感染性休克co存在低正常和高3种情况课件

严重感染和感染性休克 治疗进展 邱海波 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所 Annual incidence of severe sepsis: 3 cases/ 1,000 Kill: 1,400 people worldwide /d 25 people /h Moreover, No. of sepsis pats is projected to increase by 1.5% per annum 严重感染的病死人数超过乳腺癌、直肠癌、结肠 癌、胰腺癌和前列腺癌的总和 严重感染 vs AMI:发病率相同，病死率明显高 Sepsis in worldwide Surviving Sepsis Compaign 拯救Sepsis运动 巴塞罗那宣言巴塞罗那宣言 ESICM SCCM ISFESICM SCCM ISF 20022002年年1010月月2 2日日, , 西班牙西班牙 Commit to a goal of a 25% relative Commit to a goal of a 25% relative reduction of mortality from sepsis in 5Yreduction of mortality from sepsis in 5Y Surviving Sepsis Campaign Phase : Barcelona Declaration Phase : Guidelines creation Phase : Clinical outcome evaluation GUIDELINES FOR MANAGEMENGT OF SEVERE SEPSIS AND SEPTIC SHOCK AACCN; American Association of Critical-Care Nurses AACCN; American Association of Critical-Care Nurses ACCP: American College of Chest Physicians ACCP: American College of Chest Physicians ACEP: American College of Emergency PhysiciansACEP: American College of Emergency Physicians ATS: American Thoracic Society ATS: American Thoracic Society ANZICS: Australian and New Zealand Intensive Care SocietyANZICS: Australian and New Zealand Intensive Care Society ESCMID: European Society of Clinical Microbiology and Infectious ESCMID: European Society of Clinical Microbiology and Infectious DisDis ERS: European Respiratory Society ERS: European Respiratory Society SIF: Surgical Infection SocietySIF: Surgical Infection Society ESICM: European Society of Intensive Care MedicineESICM: European Society of Intensive Care Medicine ISF:InternationalISF:International Sepsis Forum Sepsis Forum SCCM: Society of Critical Care MedicineSCCM: Society of Critical Care Medicine Guidelines for sepsis. Intensive Care Med 2004, 30: 536-555 循证医学-推荐级别 A：至少2个级研究证实 B： 1个级研究证实 C： 级研究证实 D：至少1个级研究证实 E：或级研究证实 研究级别 I I. Large, randomized trials with . Large, randomized trials with clearcutclearcut results results II II. Small, randomized trials with uncertain results. Small, randomized trials with uncertain results IIIIII. Nonrandomized, contemporaneous controls. Nonrandomized, contemporaneous controls IVIV. Nonrandomized, historical controls and expert opinion. Nonrandomized, historical controls and expert opinion V V. Case series, uncontrolled studies, and expert opinion. Case series, uncontrolled studies, and expert opinion A-Initial resuscitation: early goal-directed therapyA-Initial resuscitation: early goal-directed therapy B-Diagnosis: appropriate cultureB-Diagnosis: appropriate culture C-Antibiotic therapy: Early broad-spectrum, C-Antibiotic therapy: Early broad-spectrum, reassessed 2-3d reassessed 2-3d D-Source controlD-Source control: : E-Fluid therapy: colloids=crystalloids,VLTE-Fluid therapy: colloids=crystalloids,VLT F-F-VasopressorsVasopressors: After VLS, NE : After VLS, NE vsvs DopaDopa, Low-dose , Low-dose dopadopa is not , is not , cathcath for for vasovaso G-G-InotropicInotropic therapy: low CO- therapy: low CO-dobudobu, high CO is not, high CO is not H-Steroid: low dose H-Steroid: low dose I- I-rhAPCrhAPC: APACHE II 25, sepsis-induced ARDS/MOF : APACHE II 25, sepsis-induced ARDS/MOF and no bleeding riskand no bleeding risk J-Blood product administration: target J-Blood product administration: target HbHb 7-9g/dl, EPO 7-9g/dl, EPO only in renal failureonly in renal failure K-Mechanical ventilation: K-Mechanical ventilation: PplaPpla20 mm Hg lContinous aspiration of subglottic secretions lContaminated condensate should be emptied ATS. Am J Respir Crit Care Med 2005;171:388-416 Modifiable Risk Factors Aspiration, body position, and feeding lSemirecumbent position (30-45) lEnteral feeding is preferred Modulation of colonization lRoutine prophylaxis is not recommended Stress bleeding prophylaxis, transfusion, and hyperglysemia lH2 antogonists or sucralfate is acceptable lRestricted transfusion trigger policy lIntensive insulin therapy ATS. Am J Respir Crit Care Med 2005;171:388-416 E. 液体治疗 1. Fluid resuscitation may consist of artificial colloids or crystalloids. There is no evidence-based support of one type of fluid over another Grade CGrade C E. 液体治疗 2. Fluid challenge in pats with suspected hypovolemia may be given at a rate of 500- 1000ml of crystalloids or 300-500ml colloids over 30min and repeated based on response (increase in BP and urine output) and tolerance (evidence of intravascular volume overload) Grade EGrade E F. 血管活性药物 1. 充分液体复苏后血压和器官灌注仍不能维持，是应用 血管活性药物的指征；对于威胁生命的低血压，即使低容量 状态尚未纠正，也应及时使用血管活性药物 Grade E 2.去甲肾上腺素和多巴胺是治疗感染性休克的一线药物 Grade D 3.小剂量多巴胺对重症感染者无肾保护作 用 Grade B F. 血管活性药物 4.应用血管活性药物时，最好采用动脉置管监测有创 血压 Grade E 5.充分容量复苏和大剂量传统血管活性药物无效的难 治性休克，可应用血管加压素（0.010.04Umin） （降低SV） Grade E NE和Dopa优于肾上腺素和苯肾上腺素 Dopa通过提高SV和HR来提高动脉BP和CI NE通过缩血管效应来提高BP，不改变SV和HR NE改善低血压状态更有效，Dopa改善心肌收缩力 更有效，但易致心律失常 血管活性药物 Martin C. Chest 1993:1826-1831 A large randomized trial and a meta- analysis Low-dose dopamine and placebo No difference in Peak serum Cr, need for RRT,Urine output, timeto recovery of normal renal function Survival, ICU stay, Hospital stay, Arrhythmias 血管活性药物 Low-dose dopamine should not be used for renal protection as part of the treatment of severe sepsis Bellomo R. Lancet 2000, 356: 2139 Kellum J. CCM, 2003, 29:1526 G.正性肌力药物 1.如果病人经充分容量复苏后,存在低CO，可应 用Dobu；对低血压者，应联合应用血管活性药物 合适的容量状态和MAP时，Dobu是低CI者首选 无CO监测时，感染性休克CO存在低、正常和高 3种情况，推荐NEDopa 能够监测血压和CO时，可目标性应用NE提升血 压，应用Dobu提高CO Grade EGrade E G.正性肌力药物 2.应用Dobu以达到超常的氧输送水平对 重症感染无效 Grade AGrade A H. 糖皮质激素 1.经足够液体复苏，但仍需应用缩血管 药物维持血压的感染性休克患者，推荐应 用皮质类固醇激素。氢化可的松200- 300mg/d，分34 次静点，连用7d Grade C a. 对于感染性休克，不需作ACTH应激 试验就可应用激素 Grade E b. 休克改善后，激素应减量 Grade E 肾上腺功能低下的感染性休克 低剂量的糖皮质激素可逆转休克、降低病死率 IObjective: evaluated low dose GS to survival in septic shock patients and AI (Post-ACTH cortisol rise 215 mg/dl maintain 180200 mg/dl Greet VB et al. N Engl J Med 2001, 345: 1359-1367 Base line Convention(n)Intensive(n) N783765 Age6263 APACHE 99 diabetes103101 Blood glucose 110598557 20010181 Reason for ICU Cardiac surgery Neurologic disease Thoracic surgery, respiratory insufficiency Abdominal surgery or peritonitis Multiple trauma or severe burns Transplantation Other 493 477 30 33 56 66 58 45 35 33 44 46 35 35 Greet VB et al. N Engl J Med 2001, 345: 1359-1367 Study design and Results P110 mg/dl 80110 mg/dl Max-dose of insulin: 50 u/h Convention insulin therapy: If 215 mg/dl 180200 mg/dl N.肾脏替代治疗 1. 合并急性肾衰时，CVVH和或间歇性 血液透析均可进行肾脏替代治疗，但对于 血流动力学不稳定者，CRRT更有利于液 体管理 (Septic shock CRRT: Vasopressor) Grade BGrade B N. 碱性药物 1.pH 7.15时不推荐应用碱性药物以对 抗由于低灌注引起的乳酸血症 Grade CGrade C Prospective, randomized, blinded, crossover study 14 pats with metabolic acidosis pH 7.13, bicarbonate 15mins Control: sodium chloride (equal dose, volume, time) Bicarbonate therapy Cooper DJ. Ann Intern Med 1990, 112:492 P.深静脉血栓预防 对于重症感染患者应该应用小剂量肝素 或低分子肝素预防DVT 对于有肝素禁忌症的全身性感染患者， 推荐使用（除非病人有外周血管疾病的禁 忌症）机械预防装置。对于极高危者，如 有DVT病史的重症感染患者，推荐联合使 用抗凝和机械预防装置 Grade AGrade A Q.应激性溃疡预防 1. 所有重症感染患者都应应用H2受体阻 断剂以预防应激性溃疡；H2受体阻断剂比 硫糖铝更有效； H2受体阻断剂与PPI缺乏 比较性研究，但制酸效果类似 G