2012+2016感染性休克指南解读

2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016中国急诊感染性休克临床实践指南,Speaker:CaiHanThe1stAffiliatedHospitalofFujianMedicalUniversity,Indexcase,Name:SunZuYuAge:63yearsSex:femaleID:0680716admissiontime:2015.06.292015.07.06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。,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,肺部CT,上腹部MRI+增强,Indexcase,Name:ChenYiMingAge:75yearsSex:maleID:Madmissiontime:2016.02.142016.02.17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WBC12.44109/L，N11.30109/L，N90.8，急诊生化：AST123U/L，糖9.73mmol/L；肺部CT：双肺炎症,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。,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,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。,Problemlist:,Inessence,atdifferentstagesoftheonesamedisease,SIRS,systemicinflammatoryresponsesyndromeGeneralvariablesFever(38.3C)，Hypothermia低体温(coretemperature90/min1ormorethantwosdabovethenormalvalueforageTachypnea呼吸急促（20次/min,PaCO212,000/L)Leukopenia(WBCcount20ml/kgover24hr)Hyperglycemia高血糖症(plasmaglucose140mg/dlor7.7mmol/L)intheabsenceofdiabetes,Definition,Sepsis,SIRSissecondarytodocumentedorsuspectedinfection.Sepsis-inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput176.8mol/LAcutelunginjurywithPao2/Fio2（OI）34.2mol/LPLT1.5),Definition,Definition,Septicshockisdefinedassepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitation.,Diagnostic,1.Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay(45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厌氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(48hrs)inserted(grade1C).,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,Recommendations:,SourceControlAntimicrobialTherapyVasopressorsCorticosteroids,AdjunctiveTherapy,BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis,Evidence-basedmedicine,SourceControl,1）recommendcrystalloids晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock(grade1B).2）addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids(grade2C).3）recommendagainsttheuseofhydroxyethylstarches(羟乙基淀粉）forfluidresuscitationofseveresepsisandsepticshock(grade1B).,SourceControl,；,AntimicrobialTherapy,1.Administrationofeffectiveintravenousantimicrobialswithin1sthour2a.Initialempiricanti-infectivetherapyofoneormoredrugs，haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)2b.Antimicrobialregimen抗菌药物组合shouldbereassesseddailyforpotentialde-escalation降阶梯(grade1B),AntimicrobialTherapy,3.UseoflowPCTlevelsorsimilarbiomarkerstoassistthecliniciansinthediscontinuationofempiricantibioticsinpatientswhoinitiallyappearedseptic,buthavenosubsequentevidenceofinfection(grade2C),4.durationoftherapy:7to10days,AntimicrobialTherapy,5.Antiviraltherapy抗病毒治疗initiatedasearlyaspossibleinpatientswithseveresepsisorsepticshockofviralorigin(grade2C).,AntimicrobialTherapy,iftheInitialfluidresuscitationdidnottargetameanarterialpressure(MAP)of65mmHg，Vasopressortherapycanbeadded(grade1C).,血管活性药物Vasopressors,NorepinephrineComparedWithDopamineinSevereSepsisSummaryofEvidence,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,4.Dopamine（DA)-analternativevasopressoragenttoNE.(2C)onlyinhighlyselectedpatients(eg.patientswithlowriskoftachyarrhythmiasandabsoluteorrelativebradycardia心动过缓)Low-dosedopamineshouldnotbeusedrenalprotection(grade1A).,Vasopressors血管活性药物,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,Corticosteroids类固醇激素,(1)Notusingintravenoushydrocortisone氢化可的松totreatadultsepticshockpatientsifadequatefluidresuscitationandvasopressortherapyareabletorestorehemodynamicstability.Incase,notachievable：hydrocortisone氢化可的松200ravenous(grade2A).Whengiven,usecontinuousinfusion(grade2C).iv-p.优于iv.,（2）NotusingtheACTHstimulationtesttoidentifyadultswithsepticshockwhoshouldreceivehydrocortisone(grade2B).（3）reducethetreatedpatientfromsteroidtherapywhenvasopressorsarenolongerrequired(grade2D).（4）Corticosteroidsnotbeadministeredforthetreatmentofsepsisintheabsenceofshock(grade1D).,Corticosteroids类固醇激素,AdjunctiveTherapyEmphasizes!,BloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsis,BloodProductAdministration血制品的输注,（1）recommendredbloodcelltransfusionoccuronlywhenthehemoglobinconcentration(HGB)decreasesto180mg/dL.(grade1A).Target：110-180mg/dlMonitorbloodglucosevaluesq1hq2hq4h(grade1C).,DeepVeinThrombosisProphylaxis深静脉血栓的预防,dailysubcutaneouslow-molecularweightheparin(LMWH)grade1BversusUFHtwicedaily.grade2CversusUFHgiventhricedaily.Ifcreatinineclearanceis30mL/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),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).,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/Fio2ratio100mmHg(grade2B)；（5）Recruitmentmaneuvers(肺复张)beusedinsepsispatientswithsevererefractoryhypoxemia顽固性低氧血症(grade2C).,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)；,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).,Enhancetheearlierrecognitionofsepsis.Resuscitationassoonaspossible.CareofEvidence-basedmedicineEmphasizesthesignificanceofadjuvanttherapy集束化（BUNDLE）治疗策略,update,Sepsisresucitationbundle初始复苏,1)Measurelactatelevel2)Obtainbloodculturespriortoadministrationofantibiotics3)Administerbroadspectrumantibiotics广谱抗生素4)Administer30mL/kgcrystalloidforhypotensionorlactate4mmol/L1h内使用抗菌药物，3h内启动监测和体液复苏！,TOBECOMPLETEDWITHIN3HOURS:,Septicshockbundle感染性休克,1)vasopressorstomaintainMAP65mmH