感染性休克的延革

1、感染性休克的延革,,指南的延革,Definitions,Sepsis ：infection + SIRSSevere sepsis ：sepsis + sepsis-induced organ dysfunction or tissue hypoperfusionSeptic shock ：sepsis-induced hypotension persisting despite adequate fluid resuscitati

2、onSepsis-induced tissue hypoperfusion ： infection-induced hypotension, elevated lactate, or oliguria.Sepsis-induced hypotension ：SBP 40 mm Hg or less than two standard deviations below normal for age in the absence of

3、 other causes of hypotension.,Crit Care Med,2013,41(2):580-637,Diagnostic Criteria for Sepsis,Infection, documented or suspected, and some of the following:General variablesFever (> 38.3°C)Hypothermia (core te

4、mperature 90/min–1 or more than two SD above the normal value for ageTachypneaAltered mental statusSignificant edema or positive fluid balance (> 20 mL/kg over 24 hr)Hyperglycemia (plasma glucose > 140 mg/dL o

5、r 7.7 mmol/L) in the absence of diabetes,Diagnostic Criteria for Sepsis,Inflammatory variablesLeukocytosis (WBC count > 12,000 μL–1)Leukopenia (WBC count 40 mm Hg in adults or less than SD below normal for age),Dia

6、gnostic Criteria for Sepsis,Organ dysfunction variablesArterial hypoxemia (Pao2/Fio2 0.5 mg/dL or 44.2 μmol/LCoagulation abnormalities (INR > 1.5 or aPTT > 60 s)Ileus (absent bowel sounds)Thrombocytopenia (pla

7、telet count 4 mg/dL or 70 μmol/L)Tissue perfusion variablesHyperlactatemia (> 1 mmol/L)Decreased capillary refill or mottling,Diagnostic Criteria for Sepsis,pediatric population signs and symptoms of inflammation

8、 infection hyper- or hypothermia (rectal temperature > 38.5° or < 35°C), tachycardia (may be absent in hypothermic patients), and at least one of the following indications of altered organ function: al

9、tered mental status hypoxemiaincreased serum lactate levelbounding pulses,Severe Sepsis,Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to th

10、e infection)Sepsis-induced hypotensionLactate above upper limits laboratory normalUrine output 2.0 mg/dL (176.8 μmol/L)Bilirubin > 2 mg/dL (34.2 μmol/L)Platelet count 1.5),感染性休克2008到 2012的延革,初始復(fù)蘇（2008和2012）,復(fù)蘇時(shí)

11、機(jī)低血壓高乳酸血癥≥4mmol/L復(fù)蘇目標(biāo)CVP 8–12 mm HgMAP ≥ 65 mm Hg尿量≥ 0.5 mL/kg/hrSCVO2≥70% or SVO2 ≥ 65%2012版指南：血乳酸正常（2C）,血流動(dòng)力學(xué)支持及輔助治療的沿革,2012,液體治療首選晶體液，反對羥乙基淀粉（1B）白蛋白（2C）30ml/kg晶體液或等量白蛋白（1C）血管活性藥物首選去甲腎上腺素（1B）腎上腺素可加用（或替代

12、）使MAP ≥65mmHg（2B）血管加壓素0.03U/min多巴胺僅限于：心律失常風(fēng)險(xiǎn)極低、絕對或相對心率緩慢的患者（2C）去氧腎上腺素：①去甲腎上腺素出現(xiàn)嚴(yán)重心律失常②高心輸出量，而血壓持續(xù)低③作為聯(lián)合正性肌力藥、升壓藥和血管加壓素仍未達(dá)到目標(biāo)MBP的補(bǔ)救治療（1C）,2008,液體治療晶體液或膠體液（1B）1000ml晶體液或300-500ml膠體液（30min）（1D）血管活性藥物首選去甲腎上腺素或多巴胺（1C）

13、腎上腺素可加用（或替代）使MAP ≥65mmHg（2B）血管加壓素0.03U/min,血流動(dòng)力學(xué)支持及輔助治療的沿革,2012,正性肌力藥心肌功能障礙,心臟充盈壓高,低心輸出量(1C)充足的血容量和MBP,依然低灌注時(shí)(1C)不建議心臟指數(shù)超正?；呗?1B)糖皮質(zhì)激素液體復(fù)蘇和血管活性藥物仍未能達(dá)到血流動(dòng)力學(xué)穩(wěn)定,氫化可的松200mg/d (2C),2008,正性肌力藥心肌功能障礙,心臟充盈壓高,低心輸出量(1C)不

14、建議心臟指數(shù)超正?；呗?1B)糖皮質(zhì)激素液體復(fù)蘇和血管活性藥物仍未能達(dá)到血流動(dòng)力學(xué)穩(wěn)定(2C)氫化可的松≤300mg/d (1A),感染問題的延革（2012）,診斷1,3 beta-D-glucan assay (grade 2B)mannan and anti-mannan antibody assays (2C)抗感染藥物盡可能覆蓋所有可疑病原菌（細(xì)菌/真菌/病毒）（1B）病毒感染所致的嚴(yán)重感染或感染性休克，遲

15、早抗病毒治療。（2C）對缺乏明確感染證據(jù)的患者，可使用PCT或類似生物標(biāo)志物停用抗生素。（2C）感染的預(yù)防SOD和SDD預(yù)防VAP（2B）,其他輔助治療的延革,感染性休克延革帶來了困惑該如何看待指南？,指南,Guidelines are the product of an explicit, systematic approach to the evaluation and synthesis of available info

16、rmation on a particular clinical topic.Guidelines also represent the best available synthesis of contemporary knowledge in this area, and for this reason we believe they must be promoted.,Implementation of a sepsis inte

17、rvention program as a standard of care in a typical hospital protocol leads to improvements in processes of care.,指南,Guidelines are not a compilation of truths.Guidelines are not rules.Guidelines do not establish legal

18、 standards of practice.A strong rating for any particular recommendation does not preclude further research.,Critical Care 2008, 12:162,Guidelines are the product of an explicit, systematic approach to the evaluation an

19、d synthesis of available information on a particular clinical topic.Their reliability depends on three factorsthe extent to which all relevant evidence is sought for evaluationthe quality of the available evidencethe

20、 rigour of the evaluation process used,GRADE,Grading of Recommendations, Assessment, Development, and Evaluation methodology which assigns a measure of the strength of the recommendation based not only on the evidence,

21、 but also on factors such as cost, plausibility, toxicity, and clinician acceptance.This method provides a more nuanced synthesis of data and, in the current guidelines, the strength of recommendation was established th

22、rough a formal voting process, in recognition of the fact that in many areas participants had divergent interpretations of the evidence.a strong Grading of Recommendations, Assessment, Development, and Evaluation recomm