《脓毒症指南》PPT课件.ppt

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1、2008国际严重脓毒症和脓毒性休国际严重脓毒症和脓毒性休克治疗指南克治疗指南International guidelines for management of severe sepsis and septic shock:2008 内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应

2、激性溃疡防治应激性溃疡防治基基 本本 概概 念念(BasicDefinition)感染性休克画在哪里感染性休克画在哪里?基基 本本 概概 念念(BasicDefinition)感染感染=无病原微生物的无病原微生物的无病原微生物的无病原微生物的地方出现病原微生物地方出现病原微生物地方出现病原微生物地方出现病原微生物菌血症菌血症=血液中出现血液中出现细菌细菌全身炎症反应综合全身炎症反应综合症症=符合符合4项中的两项中的两项项-浓毒症浓毒症=感染感染+全身炎全身炎全身炎全身炎症反应综合症症反应综合症症反应综合症症反应综合症基基 本本 概概 念念(BasicDefinition)严重严重严重严重浓毒症

3、浓毒症浓毒症浓毒症=浓毒症浓毒症浓毒症浓毒症+器器器器官功能不全官功能不全官功能不全官功能不全(或低灌注或低灌注或低灌注或低灌注)感染性休克感染性休克感染性休克感染性休克=严重感染严重感染严重感染严重感染导致循环功能不全导致循环功能不全导致循环功能不全导致循环功能不全,需需需需要血管活性药要血管活性药要血管活性药要血管活性药浓毒症相关低血压浓毒症相关低血压浓毒症相关低血压浓毒症相关低血压=-MODS=MODS=两个以上器官两个以上器官两个以上器官两个以上器官功能障碍功能障碍功能障碍功能障碍内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控

4、制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治早期复苏早期复苏*Werecommendtheprotocolizedresuscitationofapatientwithsepsis-inducedshock,definedastissuehypoperfusion(hypotensionpersistingafterinitialfluidchalleng

5、eorbloodlactateconcentrationequaltoorgreaterthan4mmol/L).ThisprotocolshouldbeinitiatedassoonashypoperfusionisrecognizedandshouldnotbedelayedpendingICUadmission.Duringthefirst6hrsofresuscitation,thegoalsofinitialresuscitationofsepsis-inducedhypoperfusionshouldincludeallofthefollowingasonepartofatreat

6、mentprotocol:4针对确定存在血流灌针对确定存在血流灌注不足注不足(经早期冲击经早期冲击液体疗法仍持续低血液体疗法仍持续低血压或血乳酸超过压或血乳酸超过4 4 mmol/L)mmol/L)的脓毒症患的脓毒症患者推荐使用常规复苏者推荐使用常规复苏方案方案.此方案应该在此方案应该在确定存在血流灌注不确定存在血流灌注不足时立即实施足时立即实施,而不而不应该延迟到进入应该延迟到进入ICUICU后再进行后再进行早期复苏早期复苏*During the first 6 hrs of resuscitation,the goals of initial resuscitation of sepsis

7、-induced hypoperfusion should include all of the following as one part of atreatment protocol:!Central venous pressure(CVP):812 mm Hg!Mean arterial pressure(MAP)65 mm Hg!Urine output 0.5 mL.kg1.hr 1!Central venous(superior vena cava)or mixed venous oxygen saturation 70%or 65%,respectively(Grade 1C)4

8、复苏开始的第一个复苏开始的第一个6 6小时小时应达到目标性复苏标准：应达到目标性复苏标准：4CVP:812 mm Hg4MAP 65 mm Hg 4尿量 0.5 mL/kg/hr4中心静脉血氧饱和度或混合静脉血氧饱和度 70%or 65%,4(Grade 1C)早期复苏早期复苏Aduringthefirst6hrsofresuscitationofseveresepsisorsepticshock,ifSCVO2orSvO2of70%or65%respectivelyisnotachievedwithfluidresuscitationtotheCVPtarget,thentransfusio

9、nofpackedredbloodcellstoachieveahematocritof30%and/oradministrationofadobutamineinfusion(uptoamaximumof20g.kg1.min1)beutilizedtoachievethisgoal(Grade2C).n在脓毒症或脓毒性休克第一在脓毒症或脓毒性休克第一个个6 6小时复苏阶段小时复苏阶段,如果液体如果液体复苏仍未使能复苏仍未使能SCVOSCVO2 2 or SvO or SvO2 2 达到达到 70%or 65%,70%or 65%,则应输血则应输血使使HCT 30%HCT 30%和和/或滴注

10、多或滴注多巴酚丁胺巴酚丁胺(最大剂量最大剂量20 20 g/kg/min)g/kg/min)内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治诊断诊断 pWerecommendobtainingappropriateculturesbeforeantimic

11、robialtherapyisinitiatedifsuchculturesdonotcausesignificantdelayinantibioticadministration.Tooptimizeidentificationofcausativeorganisms,werecommendatleasttwobloodculturesbeobtainedpriortoantibioticswithatleastonedrawnpercutaneouslyandonedrawnthrougheachvascularaccessdevice,unlessthedevicewasrecently

12、(48h)inserted.Culturesofothersites(preferablyquantitativewhereappropriate)suchasurine,cerebrospinalfluid,wounds,respiratorysecretions,orotherbodyfluidsthatmaybethesourceofinfectionshouldalsobeobtainedbeforeantibiotictherapyifnotassociatedwithsignificantdelayinantibioticadministration(Grade1C).n在不延误抗

13、生素治疗前提下在不延误抗生素治疗前提下,给给抗生素前尽量获得可靠的病原微抗生素前尽量获得可靠的病原微生物培养结果生物培养结果,使用抗生素前至使用抗生素前至少获得两份血培养标本少获得两份血培养标本,一份直一份直接经皮穿刺获得接经皮穿刺获得,另一份可由任另一份可由任一血管通路获得一血管通路获得(除非除非48H48H内新建内新建通路通路).).其他部位包括尿液、脑脊其他部位包括尿液、脑脊液、创口、呼吸道分泌物或其他液、创口、呼吸道分泌物或其他可确定感染来源的体液，也最好可确定感染来源的体液，也最好进行定量培养（进行定量培养（1C1C）诊断诊断 nimaging studies be performe

14、d promptly in attempts to confirm apotential source of infection.Sampling of potential sources of infection should occur as they are identified;however,some patients may be too unstable to warrant certain invasive procedures or transport outside of the ICU.Bedside studies,such as ultrasound,are usef

15、ul in these circumstances(Grade 1C).n尽快完成影象学检查以确定尽快完成影象学检查以确定感染源，一旦发现疑似感染感染源，一旦发现疑似感染灶应立即在该部位进行取样。灶应立即在该部位进行取样。当然，有些患者因病情不稳当然，有些患者因病情不稳定而不容许进行某些具有侵定而不容许进行某些具有侵袭性的特殊操作检查，或因袭性的特殊操作检查，或因尚在转运过程中而不具备检尚在转运过程中而不具备检查条件。一些床边检查，如查条件。一些床边检查，如超声检查也极具诊断价值超声检查也极具诊断价值（1C1C）内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗

16、抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治抗生素治疗抗生素治疗 rintravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock(1B)and severe

17、 sepsis without septic shock(1D).rAppropriate cultures should be obtained before initiating antibiotic therapy,but should not prevent prompt administration of antimicrobial therapy(Grade 1D).n脓毒性休克尽早脓毒性休克尽早(确诊后确诊后1 1小时内小时内)静脉使用抗生静脉使用抗生素素(1B)(1B)n不伴不伴休克的严重脓毒亦休克的严重脓毒亦尽早尽早(确诊后确诊后1 1小时内小时内)静静脉使用抗生素脉使用抗生

18、素(1D)(1D)n使用抗生素前获取病原使用抗生素前获取病原微生物标本微生物标本,但不因为而但不因为而防碍给予抗生素防碍给予抗生素(1D)(1D)抗生素治疗抗生素治疗 Binitial empirical anti-infective therapy include one or more drugs that have activity against all likely pathogens(bacterial and/or fungal)and that penetrate in adequate concentrations into the presumed source of se

19、psis(Grade 1B).n经验性使用一种或多种经验性使用一种或多种能覆盖可能的病原微生能覆盖可能的病原微生物物(包括真菌包括真菌)广谱抗生广谱抗生素素,并有良好组织穿透力并有良好组织穿透力(1B)(1B)抗生素治疗抗生素治疗the antimicrobial regimen be reassessed daily to optimize activity,to prevent the development of resistance,to reduce toxicity,and to reduce costs(Grade 1C).n每日对抗生素治疗效果每日对抗生素治疗效果进行评估进行评

20、估,保证疗效保证疗效,预预防耐药、减少不良反应、防耐药、减少不良反应、降低费用（降低费用（1C1C）抗生素治疗抗生素治疗(We suggest combination therapy for patients with known or suspected Pseudomonas infections as acause of severe sepsis(Grade 2D).n对已知或疑似假单胞菌感染实施抗生素联合治疗（2D）抗生素治疗抗生素治疗nWe suggest combination empiric therapy for neutropenic patients with sever

21、e sepsis(Grade 2D).n对伴中性粒细胞减少的严重脓毒症患者联合经验使用抗生素（2D）抗生素治疗抗生素治疗When used empirically in patients with severe sepsis,we suggest that combination therapy should not be administered for more than 3 to 5 days.De-escalation to the most appropriate single therapy should be performed as soon as the susceptibi

22、lity profile is known.(Grade 2D).n经验治疗不应超过35天，然后根据药敏结果降阶梯治疗，尽快单一抗生素治疗（2D）抗生素治疗抗生素治疗!We recommend that the duration of therapy typically be 710 days;longer courses may be appropriate in patients who have aslow clinical response,undrainable foci of infection,or who have immunologic deficiencies includ

23、ing neutropenia(Grade 1D).!常规治疗常规治疗7 71010天，对天，对治疗反应差、未确定感治疗反应差、未确定感染源或有粒细胞减少、染源或有粒细胞减少、免疫缺陷者，可适当延免疫缺陷者，可适当延长抗生素使用时间长抗生素使用时间 (Grade 1D).(Grade 1D).抗生素治疗抗生素治疗 nIf the presenting clinical syndrome is determined to be due to anoninfectious cause,we recommend antimicrobial therapy be stopped promptly to

24、 minimize the likelihood that the patient will become infected with an antibiotic resistant pathogen or will develop adrug related adverse effect(Grade 1D).n如果认为非感染因素如果认为非感染因素引起，立即停用抗生引起，立即停用抗生素，以最大限度减少素，以最大限度减少细菌耐药、二重感染细菌耐药、二重感染及不良反应及不良反应(Grade(Grade 1D).1D).内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治

25、疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治控制感染源控制感染源 nWe recommend that aspecific anatomic diagnosis of infection requiring consideration for emergent source control-for example necrotiz

26、ing fasciitis,diffuse peritonitis,cholangitis,intestinal infarction be sought and diagnosed or excluded as rapidly as possible(Grade 1C)and within the first 6 hours following presentation(Grade 1D).n对感染源进行准确对感染源进行准确的解剖学诊断和排的解剖学诊断和排除诊断除诊断(Grade 1C)(Grade 1C)n应在应在6 6小时内完成小时内完成(Grade 1D)(Grade 1D)控制感染源

27、控制感染源nWefurtherrecommendthatallpatientspresentingwithseveresepsisbeevaluatedforthepresenceofafocusofinfectionamenabletosourcecontrolmeasures,specificallythedrainageofanabscessorlocalfocusofinfection,thedebridementofinfectednecrotictissue,theremovalofapotentiallyinfecteddevice,orthedefinitivecontrolo

28、fasourceofongoingmicrobialcontamination(Grade1C)n感染灶的病原学感染灶的病原学检察、引流、坏检察、引流、坏死组织清除，拔死组织清除，拔除可能引起感染除可能引起感染的置管或消除微的置管或消除微生物污染生物污染(Grade(Grade 1C)1C)控制感染源控制感染源nWe suggest that when infected peripancreatic necrosis is identified as apotential source of infection,definitive intervention is best delayed u

29、ntil adequate demarcation of viable and non-viable tissues has occurred(Grade 2B).n如果发现感染源为已感染的坏死胰腺组织时,在未确切区分有活力组织和坏死组织前建议先不要进行手术治疗(2B)严重脓毒症的治疗严重脓毒症的治疗 nWe recommend that when source control is required,the effective intervention associated with the least physiologic insult be employed e.g.,percutan

30、eous rather than surgical drainage of an abscess(Grade 1D).300 mg hydrocortisone daily not be used in severe sepsis or septic shock for the purpose of treating septic shock(Grade 1A).D对于严重脓毒症或对于严重脓毒症或脓毒性休克，皮质脓毒性休克，皮质激素用量不应大于激素用量不应大于对应氢化可的松对应氢化可的松300 mg 每天(Grade 1A).皮质激素皮质激素We recommend corticosteroi

31、ds not be administered for the treatment of sepsis in the absence of shock.There is,however,no contraindication to continuing maintenance steroid therapy or to using stress does steroids if the patients endocrine or corticosteroid administration history warrants(Grade 1D).D对于不伴休克的脓对于不伴休克的脓毒症患者不常规应毒症

32、患者不常规应用皮质激素，除非用皮质激素，除非患者有相关内分泌患者有相关内分泌或皮质激素治疗史或皮质激素治疗史(Grade 1D).内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治重组人活化蛋白重组人活化蛋白C(rhAPC)BWe suggest that

33、adult patients with sepsis induced organ dysfunction associated with aclinical assessment of high risk of death,most of whom will have APACHEII 25 or multiple organ failure,receive rhAPC if there are no contraindications(Grade 2B except for patients within 30 days of surgery where it is Grade 2C).Re

34、lative contraindications should also be considered in decision making B对于伴有脓毒症所致器对于伴有脓毒症所致器官衰竭成人患者官衰竭成人患者,且存且存在临床死亡高危风险在临床死亡高危风险(APACHE(APACHEII 25 or II 25 or multiple organ multiple organ failure)failure)时时,如果无禁如果无禁忌忌,建议应用建议应用rhAPC(2B,rhAPC(2B,术后患者术后患者2C)2C)重组人活化蛋白重组人活化蛋白C(rhAPC)We recommend that

35、adult patients with severe sepsis and low risk of death,most of whom will have APACHE II 20 or one organ failure,do not receive rhAPC(Grade 1A).B对临床死亡危险度对临床死亡危险度较低较低(APACHE II (APACHE II 20 or one organ 20 or one organ failure)failure)的成人脓的成人脓毒症患者不推荐使毒症患者不推荐使用用rhAPC(1ArhAPC(1A)血液制品血液制品Once tissue hy

36、poperfusion has resolved and in the absence of extenuating circumstances,such as myocardial ischemia,severe hypoxemia,acute hemorrhage,cyanotic heart disease,or lactic acidosis(see recommendations for initial resuscitation),we recommend that red blood cell transfusion occur when hemoglobin decreases

37、 to 7.0 g/dL(70 g/L)to target a9.0 g/dL(7090 g/L)in adults(Grade 1B).B一旦组织低灌注得一旦组织低灌注得以改善以改善,且不存在某且不存在某些特殊情况些特殊情况,推荐只推荐只在血红蛋白降至在血红蛋白降至 70 g/L70 g/L时给予红细时给予红细胞胞,使血红蛋白达到使血红蛋白达到707090 g/L(1B)90 g/L(1B)内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&

38、血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治血液制品血液制品BWe recommend that erythropoietin not be used as aspecific treatment of anemia associated with severe sepsis,but may be used when septic patients have other accepted reasons for administration of er

39、ythropoietin such as renal failure-induced compromise of red blood cell production(Grade 1B).B不推荐应用促红细胞生不推荐应用促红细胞生成素治疗脓毒症相关的成素治疗脓毒症相关的贫血贫血,但由其他原因引但由其他原因引起的贫血可考虑适当使起的贫血可考虑适当使用用(1B)(1B)血液制品血液制品BWe suggest that fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence

40、of bleeding or planned invasive procedures(Grade 2D).B除非有出血或即将进行除非有出血或即将进行侵袭性手术操作侵袭性手术操作,否则否则不应使用新鲜冰冻血浆不应使用新鲜冰冻血浆来纠正实验室凝血指标来纠正实验室凝血指标的异常的异常(2D)(2D)血液制品血液制品Bagainst antithrombin administration for the treatment of severe sepsis and septic shock(Grade 1B).B反对使用抗凝血酶治疗反对使用抗凝血酶治疗严重脓毒症和脓毒性休严重脓毒症和脓毒性休克克(1B

41、)血液制品血液制品BIn patients with severe sepsis,we suggest that platelets should be administered when counts are 5000/mm3(5 109/L)regardless of apparent bleeding.Platelet transfusion may be considered when counts are 5,00030,000/mm3(530 109/L)and there is asignificant risk of bleeding.Higher platelet count

42、s(50,000/mm3(50 109/L)are typically required for surgery or invasive procedures(Grade 2D).B当存在下列情况时当存在下列情况时,输输血小板血小板:B无论是否出血无论是否出血,血小板血小板 5000/mm3 B血小板血小板5,00030,000/mm3且存在明显出血风险且存在明显出血风险B需进行外科手术或相关需进行外科手术或相关侵袭性操作侵袭性操作,且血小板且血小板 50,000/mm3 B(Grade 2D)内容提要内容提要&基本概念复习基本概念复习&早期复苏早期复苏&诊断诊断&抗生素治疗抗生素治疗&控制感

43、染源控制感染源&升压药物升压药物&强心治疗强心治疗&皮质激素皮质激素&APCAPC与感染性休与感染性休&血液制品血液制品&相关相关ARDSARDS治疗治疗&镇静、镇痛及肌松镇静、镇痛及肌松&控制血糖控制血糖&CRRTCRRT治疗治疗&相关相关DVTDVT防治防治&应激性溃疡防治应激性溃疡防治脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗BWerecommendthatclinicianstargetatidalvolumeof6ml/kg(predicted)bodyweightinpatientswithALI/ARDS(Grade1B).B将患者潮气量维将

44、患者潮气量维持在持在6 ml/kg 6 ml/kg(1B)(1B)脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗BWe recommend that plateau pressures be measured in patients with ALI/ARDS and that the initial upper limit goal for plateau pressures in apassively inflated patient be 30 cm H2O.Chest wall compliance should be considered in th

45、e assessment of plateau pressure(Grade 1C).B初期平台压维初期平台压维持持 30 cm H2O(1C)脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗Werecommendthathypercapnia(allowingPaCO2toincreaseaboveitspre-morbidbaseline,so-calledpermissivehypercapnia)beallowedinpatientswithALI/ARDSifneededtominimizeplateaupressuresandtidalvolumes

46、(Grade1C).B为将平台压和潮为将平台压和潮气量降至低水平气量降至低水平,容许出现高碳酸容许出现高碳酸血症血症(1C)脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AWe recommend that positive end-expiratory pressure(PEEP)be set so as to avoid extensive lung collapse at end-expiration(Grade 1C).n使用呼气末正压,防止呼气末出现广泛肺萎陷(1C)脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AW

47、e suggest prone positioning in ARDS patients requiring potentially injurious levels of FIO2 or plateau pressure who are not at high risk for adverse consequences of positional changes in those facilities who have experience with such practices(Grade 2C).n对于需要有潜在风险的吸氧浓度或平台压患者,建议采用俯卧位通气,只要变换体位不会造成不良后果

48、(Grade 2C).脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AA)Unless contraindicated,we recommend mechanically ventilated patients be maintained with the head of the bed elevated to limit aspiration risk and to prevent the development of ventilator-associated pneumonia(Grade 1B).B)We suggest that the head o

49、f bed is elevated approximately 3045 degrees(Grade 2C).n除非有禁忌症,否则机械通气患者应保持半卧位,以降低误吸风险,预防呼吸机相关肺炎的发生(1B)n患者头部抬高3045 degrees(Grade 2C).脓毒症相关脓毒症相关ALI/ARDSALI/ARDS的机械通气治疗的机械通气治疗AWesuggestthatnoninvasivemaskventilation(NIV)onlybeconsideredinthatminorityofALI/ARDSpatientswithmild-moderatehypoxemicrespirato

50、ryfailure(responsivetorelativelylowlevelsofpressuresupportandPEEP)withstablehemodynamicswhocanbemadecomfortableandeasilyarousable,whoareabletoprotecttheairway,spontaneouslycleartheairwayofsecretions,andareanticipatedtorecoverrapidlyfromtheprecipitatinginsult.Alowthresholdforairwayintubationshouldbem