感染性休克指南医学PPT.ppt

2016中国急诊感染性休克临床实践指南 1 医药课件交流 Indexcase Name SunZuYuAge 63yearsSex femaleID 0680716admissiontime 2015 06 29 2015 07 06主诉 repeatedfatigue13years现病史 入院前13年无明显诱因出现乏力 纳差 食欲减退为原来的1 2 就诊福州市传染病院 查转氨酶增高 未见单 行肝穿检查 肝穿病理示 慢性胆汁性肝硬化 轻度 予保肝处理后 好转出院 出院后未定期复查 1月余前无明显诱因再次出现乏力 纳差 伴眼黄 尿黄 皮肤瘙痒 就诊我院 门诊拟 肝硬化 收住入院 2 医药课件交流 Indexcase 查体 T37 5 P88次 分 R19次 分 BP125 68mmHg 神志清楚 全身皮肤 巩膜黄染 双侧肝掌 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3次 分 双下肢轻度浮肿 初步诊断 1 肝硬化失代偿期 胆汁淤积性 2 高血压病3 慢性胆囊炎治疗方案 思美泰 易善复 天晴甘美 保肝前列地尔 改善肝内循环螺内酯 利尿 3 医药课件交流 肺部CT 上腹部MRI 增强 4 医药课件交流 5 医药课件交流 6 医药课件交流 Indexcase Name ChenYiMingAge 75yearsSex maleID Madmissiontime 2016 02 14 2016 02 17主诉 suddenfeverandshiver6hours现病史 入院前6小时无明显诱因出现畏冷 发热 体温最高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WBC12 44 109 L N11 30 109 L N 90 8 急诊生化 AST123U L 糖9 73mmol L 肺部CT 双肺炎症 7 医药课件交流 Indexcase 既往史 有高血压病10余年 不规则服用 安内真 氯沙坦 双克 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 反流性食管炎 1级 慢性浅表性胃炎 2级 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 前列腺增生症 膀胱多发结石 双肾囊肿 行 经尿道前列腺切除术 膀胱切开取石术 术后无再出现排尿困难 3月前因反复腹痛20天就诊我院 诊断 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 8 医药课件交流 查体 T36 5 P88次 分 R20次 分 BP110 65mmHg 神清 精神疲乏 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 全腹部无压痛 无反跳痛 Murphy征阴性 肝脾未触及 移动性浊音阴性 肠鸣音3次 分 双下肢无水肿 初步诊断 1 肺炎2 高血压病3 脂肪肝4 胆囊结石伴慢性胆囊炎5 反流性食管炎6 慢性胃炎7 单纯性肾囊肿8 前列腺增生9 颈动脉硬化10 手术后状态 经尿道前列腺电切术 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 沐舒坦祛痰 薄芝糖肽提高免疫力 易善复保肝及补液营养支持 9 医药课件交流 2 1419 00患者突发四肢抽搐 伴发热 畏冷 寒战 查体 T38 5 P100次 分 R22次 分 BP88 50mmHg 神志欠清 双下肢皮肤花斑样改变 右侧乳头至脐水平广泛压痛 双肺呼吸音粗 双下肺有闻及少许湿性啰音 心律齐 无杂音 Morphy征可疑阳性 肠鸣音3次 分 双下肢无水肿 10 医药课件交流 11 医药课件交流 12 医药课件交流 Problemlist Inessence atdifferentstagesoftheonesamedisease 13 医药课件交流 SIRS systemicinflammatoryresponsesyndromeGeneralvariablesFever 38 3 C Hypothermia低体温 coretemperature90 min 1ormorethantwosdabovethenormalvalueforageTachypnea呼吸急促 20次 min PaCO212 000 L Leukopenia WBCcount 4000 L NormalWBCcountwithgreaterthan10 immatureforms Definition 14 医药课件交流 SIRS Alteredmentalstatus Significantedemaorpositivefluidbalance 20ml kgover24hr Hyperglycemia高血糖症 plasmaglucose 140mg dlor7 7mmol L intheabsenceofdiabetes Definition 15 医药课件交流 Sepsis SIRSissecondarytodocumentedorsuspectedinfection Sepsis inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput176 8 mol LAcutelunginjurywithPao2 Fio2 OI 34 2 mol LPLT1 5 Definition 16 医药课件交流 Definition Septicshockisdefinedassepsis inducedhypotensionpersistingdespiteadequatefluidresuscitation 17 医药课件交流 Diagnostic 1 Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay 45mins inthestartofantimicrobial s grade1C Atleast2setsofbloodcultures bothaerobic需氧andanaerobic厌氧bottles beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice unlessthedevicewasrecently 48hrs inserted grade1C 18 医药课件交流 2 diagnosisoffungus真菌infection Useofthe1 3beta D glucanassay grade2B mannanandanti mannanantibodyassays 2C 葡聚糖试验 半乳甘露聚糖试验3 Imagingstudies PlasmaC reactiveprotein CRP Plasmaprocalcitonin PCT Contributetoconfirmapotentialsourceofinfection UG Diagnostic 19 医药课件交流 Recommendations SourceControlAntimicrobialTherapyVasopressorsCorticosteroids AdjunctiveTherapy BloodProductAdministratioMechanicalVentilationofSepsis InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation Analgesia andNeuromuscularBlockadeinSepsis Evidence basedmedicine 20 医药课件交流 SourceControl 1 recommendcrystalloids晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock grade1B 2 addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids grade2C 3 recommendagainsttheuseofhydroxyethylstarches 羟乙基淀粉 forfluidresuscitationofseveresepsisandsepticshock grade1B 21 医药课件交流 SourceControl 22 医药课件交流 AntimicrobialTherapy 1 Administrationofeffectiveintravenousantimicrobialswithin1sthour2a Initialempiricanti infectivetherapyofoneormoredrugs haveactivityagainstalllikelypathogens bacterialand orfungalorviral grade1B 2b Antimicrobialregimen抗菌药物组合shouldbereassesseddailyforpotentialde escalation降阶梯 grade1B 23 医药课件交流 AntimicrobialTherapy 3 UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic buthavenosubsequentevidenceofinfection grade2C 24 医药课件交流 4 durationoftherapy 7to10days AntimicrobialTherapy 25 医药课件交流 5 Antiviraltherapy抗病毒治疗initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin grade2C AntimicrobialTherapy 26 医药课件交流 iftheInitialfluidresuscitationdidnottargetameanarterialpressure MAP of65mmHg Vasopressortherapycanbeadded grade1C 血管活性药物Vasopressors NorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidence 27 医药课件交流 1 Norepinephrine NE asthefirstchoiceofvasopressor grade1B 2 Epinephrine addedtoandsubstitutedfornorepinephrine grade2B whenanadditionalagentisneededtomaintainadequatebloodpressure 3 Vasopressin 0 03IU min tobeaddedtoNE intent raiseMAP decreaseNEdosage protectrenalfunction UG Vasopressors血管活性药物 28 医药课件交流 4 Dopamine DA analternativevasopressoragenttoNE 2C onlyinhighlyselectedpatients eg patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心动过缓 Low dosedopamineshouldnotbeusedrenalprotection grade1A Vasopressors血管活性药物 29 医药课件交流 Atrialofdobutamine多巴酚丁胺infusionupto20micrograms kg minbeadministeredoraddedtovasopressor ifinuse Inthepresenceof a myocardialdysfunction elevatecardiacfillingpressure andlowcardiacoutput b hypoperfusion低灌注 despiteachievingadequateintravascularvolumeandadequateMAP grade1C Vasopressors血管活性药物 30 医药课件交流 Corticosteroids类固醇激素 1 Notusingintravenoushydrocortisone氢化可的松totreatadultsepticshockpatientsifadequatefluidresuscitationandvasopressortherapyareabletorestorehemodynamicstability Incase notachievable hydrocortisone氢化可的松200mgqd intravenous grade2A Whengiven usecontinuousinfusion grade2C iv p 优于iv 31 医药课件交流 2 NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone grade2B 3 reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired grade2D 4 Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock grade1D Corticosteroids类固醇激素 32 医药课件交流 AdjunctiveTherapyEmphasizes BloodProductAdministratioMechanicalVentilationofSepsis InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation Analgesia andNeuromuscularBlockadeinSepsis 33 医药课件交流 BloodProductAdministration血制品的输注 1 recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration HGB decreasesto 70g L grade1B totargetaHGBof70 90g L inmergerofextenuatingcircumstances a myocardialischemia b severehypoxemia顽固性低氧血症 c acutehemorrhageorischemiccoronaryarterydisease 34 医药课件交流 2 usefreshfrozenplasma新鲜冰冻血浆 Notonlytobecorrectedlaboratoryclottingabnormalitiesbutalsotobeusedinbleedingorplannedinvasiveprocedures grade2D 3 recommendagainstantithrombin凝血酶administration grade2D 4 prophylacticallyPlateletsAdministration grade2D PLT 10 000 L intheabsenceofapparentbleeding PLT 20 000 L ifthepatienthasasignificantriskofbleeding 5 notusingEPOasaspecifictreatmentofanemia BloodProductAdministration血制品的输注 35 医药课件交流 notusingintravenousimmunoglobulins grade2B HistoryofRecommendationsRegardingUseofRecombinantActivatedProteinC rhAPC nolongeravailable 重组人活性蛋白CNotusingintravenousselenium硒收益 风险 Immunoglobulins免疫球蛋白 36 医药课件交流 BicarbonateTherapy碳酸氢盐 recommendagainsttheuseofsodiumbicarbonatetherapyforthepurposeofimprovinghemodynamicsorreducingvasopressorrequirementsinpatientswithhypoperfusion inducedlacticacidemiawithpH 7 15 grade2B 5 NaHCO3 ml 24 HCO3 weight 3 37 医药课件交流 StressUlcerProphylaxis应激性溃疡预防 Stressulcerprophylaxisusingprotonpumpinhibitors PPI grade1B ratherthanH2receptorantagonists H2RA grade2C PPI优于H2RAwithoutriskfactorsshouldnotreceiveprophylaxis grade2B 38 医药课件交流 ContinuousRenalReplacementTherapy CRRT suggestthatCRRTandIntermittentHemodialysis间断血透areequivalentinpatientswithseveresepsisandacuterenalfailure grade2B CRRTtofacilitatemanagementoffluidbalanceinhemodynamicallyunstablesepticpatients grade2D 39 医药课件交流 GlucoseControl血糖控制 Startinsulin胰岛素dosingwhentwoconsecutivebloodglucoselevelsare 180mg dL grade1A Target 110 180mg dlMonitorbloodglucosevaluesq1h q2h q4h grade1C 40 医药课件交流 DeepVeinThrombosisProphylaxis深静脉血栓的预防 dailysubcutaneouslow molecularweightheparin LMWH grade1BversusUFHtwicedaily grade2CversusUFHgiventhricedaily Ifcreatinineclearanceis 30mL min werecommenduseofUFH grade1A patientswhohaveacontraindication禁忌症toheparinreceivemechanicalprophylactictreatment充气性机械装置 eg thrombocytopenia血小板减少症 activebleeding recentintracerebralhemorrhage脑内出血 41 医药课件交流 Nutrition营养支持 suggestadministeringoralorenteralfeedings肠内营养 astolerated ratherthaneithercompletefasting禁食orgiveonlyintravenousglucosewithinthefirst48hrs grade2C suggestusingintravenousglucoseandenteralnutritionratherthantotalparenteralnutrition TPN inthefirst7days grade2B Avoidfullcaloricfeedinginthefirstweek suggestlowdosefeeding eg upto500caloriesperday advancingonlyastolerated grade2B 42 医药课件交流 MechanicalVentilation机械通气ofSepsis InducedAcuteRespiratoryDistressSyndrome ARDS 1 Targetatidalvolume 潮气量 of6mL kgpredictedbodyweight 2 initialupperlimitgoalforPlateaupressures 平台压 30cmH2O grade1B 3 Positiveend expiratorypressure 最低PEEP beappliedtoavoidalveolarcollapse肺泡塌陷atendexpiration grade1B 4 Pronepositioning 俯卧位通气 beusedinsepsis inducedARDSpatientswithaPao2 Fio2ratio 100mmHg grade2B 5 Recruitmentmaneuvers 肺复张 beusedinsepsispatientswithsevererefractoryhypoxemia顽固性低氧血症 grade2C 43 医药课件交流 MechanicalVentilationofSepsis InducedAcuteRespiratoryDistressSyndrome ARDS 6 bemaintainedwiththeheadofthebedelevatedto30 45degreestolimitaspirationrisk误吸andventilator associatedpneumonia呼吸机相关肺炎 grade1B 7 noninvasivemaskventilation无创面罩beusedinthatminorityofpatientsinwhomthebenefitsofNIVhavebeencarefullysonsideredandarethoughttooutweighttherisks grade2B 8 Againsttheroutineuseofthepulmonaryarterycatheter 肺动脉导管 44 医药课件交流 SettingGoalsofCare确立治疗目标 1 Discussgoalsofcareandprognosiswithpatientsandfamilies grade1B 将诊断及进一步治疗方案与患者家属沟通 2 Incorporategoalsofcareintotreatmentandend of lifecareplanning utilizingpalliativecareprincipleswhereappropriate grade1B 包括预后 终止生命的方式以及姑息治疗措施 3 Addressgoalsofcareasearlyasfeasible butnolaterthanwithin72hoursofICUadmission grade2C 45 医药课件交流 Enhancetheearlierrecognitionofsepsis Resuscitationassoonaspossible CareofEvidence basedmedicineEmphasizesthesignificanceofadjuvanttherapy集束化 BUNDLE 治疗策略 update 46 医药课件交流 Sepsisresucitationbundle初始复苏 1 Measurelactatelevel2 Obtainbloodculturespriortoadministrationofantibiotics3 Administerbroadspectrumantibiotics广谱抗生素4 Administer30mL kgcrystalloidforhy