音阴性，肠痛、反跳痛，肝脾肋下未触及，墨菲氏征阴性，移动性浊音阴性，肠鸣音鸣音3次次/分，分，双下肢轻度浮肿双下肢轻度浮肿。初步诊断：初步诊断：1.肝硬化失代偿期肝

2、硬化失代偿期(胆汁淤积性胆汁淤积性)2.高血压病高血压病3.慢性胆囊炎慢性胆囊炎治疗方案：思美泰、易善复、天晴甘美治疗方案：思美泰、易善复、天晴甘美保肝保肝前列地尔前列地尔改善肝内循环改善肝内循环螺内酯螺内酯利尿利尿2感染性休克指南解读宣讲Baseline（6.29）（7.3）WBC6.104.54N%51.449.5Lac/PH/TB67.256.5ALB24.530.4ALT2935CHE11971281Cr74.675GRR56.8358.11CRP9.2614.22PCT12PH/7.25TB67.256.546.9ALB24.530.425.7ALT293531CHE11971281

3、772Cr74.675121.1212.6GRR56.8358.11CRP9.2614.2213.2822.92PCT5000Pro-BNP168/4100INR1.531.532.19culturesEscherichia coli(+)*25感染性休克指南解读宣讲Index caseName:ChenYiMingAge:75yearsSex:maleID:Madmissiontime:2016.02.142016.02.17主诉：主诉：suddenfeverandshiver6hours现病史：入院前现病史：入院前6小时无明显诱因出现畏冷、发热，体温最高小时无明显诱因出现畏冷、发热，体温最

4、高39.1，伴寒战、右侧胸痛，偶有咳嗽、咳痰，急诊我院，查血常规提示伴寒战、右侧胸痛，偶有咳嗽、咳痰，急诊我院，查血常规提示WBC12.44109/L，N11.30109/L，N90.8，急诊生化：，急诊生化：AST123U/L，糖，糖9.73mmol/L；肺部；肺部CT：双肺炎症：双肺炎症6感染性休克指南解读宣讲Index case既往史：有高血压病既往史：有高血压病10余年，不规则服用余年，不规则服用“安内真、氯沙坦、双克安内真、氯沙坦、双克”等药物，未监测血压；等药物，未监测血压；6年前出现反酸、嗳气，就诊我院行胃镜后诊断年前出现反酸、嗳气，就诊我院行胃镜后诊断“反流性食管炎（反流性食管

5、炎（1级）级），慢性浅表性胃炎（，慢性浅表性胃炎（2级）级）”，间断服用保胃药，现仍偶有反酸；，间断服用保胃药，现仍偶有反酸；4年前因进行性排尿困难，就诊我院，诊断年前因进行性排尿困难，就诊我院，诊断“前列腺增生症，膀胱多发前列腺增生症，膀胱多发结石，双肾囊肿结石，双肾囊肿”，行，行“经尿道前列腺切除术膀胱切开取石术经尿道前列腺切除术膀胱切开取石术”，术，术后无再出现排尿困难。后无再出现排尿困难。3月前因反复腹痛月前因反复腹痛20天就诊我院，诊断天就诊我院，诊断“胆囊穿孔、胆囊结石并胆囊炎胆囊穿孔、胆囊结石并胆囊炎”，予保肝、解痉止痛等保守治疗后症状好转。，予保肝、解痉止痛等保守治疗后症状好转

6、。7感染性休克指南解读宣讲查体：查体：T36.5，P88次次/分，分，R20次次/分，分，BP110/65mmHg。神清，。神清，精精神疲乏神疲乏，锁骨上等浅表淋巴结未触及肿大，锁骨上等浅表淋巴结未触及肿大，双肺呼吸音粗，双下肺有闻双肺呼吸音粗，双下肺有闻及少许湿性啰音及少许湿性啰音。心律齐，各瓣膜听诊区未闻及杂音，腹平软，全腹部。心律齐，各瓣膜听诊区未闻及杂音，腹平软，全腹部无压痛，无反跳痛，无压痛，无反跳痛，Murphy征阴性，肝脾未触及，移动性浊音阴性，征阴性，肝脾未触及，移动性浊音阴性，肠鸣音肠鸣音3次次/分，双下肢无水肿。分，双下肢无水肿。初步诊断：初步诊断：1.肺炎肺炎2.高血压病

7、高血压病3.脂肪肝脂肪肝4.胆囊结石伴慢性胆囊炎胆囊结石伴慢性胆囊炎5.反流反流性食管炎性食管炎6.慢性胃炎慢性胃炎7.单纯性肾囊肿单纯性肾囊肿8.前列腺增生前列腺增生9.颈动脉硬化颈动脉硬化10.手手术后状态术后状态(经尿道前列腺电切术经尿道前列腺电切术+膀胱切开取石术膀胱切开取石术)治疗方案：考虑患者为社区获得性肺炎，予头孢美唑抗感染，沐舒坦祛治疗方案：考虑患者为社区获得性肺炎，予头孢美唑抗感染，沐舒坦祛痰，薄芝糖肽提高免疫力，易善复保肝及补液营养支持痰，薄芝糖肽提高免疫力，易善复保肝及补液营养支持8感染性休克指南解读宣讲门诊门诊（2.14）变症变症（2.14）WBC12.4411.89N

8、11.3010.86N%90.891.4Cr83.3CRP120PCT10Pro-BNP4800INR1.432.1419:00患者突发四肢抽搐，伴发热、患者突发四肢抽搐，伴发热、畏冷、寒战。查体：畏冷、寒战。查体：T38.5，P100次次/分，分，R22次次/分，分，BP88/50mmHg。神志。神志欠清，双下肢皮肤花斑样改变，右侧乳欠清，双下肢皮肤花斑样改变，右侧乳头至脐水平广泛压痛，头至脐水平广泛压痛，双肺呼吸音粗，双肺呼吸音粗，双下肺有闻及少许湿性啰音。心律齐，双下肺有闻及少许湿性啰音。心律齐，无杂音，无杂音，Morphy征可疑阳性征可疑阳性，肠鸣音，肠鸣音3次次/分，双下肢无水肿。分

9、，双下肢无水肿。9感染性休克指南解读宣讲10感染性休克指南解读宣讲11感染性休克指南解读宣讲Problemlist:In essence,at different stages of the one same disease12感染性休克指南解读宣讲SIRSsystemicinflammatoryresponsesyndromeGeneralvariables Fever(38.3C)，Hypothermia低体温低体温(coretemperature90/min1ormorethantwosdabovethenormalvalueforage Tachypnea呼吸急促呼吸急促（20次次/m

10、in,PaCO212,000/L)Leukopenia(WBCcount20ml/kgover24hr)Hyperglycemia高血糖症高血糖症(plasmaglucose140mg/dlor7.7mmol/L)intheabsenceofdiabetes Definition14感染性休克指南解读宣讲SepsisSIRS is secondary to documented or suspected infection.Sepsis-induced hypotensionLactate乳酸 above upper limits laboratory normalUrine output 1

11、76.8 mol/LAcute lung injury with Pao2/Fio2（OI）34.2 mol/LPLT 1.5)Definition15感染性休克指南解读宣讲DefinitionSepticshockis defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.16感染性休克指南解读宣讲Diagnostic1.Culturesas clinically appropriate before antimicrobial therapy if no significa

12、nt delay(45 mins)in the start of antimicrobial(s)(grade 1C).At least 2 sets of blood cultures(both aerobic需氧 and anaerobic厌氧 bottles)be obtained before antimicrobial therapy with at least 1 drawn percutaneously经皮地 and 1 drawn through each vascular access device，unless the device was recently(48hrs)i

13、nserted(grade 1C).17感染性休克指南解读宣讲2.diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay(grade 2B),mannan and anti-mannan antibody assays(2C).葡聚糖试验、半乳甘露聚糖试验3.Imaging studies、Plasma C-reactive protein（CRP）、Plasma procalcitonin（PCT）Contribute to confirm a potential source of infection(UG).D

14、iagnostic18感染性休克指南解读宣讲Recommendations:l SourceControll AntimicrobialTherapyl Vasopressorsl CorticosteroidspAdjunctiveTherapylBlood Product Administratio lMechanical Ventilation of Sepsis-Induced ARDslGlucose ControllStress Ulcer ProphylaxislDeep Vein Thrombosis Prophylaxis lNutritionlRenal Replaceme

15、nt TherapylSedation,Analgesia,and Neuromuscular Blockade in SepsispEvidence-basedmedicine19感染性休克指南解读宣讲SourceControl1）recommend crystalloids晶体液晶体液 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白蛋白白蛋白 in the fluid resusci

16、tation when patients require substantial amounts of crystalloids(grade 2C).3）recommend against the use of hydroxyethylstarches(羟乙基淀粉）for fluid resuscitation of severe sepsis and septic shock(grade 1B).20感染性休克指南解读宣讲SourceControl；achieve 30 mL/kg of crystalloids administrationQuantity量量MAP、SVV、CO、SBP、

17、HRmonitoringIndex监测指标监测指标CVP 8-12mmH2O，MAP65 mmHg，Urine output 0.5ml/kg/h，ScvO270%或SvO265%GoalsforInitialResuscitation(6hrs)复苏目标复苏目标21感染性休克指南解读宣讲AntimicrobialTherapy1.Administration of effective intravenous antimicrobials within 1st hour2a.Initial empiric anti-infective therapy of one or more drugs，

18、have activity against all likely pathogens(bacterial and/or fungal or viral)(grade 1B)2b.Antimicrobial regimen抗菌药物组合 should be reassessed daily for potential de-escalation降阶梯(grade 1B)22感染性休克指南解读宣讲AntimicrobialTherapy3.Use of low PCT levels or similar biomarkers to assist the clinicians in the disco

19、ntinuation of empiric antibiotics in patients who initially appeared septic,but have no subsequent evidence of infection(grade 2C)23感染性休克指南解读宣讲4.duration of therapy:7 to 10 days AntimicrobialTherapy Neutropenic patients粒缺 multidrug-resistant Acinetobacter多重耐药菌不动杆菌Pseudomonas spp铜绿假单胞菌(grade 2B)combi

20、nation empiric therapy have a slow clinical response undrainable oci of infection感染灶无法很好的引流 bacteremia with S.aureus金葡;some fungal and viral infections immunologic deficiencies(grade 2C)longer courses24感染性休克指南解读宣讲5.Antiviral therapy抗病毒治疗 initiated as early as possible in patients with severe sepsis

21、or septic shock of viral origin(grade 2C).AntimicrobialTherapy25感染性休克指南解读宣讲iftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).血管活性药物血管活性药物VasopressorsNorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidenceOutcomesAssumed riskC

22、orresponding riskRelative effectNo.of participantsDANE0.91(0.83 to 0.99)2043(6 studies)Short-term mortality530/1000482/1000(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

23、)26感染性休克指南解读宣讲1.Norepinephrine（NE）as the first choice of vasopressor(grade 1B).2.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;p

24、rotect renal function(UG).Vasopressors血管活性药物血管活性药物27感染性休克指南解读宣讲4.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心动过缓)Low-dose dopamine should not be used renal protection(grade

25、 1A).Vasopressors血管活性药物血管活性药物28感染性休克指南解读宣讲A trial of dobutamine多巴酚丁胺 infusion up to 20 micrograms/kg/minbe administered or added to vasopressor(if in use)Inthepresenceof:(a)myocardial dysfunction-elevate cardiac filling pressure,and low cardiac output,(b)hypoperfusion低灌注,despite achieving adequate i

26、ntravascular volume and adequate MAP(grade 1C).Vasopressors血管活性药物血管活性药物29感染性休克指南解读宣讲Corticosteroids类固醇激素类固醇激素(1)Not using intravenous hydrocortisone氢化可的松 to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.In case,not

27、 achievable：hydrocortisone氢化可的松 200 mg qd.intravenous(grade 2A).When given,use continuous infusion(grade 2C).iv-p.优于iv.30感染性休克指南解读宣讲（2）Not using the ACTH stimulation test to identify adults with septic shock who should receive hydrocortisone(grade 2B).（3）reduce the treated patient from steroid thera

28、py 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类固醇激素类固醇激素31感染性休克指南解读宣讲AdjunctiveTherapyEmphasizes!BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseContro

29、lStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis32感染性休克指南解读宣讲BloodProductAdministration血制品的输注血制品的输注u（1）recommend red blood cell transfusion occur only when the hemoglobin concentration(HGB)decreases to 70 g/L(grad

30、e 1B).u to target a HGB of 70-90 g/L,in merger of extenuatingcircumstances:(a)myocardial ischemia(b)severe hypoxemia顽固性低氧血症(c)acute hemorrhage or ischemic coronary artery disease33感染性休克指南解读宣讲（2）use fresh frozen plasma新鲜冰冻血浆.Not only to be corrected laboratory clotting abnormalities but also to be us

31、ed in bleeding or planned invasive procedures(grade 2D)；（3）recommend against antithrombin凝血酶 administration(grade 2D).（4）prophylactically 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 E

32、PO as a specific treatment of anemia.BloodProductAdministration血制品的输注血制品的输注34感染性休克指南解读宣讲not using intravenous immunoglobulins(grade 2B).History of Recommendations Regarding Use of Recombinant Activated Protein C(rhAPC)-no longer available.重组人活性蛋白CNot using intravenous selenium硒 收益收益7.15(grade 2B).5%

33、NaHCO3（ml）=(24-HCO3-)*weight/3 36感染性休克指南解读宣讲StressUlcerProphylaxis应激性溃疡预防应激性溃疡预防 Stress ulcer prophylaxis using proton pump inhibitors(PPI)(grade 1B)rather than H2 receptor antagonists(H2RA)(grade 2C).PPI优于H2RA without risk factors should not receive prophylaxis(grade 2B).37感染性休克指南解读宣讲ContinuousRena

34、lReplacementTherapy(CRRT)suggest that CRRT and Intermittent Hemodialysis间断血透 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感染性休克指南解读宣讲DeepVeinThrombosisProphylaxis

35、深静脉血栓的预防深静脉血栓的预防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禁忌症 to heparin receive mechanical prophylactic treatm

36、ent充气性机械装置(eg,thrombocytopenia血小板减少症,active bleeding,recent intracerebral hemorrhage脑内出血)40感染性休克指南解读宣讲Nutrition营养支持营养支持suggest administering oral or enteral feedings肠内营养,as tolerated,rather than either complete fasting禁食 or give only intravenous glucose within the first 48hrs(grade 2C).suggest using

37、 intravenous glucose and enteral nutrition rather than total parenteral nutrition(TPN)in the first 7 days(grade 2B).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).41感染性休克指南解读宣讲MechanicalVentilation机械通气机械通气ofS

38、epsis-InducedAcuteRespiratoryDistressSyndrome(ARDS)（1）Target a tidal volume(潮气量)of 6 mL/kg predicted body weight（2）initial upper limit goal for Plateau pressures(平台压)30 cm H2O(grade 1B)；（3）Positive end-expiratory pressure(最低PEEP)be applied to avoid alveolar collapse肺泡塌陷 at end expiration(grade 1B).（

39、4）Prone positioning(俯卧位通气)be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio 100 mm Hg(grade 2B)；（5）Recruitment maneuvers(肺复张)be used in sepsis patients with severe refractory hypoxemia顽固性低氧血症(grade 2C).42感染性休克指南解读宣讲MechanicalVentilationofSepsis-InducedAcuteRespiratoryDistressSyndrome(AR

40、DS)（6）be maintained with the head of the bed elevated to 30-45 degrees to limit aspiration risk误吸 and ventilator-associated pneumonia呼吸机相关肺炎(grade 1B)；（7）noninvasive mask ventilation无创面罩 be used in that minority of patients in whom the benefits of NIV have been carefully sonsidered and are thought t

41、o outweight the risks(grade 2B)；（8）Against the routine use of the pulmonary artery catheter(肺动脉导管)；43感染性休克指南解读宣讲SettingGoalsofCare确立治疗目标确立治疗目标（1）Discuss goals of care and prognosis with patients and families(grade 1B).将诊断及进一步治疗方案与患者家属沟通（2）Incorporate goals of care into treatment and end-of-life care

42、 planning,utilizing palliative care principles where appropriate(grade 1B).包括预后，终止生命的方式以及姑息治疗措施（3）Address goals of care as early as feasible,but no later than within 72 hours of ICU admission(grade 2C).44感染性休克指南解读宣讲 Enhance the earlier recognition of sepsis.Resuscitation as soon as possible.Care of

43、Evidence-basedmedicine Emphasizes the significance of adjuvant therapy 集束化（BUNDLE）治疗策略update45感染性休克指南解读宣讲Sepsisresucitationbundle初始复苏初始复苏 1)Measure lactate level 2)Obtain blood cultures prior to administration of antibiotics 3)Administer broad spectrum antibiotics广谱抗生素 4)Administer 30 mL/kg crystall

44、oid for hypotension or lactate 4mmol/L 1h内使用抗菌药物，内使用抗菌药物，3h内启动监测和体液复苏！内启动监测和体液复苏！TOBECOMPLETEDWITHIN3HOURS:46感染性休克指南解读宣讲Septicshockbundle感染性休克感染性休克1)vasopressors to maintain MAP 65 mm Hg2)In the event of persistent arterial hypotension顽固性低血压 despite volume resuscitation(septic shock)or initial lacta

45、te 4 mmol/L(36 mg/dL):-Measure CVP*-Measure SCVO2*-Remeasure lactate if initial lactate was elevated*Targets for quantitative resuscitation in cluded in the guidelines are CVP of 8 mm H2O,SCVO270%,and normalization of lactate.6h内达成治疗目标及再次评估！内达成治疗目标及再次评估！TOBECOMPLETEDWITHIN6HOURS:47感染性休克指南解读宣讲2016中国急

46、诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update48感染性休克指南解读宣讲2016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update49感染性休克指南解读宣讲2016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update 容量反应评估方法容量反应评估方法 CVP指导的补液试验指导的补液试验 PAWP导向的补液试验导向的补液试验 功能性血流动力学参数：功能性血流动力学参数：SVV、PPV、SPV 超声：超声：SV、CO、SVR 被动抬腿试验被动抬腿试验50感染性休克指南解读宣讲2016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实

47、践指南update Expound physiopathologic mechanism Opportunity of Steroids and immunomodulatory drugs病原体病原体免疫细胞免疫细胞细胞因子细胞因子炎症介质炎症介质级联反应级联反应SIRS过量抗炎物质过量抗炎物质CARS感染性休克可以不依赖细菌和毒素的持续存在而发生和发展，细菌和感染性休克可以不依赖细菌和毒素的持续存在而发生和发展，细菌和毒素仅起到毒素仅起到触发触发急性全身感染的作用，其发展与否及轻重程度完全取急性全身感染的作用，其发展与否及轻重程度完全取决于决于机体的反应性机体的反应性。因此在治疗感染性休克

48、时，应正确评价个体的免疫状态。因此在治疗感染性休克时，应正确评价个体的免疫状态。MODS51感染性休克指南解读宣讲2016中国急诊感染性休克临床实践指南中国急诊感染性休克临床实践指南update在在SIRS反应反应初期初期，激素激素应用对患者有积极作用，但对于免疫抑制的应用对患者有积极作用，但对于免疫抑制的患者应谨慎使用患者应谨慎使用保护血管内皮保护血管内皮乌司他丁乌司他丁抑制炎症介质的产生和释放抑制炎症介质的产生和释放改善微循环改善微循环 Expond physiopathologic mechanism Opportunity of Steroids and immunomodulatory drugsSIRSCARS52感染性休克指南解读宣讲53感染性休克指南解读宣讲