3.mods09多器官功能衰竭

多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS)中山大学附属一院急诊科 李玉杰目的1. 掌握 SIRS、 sepsis、 MODS的概念2. 熟悉 SIRS的诊断标准3. 了解： SIRS的发病机制、治疗原则sepsis的病理生理、诊断、治疗原则MODS的发病机制、诊断、治疗原则4. 自学：其他内容 第一节全身炎症反应综合征(systemic inflammatory response syndrome, SIRS )SIRS（ 1）定义 机体对致病因子的过度应激反应，引起炎症性损伤的综合征病因 感染 病原生物非感染 所有损害机体健康的事件SIRS（ 2）发病机制炎症细胞（单核 -巨噬细胞等）的激活，促进释放炎症介质（ TNF-,IL-1;IL-6,IL-8,PAF,NO），引发免疫功能失调（炎症 /抗炎失衡）和生理功能紊乱（血管、血液成分、酶等）SIRS（ 3）发展阶段局部反应期全身炎症反应始动期全身炎症反应期过度免疫抑制期免疫功能紊乱期SIRS（ 4）诊断1. 体温 T 38 / 90 bpm3. 呼吸 R 20 bpm / PaCO2 12109 / L / 10 %符合 2项或以上ACCP/SCCM 1991SIRS（ 5）诊断标准*敏感性高，特异性低（假阳性）*结合其他评分系统*预警作用early recognitionEffective treatment requires early recognition of SIRSand the best way to catch the syndrome in its early stages is to identify patients who are most at risk for developing it. They include:* very young and very old patients* malnourished or immunocompromised patients* patients who have invasive catheters* patients with preexisting chronic disease* critically ill or critically injured patients* patients on long-term steroid medications or antibiotics* patients who are comatose when admitted.SIRS（ 6）治疗原则去除诱因治疗病因拮抗炎症介质单抗、拮抗剂、清除恢复免疫平衡对症支持中医中药第二节脓毒症 /病(sepsis)Sepsis(1)定义The presence of pathogenic micro-organisms or their toxins in tissues or in the blood. Systemic disease caused by the spread of the microorganisms via the circulating blood is commonly called septicemia (败血症/病 ) .sepsis=SIRS（感染性病原生物）SEPSIS IS SERIOUS BUSINESSIn 2003, septicemiaa type of sepsisranked as the 10th leading cause of death in the United States. About 750,000 patients are diagnosed with sepsis each year, and its the leading cause of noncardiac deaths in intensive care units. Despite intensive research efforts to develop effective treatments, the sepsis mortality rate hasnt declined: 28% to 50% of patients who develop sepsis die.Not only is the condition physically devastating for patients, but it also places an enormous strain on the health care system. The annual cost for treating sepsis is a staggering $16 billion to $17 billionapproximately $22,000 per sepsis patient.SepsisSepsis can be described as a step along a continuum that begins with a generalized inflammatory response to a trigger. The progression from infection to sepsis to septic shock to multiple organ dysfunction syndrome (MODS) is known as systemic inflammatory response syndrome (SIRS). The trigger is often a general or localized infection, but SIRS can also result from a noninfectious injury, such as a trauma or burn, or a serious illness, such as pancreatitis. SepticemiaSepticemia, which often proceeds MODS, is associated with microbial invasion from dirty wounds or dressings, and results in bacteraemia, SIRS, sepsis (hyper- or hypothermia, tachycardia, tachypnoea, leukocytosis), then severe sepsis hypotension, hypoxia, metabolic acidosis, diarrhea, disseminated intravasular coagulation (DIC) and septic shock (severe sepsis with hypotension unresponsive to i.v. volume replacement). sepsis（ 2）相关概念感染灶 局部 /全身（血循环）病原学 证实 /无依据感 染 轻 /重（多见）表 现 SIRS+病原性损害严重脓毒症 sepsis+MODS/MOF脓毒性休克 sepsis+shocksepsis（ 3）病理生理防御能力降低 抗炎介质心肌抑制、 EC受损和血管通透性增加、凝血系统活化及微血栓形成低血压和氧传输 /利用障碍高代谢和消耗：营养不良肠道细菌 /内毒素 移位 /易位外毒素基因多态性sepsis（ 4）临床表现全身表现感染征象血流动力学代谢变化组织灌注改变器官功能障碍Indication(1)Two or more of the following SIRS conditions can indicate sepsis:* temperature more than 38C (100.4F) or less than 36C (96.8F)* heart rate more than 90 beats per minute* respiratory rate more than 20 breaths per minute or PaCO2 less than 32 mm Hg (less than 4.3 kPa)* white blood cell count more than 12,000 cells/mm3, less than 4,000 cells/mm3, or more than 10 % immature (band) forms. Indication(2)Other signs and symptoms of sepsis include:* chills* hypotension* decreased skin perfusion* decreased urine output* significant edema or positive fluid balance (more than 20 ml/kg over 24 hours)* decreased capillary refill or mottling* hyperglycemia (plasma glucose more than 120 mg/dl) in the absence of diabetes* unexplained change in mental status. sepsis（ 6）治疗稳定血流动力学 液体复苏血管活性药物抗感染治疗器官功能监测与支持对症处理免疫调节中医中药four stages (1)1.Infection can be caused by Gram-negative microorganisms, Gram-positive microorganisms, fungi, viruses, or parasites. 2.Sepsis involves organ dysfunction, as the pathogens or toxins from pathogens travel through the blood and into tissues. Any organ system can be affected, but the cardiovascular and pulmonary systems are often the first to become involved.four stages (2)3.Septic shock is the next stage in the continuum. It presents differently in adults than in children. The hallmark of septic shock in adults is persistent unexplained hypotension despite adequate fluid volume resuscitation. In children, the earliest sign of septic shock is usually tachycardia, with signs of decreased tissue perfusion. 4.MODS, also referred to as multisystem organ failure, is the end stageand the most severe stageof SIRS, and it frequently ends in death. 第一部分定义概念及其演变定义指在多种急性致病因素所致机体原发病变的基础上，相继引发 2个或 2个以上器官同时或序贯出现的可逆性功能障碍。Multiple organ dysfunction syndrome (MODS), characterized by severe systemic inflammation and resulting in progressive loss of function of one or more vital organ after another, is a leading cause of mortality in intensive care units, and has been recognized as a distinct clinical entity since the 1970s. 单一器官衰竭循环系统：休克急性肾衰竭急性呼吸衰竭*疾病过程中，功能最脆弱的器官最早发生衰竭，临床医学的进步，对单一器官衰竭的救治积累了经验多器官衰竭：命名的演变1973 Tilney18 例腹主动脉瘤破裂，手术成功，病情稳定后不久出现肾衰竭，全身感染，心、肺、肝、胃肠、胰腺、 CNS衰竭sequential system failure序贯性系统衰竭Tilney