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1、关于儿科感染性休克关于儿科感染性休克诊治进展诊治进展第一页，本课件共有61页主要内容主要内容n n感染休克诊治进展标志性事件感染休克诊治进展标志性事件n n国内儿科感染性休克诊治推荐方案的主要内国内儿科感染性休克诊治推荐方案的主要内容容n n简介简介Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock：2008之儿科建议之儿科建议n n液体复苏应注意的问题液体复苏应注意的问题第二页，本课件共有61页进展的重要标志进展的重要标志n n国外 Sepsis、Septic shock
2、定义的更新 （1992、2001成人；2002儿科）拯救脓毒症运动拯救脓毒症运动(Surviving Sepsis Campaign,SSC，2002)n n国内 修订儿科感染性休克诊疗方案第三页，本课件共有61页拯救脓毒症运动拯救脓毒症运动n n第一阶段标志:“巴塞罗那宣言”2002 2002年年 美国危重病医学会（美国危重病医学会（SCCMSCCM）、欧洲危重病医）、欧洲危重病医学会（学会（ESICMESICM）和国际感染论坛（）和国际感染论坛（ISFISF）在）在ESICMESICM第十第十五届国际会议上共同发起拯救脓毒症的全球性创议，五届国际会议上共同发起拯救脓毒症的全球性创议，签署了
3、著名的签署了著名的“巴塞罗那宣言巴塞罗那宣言”“呼吁全球医务工作者和他们的医学专业组织、政呼吁全球医务工作者和他们的医学专业组织、政府、慈善机构甚至公众对该行动的支持，力图在府、慈善机构甚至公众对该行动的支持，力图在5 5年内将脓毒症的病死率减少年内将脓毒症的病死率减少2525”第四页，本课件共有61页拯救脓毒症运动n n第二阶段标志：制定治疗指南第二阶段标志：制定治疗指南第二阶段标志：制定治疗指南第二阶段标志：制定治疗指南 2003.10 2003.10代表代表1111个国际学术组织的个国际学术组织的4646位专家根据过去位专家根据过去1010年临床研究资料年临床研究资料,进行循证医学分析进
4、行循证医学分析,制定了制定了Surviving Sepsis Campaign guidelines for Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shockmanagement of severe sepsis and septic shock 该指南2004年同时在Crit Care Med 和 Intensive Care Med上发表 对成人严重脓毒症和脓毒性休克的治疗提出了新的建对成人严重脓毒症和脓毒性休克的治疗提出了新的建议议,并给出了证据可靠程度分级标准，同时
5、也提出了儿并给出了证据可靠程度分级标准，同时也提出了儿科建议科建议第五页，本课件共有61页拯救脓毒症运动n n第三阶段：第三阶段：将将将将致力于治疗指南的临床应用和疗效评估及修订致力于治疗指南的临床应用和疗效评估及修订致力于治疗指南的临床应用和疗效评估及修订致力于治疗指南的临床应用和疗效评估及修订 期望每年评估修订一次期望每年评估修订一次期望每年评估修订一次期望每年评估修订一次,并在网上发表并在网上发表并在网上发表并在网上发表 Surviving Sepsis Campaign guidelines for Surviving Sepsis Campaign guidelines for ma
6、nagement of severe sepsis and septic shockmanagement of severe sepsis and septic shock20082008 http:/ Crit Care Med,2008,36(1):296-327 Crit Care Med,2008,36(1):296-327第六页，本课件共有61页国内儿科感染性休克诊疗方案修订国内儿科感染性休克诊疗方案修订n n2005 年中华医学会儿科学会急诊学组中华急诊学会儿科学组参照国内外大量文献，对儿科感染性休克诊断标准和治疗方案进行了重新修订，最终定稿儿科感染性休克（脓毒性休克）诊疗推荐方案
7、n n2006年发表于中华儿科杂志、中国小儿急救医学、中华急诊医学杂志 第七页，本课件共有61页国际儿科脓毒症定义国际儿科脓毒症定义n n全身炎症反应综合征（全身炎症反应综合征（SIRSSIRS）n n感染(infection)n n脓毒症(sepsis)n n严重脓毒症(severe sepsis)n n脓毒性休克脓毒性休克(septic shock)(septic shock)n n多器官功能障碍多器官功能障碍(MODS)(MODS)Pediatr Crit Care Med 2005;6:2-8Pediatr Crit Care Med 2005;6:2-820022002年年2 2月来
8、自加拿大、月来自加拿大、法国、荷兰、英国和美法国、荷兰、英国和美国的从事脓毒症临床研国的从事脓毒症临床研究的究的2020余位专家组成国余位专家组成国际小组际小组,在得克萨斯圣安在得克萨斯圣安东尼奥召开了脓毒症定东尼奥召开了脓毒症定义大会义大会第八页，本课件共有61页SIRS（1）至少出现下列四项中的两项，其中必须包括体至少出现下列四项中的两项，其中必须包括体温或白细胞计数异常温或白细胞计数异常n n中心温度中心温度38.5 或或同年龄组正常值同年龄组正常值2个标准差个标准差以上（无外界刺激、慢性药物或疼痛刺激）或不以上（无外界刺激、慢性药物或疼痛刺激）或不可解释的持续性增快超过可解释的持续性增
9、快超过0.54h 或或1y心动过缓：平均心率心动过缓：平均心率各年龄组正常值2个标准差以上，或急性病程需机械通气（无神经肌肉病、麻醉影响）n nWBC 升高或降低（非继发于化疗的减少）或杆状核10%第十页，本课件共有61页年龄组年龄组心率（次心率（次/分）分）心动过速心动过速 心动过缓心动过缓呼吸频率呼吸频率（次（次/分）分）白细胞计数白细胞计数（10109 9）11周周1801801005050343411月月18018010040 40 19.519.518018090343417.517.5140140NANA222215.515.5130130NANA181813.513.511011
10、0NANA141411.011.05ug/kg.min,或任何剂量多巴酚丁胺、肾上腺素、去甲肾上腺素）n n具备下列两条 不可解释的代酸：碱缺失mmol/L第十七页，本课件共有61页心血管功能障碍（心血管功能障碍（2）动脉血乳酸增加：为正常上限两倍的以上无尿：尿量基线20mmHg以上n n证明需高氧（增加流量方能维持血氧含量）或FiO2.方能维持SaO292%n n需紧急侵入或非侵入性机械通气第十九页，本课件共有61页神经功能障碍神经功能障碍n nGlasgow 评分分n n精神状态急性改变伴Glasgow 评分从基线下降降分分第二十页，本课件共有61页血液系统障碍血液系统障碍n n血小板计数
11、80,000mm或过去天内从最高值下降50（适用与慢性血液肿瘤患儿）n n国际标准化比值2（标准化的）第二十一页，本课件共有61页肾功能障碍肾功能障碍血清肌酐为各年龄组正常值上限的倍或较基线增加倍第二十二页，本课件共有61页肝功能障碍肝功能障碍n n总胆红素4mg/dl（新生儿不适用）n nALT 2倍于同年龄正常值上限 与过去的不同：胃肠功能障碍未列入其中第二十三页，本课件共有61页胃肠功能障碍n n应激溃疡出血应激溃疡出血 需输血需输血n n中毒性肠麻痹中毒性肠麻痹 高度腹胀高度腹胀第二十四页，本课件共有61页国内新修订的儿科感染性休克（脓国内新修订的儿科感染性休克（脓毒性休克）诊断标准毒
12、性休克）诊断标准n n代偿期：临床表现符合下列6项中3项 1、意识改变 烦躁不安或萎靡，表情淡漠。意识模 糊，甚至昏迷、惊厥 2、皮肤改变 面色苍白发灰，唇周、指趾紫绀，皮肤 花纹，四肢凉。如有面色潮红，四肢温 暖，皮肤干燥为暖休克 3、心率脉搏 外周动脉搏动细弱，心率脉搏增快中华儿科杂志中华儿科杂志中华儿科杂志中华儿科杂志,2006;44(8):15,2006;44(8):15第二十五页，本课件共有61页国内新修订的儿科感染性休克（脓毒国内新修订的儿科感染性休克（脓毒性休克）诊断标准性休克）诊断标准 4、毛细血管再充盈时间3秒 5、尿量1ml/kg.h 6 6、代谢性酸中毒（除外其他缺氧及代
13、谢因、代谢性酸中毒（除外其他缺氧及代谢因 素）素）n n失代偿期：代偿期临床表现加重伴血压下降。收缩失代偿期：代偿期临床表现加重伴血压下降。收缩压压 该年龄组第该年龄组第5 5百分位或百分位或 该年龄组正常值该年龄组正常值2 2个标准个标准差差 即：即：112112月月70mmHg70mmHg 110 110岁岁70mmHg+2 10岁 200mg/dl,200mg/dl,用胰岛素用胰岛素用胰岛素用胰岛素0.05u/kg.h0.05u/kg.hn n根据临床体征及相关检查鉴别心源性休克根据临床体征及相关检查鉴别心源性休克根据临床体征及相关检查鉴别心源性休克根据临床体征及相关检查鉴别心源性休克第
14、二十八页，本课件共有61页液体复苏（液体复苏（2）n n继续和维持输液：继续和维持输液：n n继续输液可用继续输液可用继续输液可用继续输液可用1/22/31/22/3张液体，张液体，张液体，张液体，6h6h内输液速度内输液速度内输液速度内输液速度510ml/kg.h510ml/kg.hn n维持输液用维持输液用维持输液用维持输液用1/31/3液体，液体，液体，液体，24h24h内内内内24ml/kg.h24ml/kg.hn n根据电解质调节液体张力根据电解质调节液体张力根据电解质调节液体张力根据电解质调节液体张力n n保证通气前提下根据血气纠酸，至保证通气前提下根据血气纠酸，至保证通气前提下根
15、据血气纠酸，至保证通气前提下根据血气纠酸，至PH7.25PH7.25即可即可即可即可n n可适当补充胶体液，如血浆等可适当补充胶体液，如血浆等n nHCT30%HCT100g/LHB100g/L第二十九页，本课件共有61页血管活性药物（血管活性药物（1）n n充分液体复苏仍有低血压低灌注充分液体复苏仍有低血压低灌注充分液体复苏仍有低血压低灌注充分液体复苏仍有低血压低灌注 首选多巴胺：首选多巴胺：首选多巴胺：首选多巴胺：510ug/kg.min 20ug,IV 510ug/kg.min 20ug,IV 泵维泵维泵维泵维n n冷休克、多巴胺抵抗冷休克、多巴胺抵抗 首选肾上腺素首选肾上腺素首选肾上腺
16、素首选肾上腺素0.052ug/kg.min,IV 0.052ug/kg.min,IV 泵维泵维泵维泵维n n暖休克、多巴胺抵抗暖休克、多巴胺抵抗 首选去甲肾上腺素首选去甲肾上腺素首选去甲肾上腺素首选去甲肾上腺素0.050.3ug/kg.min0.050.3ug/kg.min，IV IV 泵维泵维泵维泵维n n去甲肾上腺素抵抗去甲肾上腺素抵抗去甲肾上腺素抵抗去甲肾上腺素抵抗 试用血管紧张素和精氨酸血管加压素试用血管紧张素和精氨酸血管加压素试用血管紧张素和精氨酸血管加压素试用血管紧张素和精氨酸血管加压素中华儿科杂志中华儿科杂志中华儿科杂志中华儿科杂志,2006;44(8):15,2006;44(8
17、):15第三十页，本课件共有61页血管活性药物血管活性药物(2)n n莨菪类可选用莨菪类可选用莨菪类可选用莨菪类可选用n n心功能障碍时儿茶酚胺类药物取代洋地黄类心功能障碍时儿茶酚胺类药物取代洋地黄类心功能障碍时儿茶酚胺类药物取代洋地黄类心功能障碍时儿茶酚胺类药物取代洋地黄类多巴酚丁胺多巴酚丁胺510ug/kg.min,70%n n心脏指数3.3L/min/m2,6.0L/min/m2 Crit Care Med 2009;37(2):666-688Crit Care Med 2009;37(2):666-688第三十七页，本课件共有61页Surviving Sepsis Campaign:I
18、nternational Guidelines for Management of Severe Sepsis and Septic Shock:2008International Surviving Sepsis Campaign Guidelines Committee Pediatric Considerations in Severe SepsisCrit Care Med.2008;36(1):296-327 http:/ 第三十八页，本课件共有61页Pediatric Considerations in Severe SepsisA.AntibioticsA.Antibiotics
19、 We recommend that antibiotics be administered within We recommend that antibiotics be administered within 1 hr1 hr of the of the identification of severe sepsis,identification of severe sepsis,after appropriate culturesafter appropriate cultures have have been obtained(grade 1D)been obtained(grade
20、1D)Early antibiotic therapy is as critical for children with Early antibiotic therapy is as critical for children with severe sepsis as it is for adults.severe sepsis as it is for adults.B.Mechanical VentilationB.Mechanical Ventilation No graded recommendations.No graded recommendations.Due to low f
21、unctional residual capacity,Due to low functional residual capacity,young infants and young infants and neonatesneonates with severe sepsis may require with severe sepsis may require early intubationearly intubation第三十九页，本课件共有61页Pediatric Considerations in Severe SepsisC.Fluid ResuscitationC.Fluid R
22、esuscitation We suggest that initial resuscitation begin with infusion of We suggest that initial resuscitation begin with infusion of crystalloids with boluses of crystalloids with boluses of 20 mL/kg20 mL/kg over 5-105-10 mins,mins,titrated to clinical monitors of cardiac output,including titrated
23、 to clinical monitors of cardiac output,including heart rate,urine output,capillary refill,and level of heart rate,urine output,capillary refill,and level of consciousness(grade 2C)consciousness(grade 2C)D.Vasopressors/Inotropes(Should Be Used in Volume-LoadedVolume-Loaded Patients With Fluid Refrac
24、tory Patients With Fluid Refractory Shock)Shock)We suggest We suggest dopaminedopamine as the as the first choicefirst choice of support for the of support for the pediatric patient with hypotension refractory to fluid pediatric patient with hypotension refractory to fluid resuscitation(grade 2C)res
25、uscitation(grade 2C)第四十页，本课件共有61页Pediatric Considerations in Severe SepsisDopamine-refractory shock may reverse with epinephrine or norepinephrine infusionWe suggest that patients with low cardiac output and elevated systemic vascular resistance states(cool extremities,prolonged capillary refill,dec
26、reased urine output but normal blood pressure following fluid resuscitation)be given dobutamine(grade 2C)第四十一页，本课件共有61页Pediatric Considerations in Severe SepsisE.Therapeutic End Points We suggest that the therapeutic end points of resuscitation of septic shock be normalization of the heart rate,capi
27、llary refill of 1 mL kg-1 hr-1,and normal mental status(grade 2C)第四十二页，本课件共有61页Pediatric Considerations in Severe SepsisF.Approach to Pediatric Septic ShockF.Approach to Pediatric Septic Shock（略）（略）G.SteroidsWe suggest that We suggest that hydrocortisone therapy be reserved for use in children with
28、catecholamine resistance and catecholamine resistance and suspected or proven adrenal insufficiencysuspected or proven adrenal insufficiency(grade 2C).(grade 2C).Patients at risk for adrenal insufficiencyat risk for adrenal insufficiency include children include children with severe septic shock and
29、 purpura,children who have with severe septic shock and purpura,children who have previously received steroid therapies for chronic illness,previously received steroid therapies for chronic illness,and children with pituitary or adrenal abnormalities.and children with pituitary or adrenal abnormalit
30、ies.Children who have clear risk factors for adrenal Children who have clear risk factors for adrenal insufficiency should be treated with insufficiency should be treated with stress-dose steroidsstress-dose steroids(hydrocortisone 50 mg/m2/24 hrs)第四十三页，本课件共有61页Pediatric Considerations in Severe Sep
31、sisH.Protein C and Activated Protein C We recommend against the use rhAPC in children(grade 1B)I.DVT Prophylaxis We suggest the use of DVT prophylaxis in postpubertal children with severe sepsis(grade 2C)J.Stress Ulcer Prophylaxis No graded recommendations.第四十四页，本课件共有61页Pediatric Considerations in S
32、evere SepsisK.Renal Replacement Therapy No graded recommendationsL.Glycemic Control No graded recommendationsM.Sedation/Analgesia We recommend sedation protocols with a sedation goal when sedation of critically ill mechanically ventilated patients with sepsis is required(grade 1D)第四十五页，本课件共有61页Pedia
33、tric Considerations in Severe SepsisN.Blood ProductsN.Blood Products No graded recommendationsO.Intravenous ImmunoglobulinO.Intravenous Immunoglobulin We suggest that immunoglobulin be considered in children We suggest that immunoglobulin be considered in children with severe sepsis(grade 2C)with se
34、vere sepsis(grade 2C)P.Extracorporeal Membrane Oxygenation(ECMO)P.Extracorporeal Membrane Oxygenation(ECMO)We suggest that use of ECMO be limited to refractory We suggest that use of ECMO be limited to refractory pediatric septic shock and/or respiratory failure that cannot pediatric septic shock an
35、d/or respiratory failure that cannot be supported by conventional therapies(grade 2C)be supported by conventional therapies(grade 2C)第四十六页，本课件共有61页Fluid in early septic shockn nRetrospectiveRetrospective review of 34 pediatric patients with culture review of 34 pediatric patients with culture+septic
36、 shock,from 1982-1989.+septic shock,from 1982-1989.n nHypovolemia determined by PCWP,u.o and hypotension.Hypovolemia determined by PCWP,u.o and hypotension.n nOverall,patients received 33 cc/kg at 1 hour and 95 Overall,patients received 33 cc/kg at 1 hour and 95 cc/kg at 6 hours.cc/kg at 6 hours.n n
37、Three groups:Three groups:1:received up to 20 cc/kg in 11:received up to 20 cc/kg in 1stst 1 hour 1 hour 2:received 20-40 cc/kg in 12:received 20-40 cc/kg in 1stst hour hour 3:received greater than 40 cc/kg in 13:received greater than 40 cc/kg in 1stst hour hourn nNo difference in ARDS between the 3
38、 groupsNo difference in ARDS between the 3 groups Carcillo,et al,JAMA,1991;266(9):1242-5Carcillo,et al,JAMA,1991;266(9):1242-5.第四十七页，本课件共有61页Fluid in early septic shockGroup 1Group 1(n=14)(n=14)Group 2Group 2(n=11)(n=11)Group 3Group 3(n=9)(n=9)Hypovolemic at 6 Hypovolemic at 6 hours hours -Deaths -D
39、eaths6 66 62 22 20 0 0 0Not hypovolemic at Not hypovolemic at 6 hours 6 hours -Deaths -Deaths8 82 29 95 59 9 1 1Total deathsTotal deaths8 87 71 1Carcillo,et al,JAMA,1991;266(9):1242-5Carcillo,et al,JAMA,1991;266(9):1242-5.第四十八页，本课件共有61页 Improved Outcomes AssociatedWith Early Resuscitation in SepticS
40、hock:Do We Need to Resuscitatethe Patient or the Physician?Aileen Kirby and Brahm Goldstein Aileen Kirby and Brahm Goldstein Pediatrics Pediatrics 2003;112;976-9772003;112;976-977第四十九页，本课件共有61页Early Reversal shock and outcomn nRetrospective clinical study(from 19932001)n n91 infants and children wit
41、h septic shock from local community hospitalsand transport to Childrens hospital Shock reversal(defined by return of normal SBP and CRT)Resuscitation practice concurrence with ACCM PALS Guidelines Hospital mortalityHan,et al.Pediatrics 2003;112;793-799第五十页，本课件共有61页Early Reversal shock and outcomShoc
42、k state and management Shock state and management with survivalwith survivalSurvivalSurvivalincreased odds of increased odds of survival survival Shock reversed at a median Shock reversed at a median time of 75 min(n=24)time of 75 min(n=24)96%96%9-fold9-foldPersistent shock(n=67)Persistent shock(n=6
43、7)63%63%Resuscitation consistent with Resuscitation consistent with ACCM-PALS ACCM-PALS guidlinesguidlines92%92%6-fold increased6-fold increasedResuscitation not consistent Resuscitation not consistent with with ACCM-PALSACCM-PALS guidlines guidlines62%62%Han,et al.Pediatrics 2003;112;793-799第五十一页，本
44、课件共有61页Early Reversal shock and outcomShock state and management with Shock state and management with mortalitymortalityodds of odds of mortalitymortalitypassed each hour of persistent passed each hour of persistent shockshock 2-fold2-foldeach hour of delay in institution of each hour of delay in in
45、stitution of resuscitation consistent with resuscitation consistent with ACCM-PALS GuidelinesACCM-PALS Guidelines 50%50%Unfortunately,resuscitation practice was consistent with ACCM-PALS Guidelines in only 27(30%)patients Han,et al.Pediatrics 2003;112;793-799第五十二页，本课件共有61页Early Reversal shock and ou
46、tcomn nCompared with survivors,nonsurvivors treated with more inotropic therapies,not increased fluid therapy:dopamine/dobutamine:42%vs 20%epinephrine/norepinephrine:42%vs 6%fluid:20.0 mL/kg vs 32.9 mL/kg Han,et al.Pediatrics 2003;112;793-799第五十三页，本课件共有61页目前对液体选择的看法（目前对液体选择的看法（1）n n只要液体量达到相同的充盈压（CVP
47、）水平时，都能恢复相同水平的组织灌注。因此，确定应给予的液体量比选择液体的种类更重要n n无循证医学证据证实晶体液或胶体液复苏对存活率有不同影响或哪一种液体较其他好，但有报道乳酸盐LR治疗者恢复较慢 n n欧洲喜欢用胶体，北美更常用晶体液，国内推荐首选NS第五十四页，本课件共有61页目前对液体选择的看法（目前对液体选择的看法（2）n n若脉压小，胶体可能对恢复脉压更有效n n晶体复苏效果不佳可适当补充胶体，如血浆n n白蛋白问题：无文献报道白蛋白可改善预后和降低病死率，故不推荐常规使用白蛋白，只用于低蛋白血症患儿 n n其他血制品不做推荐，以避免相关的危险性，但失血性休克首选输血 第五十五页，
48、本课件共有61页骨骨 髓髓 输输 液液首次首次 19 19世纪世纪2020年代年代8080年代重新重视年代重新重视19881988年年美美国国心心脏脏病病学学会会（AHAAHA）主主张张666岁乃至成人均可用岁乃至成人均可用20002000年年 AHAAHA规规定定 90”390”3次次静静脉脉穿穿刺刺失失败败即即作作骨髓输液骨髓输液只用于危重婴幼儿作为暂时性措施只用于危重婴幼儿作为暂时性措施第五十六页，本课件共有61页骨髓输液的并发症骨髓输液的并发症n n并发症1n n并发症包括：胫骨骨折 腔隙综合征 皮肤坏死 骨髓炎第五十七页，本课件共有61页液体复苏应注意的问题液体复苏应注意的问题液体复苏实施过程中的一些问题：n n复苏液量不足，速度不够n n血管活性药物使用不当n n液体配置不当：用糖稀释高涨液，过多使用碱性液n n血管通路：建立困难，通路本身不畅第五十八页，本课件共有61页液体复苏应注意的问题液体复苏应注意的问题判断失误导致治疗延迟或错误：n n休克误诊为心力衰竭：强心、利尿、限液n n休克误诊为颅内感染：脱水、限液n n炎性水肿误判为液体超负荷：利尿、限液 第五十九页，本课件共有61页第六十页，本课件共有61页感感谢谢大大家家观观看看08.12.2022第六十一页，本课件共有61页