早期脓毒症2015新进展

,面对早期脓毒症我们该怎么做？,张 舸,Definition,SIRS (systemic inflammatory response syndrome )SepsisSevere sepsisSeptic shock,The presence of 2 or more of the following:BT 38 C or 90/minRR 20/minWBC 10000 or 4000,Definition,SIRS (systemic inflammatory response syndrome )SepsisSevere sepsisSeptic shock,Defined as the systemic host response to infection with SIRS plus a documented infection,Definition,SIRS (systemic inflammatory response syndrome )SepsisSevere sepsisSeptic shock,Defined as sepsis with 1 sign of organ failureCardiovascularRenalRespiratoryHepaticHematologicCNSMetabolic acidosis,Definition,SIRS (systemic inflammatory response syndrome )SepsisSevere sepsisSeptic shock,Defined as sepsis with refractory hypotension, despite fluid resuscitation, and evidence of inadequate tissue perfusion,Sepsis 2.0,SIRS诊断全身炎症反应综合征的特异性低,Of 1,171,797 patients, a total of 109,663 had infection and organ failure. Among these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%)had SIRS-negative severe sepsis.约有1/8的患者(12%)为SIRS阴性严重全身性感染或感染性休克。,Over a period of 14 years, these groups had similar characteristics and changes in mortality,SIRS标准诊断全身性感染的实际敏感性较低。SIRS标准将会遗漏很多全身性感染患者。这项研究表明，一部分严重脓毒症或脓毒性休克的患者即便不满足SIRS标准，仍然需要立即接受积极地治疗。,Sepsis的定义应以器官衰竭为核心,Sepsis应该指情况糟糕的感染，是机体对于感染的失控反应，这种感染情况可导致器官衰竭并威胁生命。Sepsis重新定义的目的：感染不在仅仅是感染，而会发展到更严重的后果。,Sepsis 3.0,Sepsis3.0=感染+SOFA2,sepsis 3.0,Sepsis 3.0是过去severe sepsis的定义，是机体对感染的失控反应并出现了可以威胁生命的器官功能衰竭。,SSC：巴塞罗那宣言,呼吁全球的医务人员、卫生机构和政府乃至公众应高度认识和重视严重脓毒症和脓毒症休克,力争5 年内将全身性感染患者的病死率降低25 %作为行动目标。,制定严重脓毒症和脓毒症休克管理指南,旨在提高对严重感染的认识并努力改善预后。,将致力于治疗指南的临床应用和疗效评估, 以期最终降低严重脓毒症患者的病死率。在评估指南中临床疗效的同时, 将根据临床研究的进展和新的依据, 每年对指南进行修订。,2002年10月在西班牙巴塞罗那召开的欧洲危重病医学学术会议上, 由欧洲危重病医学会(ESICM) 、美国危重病医学会(SCCM) 和国际感染论坛(ISF)共同签署了全球性拯救脓毒症运动倡议(Surviving Sepsis Campaign , SSC), 同时发表了著名的巴塞罗那宣言，并计划在5年内将脓毒症患者的死亡率减少25%。,Surviving Sepsis Campaign,2004年制定了严重脓毒症和脓毒症休克诊疗指南。2008年更新根据多个研究统计表明，至2010年，脓毒症患者死亡率从38.8%下降至31%，在38%的基础上下降率达到20.1%。 2012年10月13-17日第25届欧洲危重症年会在葡萄牙首都里斯本召开，会议就2012年SSC指南的更新进行了披露。欧洲危重症医学学会(ESICM)，国际脓毒血症基金会（ISF）联合美国重症监护医学学会（SCCM）在休斯敦2012年美国重症监护医学学会上对2004及2008版重症脓毒血症和脓毒血症休克的治疗指南进行修订,初始复苏,对脓毒症所致组织灌注不足和疑似血容量不足的患者可采取早期液体冲击疗法，最少按 30mL/kg 给予晶体液 ( 部分患者可能需要加快给药速度及增加晶体液量) (1C) 根据动态及静态变量指标，持续使用液体冲击疗法直至患者血液动力状态得到改善 (UG),We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania。,Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.,There are only limited data to support the use offluidbolustherapy in hospitalized children.FluidBolusTherapy-Based Resuscitation for SevereSepsisin Hospitalized Children: A Systematic Review.Pediatr Crit Care Med.2015 Oct;16(8):e297-307.,初始复苏,1. 对脓毒症诱发组织低灌注患者（经过最初的液体冲击后持续低血压或者血乳酸浓度 4 mmol/L）采取规范化的定量复苏。应当在识别低灌注后的第一时间进行而不是延迟到患者入住 ICU 后才实施。在进行初始复苏的最初6小时内，脓毒症诱发低灌注的复苏目标应包括以下所有作为治疗方案的一部分（等级：1C）： a）中心静脉压（CVP） 812 mm Hg b）平均动脉压（MAP） 65 mm Hg c）尿量 0.5 mLkg时 d）上腔静脉血氧饱和度（Scvo2）或者混合静脉氧饱和度分别是（Svo2）70%或65%。2. 对于乳酸水平上升标志着组织低灌注的患者，采用定向化复苏使患者乳酸恢复正常（等级：2C）。,Early goal-directed therapy in the treatment of severe sepsis and septic shock,Engl J Med. 2001 Nov 8;345(19):1368-77.,Rivers E,ProCESSProMISeARISE,Protocol-based standard therapy required adequate peripheral venous access (with placement of a central venous catheter only if peripheral access was insufficient) and administration of fluids and vasoactive agents to reach goals for systolic blood pressure and shock index (the ratio of heart rate to systolic blood pressure) and to address fluid status and hypoperfusion, which were assessed clinically at least once an hour.,During the first 6 hours, the volume of intravenous fluids,2.8 liters in the protocol-based EGDT group,3.3 liters in the protocol-based standard-therapy group, and2.3 liters in the usualcare group,More patients in the protocol-based EGDT group than in the protocol-based standard-therapy group or the usual-care group received dobutamine and packed red-cell transfusions (dobutamine use, 8.0% vs. 1.1% and 0.9%, respectively; P 70%（ProCESS研究中为71%）。ScvO2反应的是氧供和氧耗的平衡，如何判断患者的容量状态和心输出量有更可靠地方法。,EGDT推广的意义,引起广大医护人员对脓毒症的重视。早期识别，早期处理脓毒症。液体复苏与容量的判断。早期抗感染药物的使用和感染源的去除。,SSC推荐的脓毒症集束化治疗意见,集束化目标的修订,TO BE COMPLETED WITHIN 3 HOURS:1) Measure lactate level2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L,集束化目标的修订,TO BE COMPLETED WITHIN 6 HOURS:5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg6) In the event of persistent hypotension after initial fluid administration (MAP 65 mm Hg) or if initial lactate was 4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1.7） Re-measure lactate if initial lactate elevated.,集束化目标的修订, Repeat focused exam (after initial fluid resuscitation)including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.OR TWO OF THE FOLLOWING: Measure CVP Measure ScvO2 Bedside cardiovascular ultrasound Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge,G. Fluid Therapy of Severe Sepsis,1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG).,危重病患者应用人血白蛋白可能是有害的。Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998;317:235-40.SAFE研究表明4%的人血白蛋白在危重病人中应用是安全的。A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56.,We conducted the Albumin Italian Outcome Sepsis (ALBIOS) study an investigator-initiated, multicenter, open-label, randomized, controlled trial in 100 intensive care units (ICUs) in Italy.Patients were randomly assigned to receive either 20% albumin and crystalloid solution (albumin group) or crystalloid solution alone (crystalloid group) from randomization until day 28 or discharge from the ICU.,After randomization, patients in the albumin group received 300 ml of 20% albumin solution. From day 1 until day 28 or ICU discharge (whichever came first), 20% albumin was administered on a daily basis, to maintain a serum albumin level of 30 g per liter or