毒血癥膿毒血癥休克的臨床診治路徑

1、低血壓急診處置路徑,（一）適用對象,第一診斷為低血壓,（二）診斷依據(jù),有引起血壓下降的原發(fā)?。?血容量不足（出血、嚴重嘔吐、腹瀉）、感染、創(chuàng)傷、疼痛、過敏、心源性、中毒、降壓藥物過量、低血糖反應(yīng)、肺栓塞、糖尿病高滲綜合癥。,有低血壓癥狀：,頭暈、視物模糊、乏力、心悸、皮膚濕冷、意識改變、尿,量減少等。,血壓值：,收縮壓（SBP）≤90/60mmHg，動脈平均壓（MAP）≤60mmHg 或收縮壓（SBP）較基礎(chǔ)水平下降≥40 mmH

2、g，,脈壓差減少。,（三）急診就診,評估生命體征，保證氣道通暢,病史體檢查找低血壓的原因,給氧，開放靜脈通道,心電監(jiān)護、脈搏氧飽和度和自動血壓監(jiān)測，,12導(dǎo)聯(lián)心電圖 ，床邊胸部X線檢查,（四）低血壓的治療,1,快速鑒別低血壓原因詳細詢問病史全面體格檢查完善輔助檢查血容量不足（出血、嚴重嘔吐、腹瀉）、感染、創(chuàng)傷、疼痛、過敏、心源性、中毒、降壓藥物過量、低血糖反應(yīng)、肺栓塞、糖尿病高滲綜合癥,11. 液

3、體復(fù)蘇,晶體溶液(如生理鹽水和等張平衡鹽溶液)或膠體溶液(如白蛋白和人工膠體液)。,建立快速靜脈通路，中心靜脈導(dǎo)管以及肺動脈導(dǎo)管。,22.輸血治療,在補充血液容量的同時，酌情補充血細胞成分，如濃縮紅細胞、新鮮冰凍血漿、血小板、凝血因子、纖維蛋白原等。,注意輸血不良反應(yīng)甚至嚴重并發(fā)癥。,33. 血管活性藥與正性肌力藥,足夠的液體復(fù)蘇后仍存在低血壓或者輸液還未開始的嚴重低血壓病人．,不常規(guī)使用血管活性藥，才考慮應(yīng)用血管活性藥與正

4、性肌力藥。,血管活性藥物的選擇,（1）多巴胺 作用于多巴胺受體、β1-受體和α-受體。11-,3μg／(kg·min) ，使血管擴張，增加尿量；22-l0μg,(kg·min)時主要作用B-受體，增強心肌收縮能力而增加心輸出量，也增加心肌氧耗；>10μg (kg·min)時以α-受體興奮為主，收縮血管。,（2） 多巴酚丁胺 β1、β2受體激動劑，使心肌收縮力增,強， 血管擴張和減少后負荷。,（3）

5、去甲腎上腺素，主要效應(yīng)是增加外周阻力來提高血壓，,同時也不同程度地收縮冠狀動脈。,44.原發(fā)病的治療,過敏性休克,感染性休克,神經(jīng)源性休克,心源性休克,外傷性休克,（五）輔助檢查,11.必需檢查項目：,（1）血常規(guī)+血型、尿常規(guī)+酮體、便常規(guī)+潛血、網(wǎng)織紅,細胞；,（2）凝血功能、肝腎功能、血糖、血脂、電解質(zhì)、血沉、C,反應(yīng)蛋白、血乳酸；,（3）胸部正側(cè)位片、心電圖、腹部B超。,2.根據(jù)患者情況進行：,血氣分析、CT、D-二聚體、血管超

6、聲、心臟超聲、診斷,性穿刺等檢查，條件允許行血流動力學(xué)監(jiān)測。,（六）治療方案與藥物選擇,評估引起低血壓原發(fā)病因，立即液體復(fù)蘇。,監(jiān)測皮溫、神志、血壓、心率、尿量，必要時有創(chuàng)血流動力學(xué),監(jiān)測（MAP、CVP和PAWP、CO和SV）。,血管活性藥物。,根據(jù)患者具體情況可輸注血液制品。,臨床評估，根據(jù)患者病情變化調(diào)整治療。,根據(jù)患者病情，內(nèi)科保守治療無效可必要時行外科手術(shù)治療。,對癥支持治療，控制血糖、預(yù)防感染。,（七）出院標準,1.生命體征

7、平穩(wěn)，癥狀好轉(zhuǎn)，無活動性出血，低血,容量的病因得以改善。,2.血流動力學(xué)穩(wěn)定。,3.無其他需要繼續(xù)住院處理的并發(fā)癥。,（八）變異及原因分析,伴有影響本病治療效果的合并癥，需要進行相關(guān)診斷和治療。,病情較重，需要手術(shù)相關(guān)科室治療，轉(zhuǎn)入相應(yīng)路徑。,常規(guī)治療無效或加重，轉(zhuǎn)入相應(yīng)路徑。,出現(xiàn)嚴重并發(fā)癥。,嚴重膿毒癥及膿毒性休克,急診處置路徑,Epidemiology in the US,Leading cause of death in the

8、 non-coronary ICU.,750,000 new cases that occur in the United States each year.,Grow at a rate of 1.5% per year as medicine becomes more aggressive.,Mortality is 30% to 50% for severe sepsis and 50% to 60% for septic sho

9、ck.,Accounting for 40% of total ICU expenditure,Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea--Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G,Zimmerman JL, Vincent JL, Levy MM and the SSC

10、Management Guidelines Committee。 Crit Care Med 2004;32:858--873 Intensive Care Med2004;30:536--555,Sepsis: A Complex Disease,Adapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S8

11、1-2.,Sepsis mortality in Cooper（USA）40353025,PercentMortality,0,2015105,Trauma,Acute MI,SevereSepsis,診斷治療的難度Sepsis心肌梗死,癥狀心電圖酶學(xué)標志物,86% said that symptomsof sepsis can easilyb

12、e misattributed to otherconditions.89% said doctors areeager for a breakthroughin treating sepsis.,病例,患者 男性，84歲，因“意識障礙半天”來診。,患者因腦出血后遺癥長期臥床，近一周出現(xiàn)精神倦怠，進食少，有嗆咳，三天來呼之不應(yīng)，測,體溫35.2 ℃，有痰不易咳出，來急診。,初步診斷？,進一步檢查？,診斷的難度,嚴

13、重膿毒癥,膿毒癥高熱T>38.3OC (101. OF),寒戰(zhàn)血白細胞升高>12000/mm3低體溫T90bpm血白細胞降低20bpm,????????,SBP2.0mg/dl(176.8mmol/L)超過2小時排尿量2.0mg/dl(34.2mmol/L)血小板計數(shù)2mmol/L(18.0mg/dl),非糖尿病患者血糖升高>120mg/dl ???,凝血功能異

14、常，(INR>1.5 或aPTT>60秒 )雙肺浸潤性改變PaO2/FiO290%,2004, 2008 Guideline,Sponsoring Organizations,American Association of Critical Care NursesAmerican College of Chest Physicians,American College of Emergency PhysiciansAm

15、erican Thoracic Society,Australian and New Zealand Intensive Care Society,European Society of Clinical Microbiology and Infectious DiseasesEuropean Society of Intensive Care MedicineEuropean Respiratory SocietyInterna

16、tional Sepsis Forum,Society of Critical Care MedicineSurgical Infection Society,診斷突破--標志物？,診斷？,預(yù)后？,敏感性？,特異性？,PCT and CRP have been most widelyy used,, but even these have limitedability to distinguish sepsis from other

17、 inflammatory conditions or to predictoutcome.,Many biomarkers have been evaluated for use in sepsis. Most of thebiomarkers had been tested clinically, primarily as prognostic markers insepsis; relatively few have bee

18、n used for diagnosis. None has sufficientspecificity or sensitivity to be routinely employed in clinical practice.,)ality(%Morta,Sepsis Protocols:Implementation Consistently Reduces Mortality,53,48,41,29,20,20,6040,C

19、ontrol,28*,27 *,30*,0,PProtocoll,?,?,?,Sebat,Kortgen,Shapiro,Micek,*P < .05 compared with control; ?In-hospital mortality; ?28-day mortality.Sebat F, et al. Chest. 2005;127:1729-1743; Kortgen A, et al. Crit Care Me

20、d. 2006;34(4):943-949; Shapiro NI,et al. Crit Care Med. 2006;34(4):1025-1032; Micek ST, et al. Crit Care Med. 2006;34(11):2707-2713.,Sepsis Protocols: Economic Benefit,Significant difference in median per-patient costs

21、 (black lines),Per-patient Cost Before and AfterProtocol Implementation,$21,985 before$16,103 afterAttributable to ICU and ward bed daychargesSignificantly lower median length ofstay by 5 days (P = .023)

22、Shorr AF, et al. Crit Care Med. 2007;35(5):1257-1262.,Improvement in Process of Careand Outcome After a MulticenterSevere Sepsis Educational Program,in Spain,Ferrer R, Artigas A, Levy MM, et al.,JAMA 2008;

23、299(19):2294--2303,Results,2600 severe sepsis patients,Pre--intervention,Intervention with SSC bundlesLong term follow--up,Improved compliance,Decreased mortality which was sustained,P = 0.04,Statistically significant c

24、ompliance maintained inmanagement bundle but lost in resuscitationbundle.,GRANDEARROYO,O,MEMORIALSAINTFRANCIS,M,STJOSEPH'SST,TOCKTON,MERCEDMERCY,Y,HOSPITALMETHODIST,H,SESIENASTRO,NTACRUZDOMINICANSA,RY'SRENO,STM

25、AR,HOSPITALCALIFORNIA,H,MERCYBAK,KERSFIELD,GENERALMERCY,NGBEACH,STMARYLON,WOODLANDHEA,ALTHCARE,DELIMASTROSE,E,STBER,RNARDINE,MEMORIALGLENDALE,M,MARTINSTROSESAN,N,HOSPITALMARKTWAIN,H,MEMORIALBAKERSFIELD,M,PHOENIXSTJOSEPH&

26、#39;S,ROSCOENORTHRIDGE,E,S,STMARY'SSANFR,RANCISCO,CENTERMARIANMEDICA,AL,SANJUANMERCY,S,REGIONALCHANDLER,FOLSOMMERCY,Y,S,CENTERSTJOHNSMEDICA,AL,NEVADASIERRA,A,STEL,LIZABETH,HOSPITALFRENCH,H,GILBERTMERCY,Y,COM,MMUNITYS

27、ANBER,RNARDINO,PLE,HOSPITALEASANTVALLEY,REDDINGMERCY,Y,HOSPITALSEQUOIA,H,SHASTAMERCYMT,T,CHW Mortality RateThrough 2008Catholic Healthcare WestFY07 Sepsis Mortality Rate by Hospital compared to FY08 Feb YTD

28、60.0%,FY07 CHWM edian32.3%,FY08 CHWM edian26.6%,50.0%40.0%30.0%20.0%10.0%0.0%,Baseline Mortality Rate,FY08 Mortality Rate,FY07 CHW Median Mortality,FY08 CHW Median Mortality,Conclusions,A national

29、 educational effort to promotebundles of care for severe sepsis and septicshock was associated with improved,guideline compliance and lower hospitalmortality. However, compliance rates werestill low, and the impro

30、vement in theresuscitation bundle lapsed by 1 year.,Networks,?,North America,?,Europe,?????????,ColoradoCalifornia: SutterBaltimore/D.C.IHIKansasPuerto RicoTexas (State--wide)Illinois? Chica

31、goMinnesota,?????????,United KingdomIrelandGermanyPortugalSpainNetherlandsItalyCroatiaPoland,Latin America,? Minneapolis,?,SCCM Collaborative,?,East Coast Collab,?,?,Brazil,?,Chile,?,West Coast

32、 Collab,?,AsiaChina?,（一）適用對象,嚴重膿毒癥,膿毒性休克,（二）診斷依據(jù),2001年國際膿毒癥定義診斷標準,系統(tǒng)性炎癥反應(yīng)綜合癥(SIRS),1.體溫>38ºC或<36ºC,2.心率>90次/分,3.呼吸>20次/分或PaCO2<4.3 kPa(32mmHg),4.白細胞計數(shù)>12×109/L或10,膿毒癥,有SIRS,有感染證據(jù)，且具有

33、SIRS指標兩項或兩項以上者,（二）診斷依據(jù),2001年國際膿毒癥定義診斷標準,嚴重膿毒癥,膿毒癥+ 器官功能衰竭,膿毒性休克,癥+,膿毒癥+ 循環(huán)器官功能衰竭((低血壓休克)),表2 下列任意一項器官功能不全表現(xiàn),收縮壓(SBP)<90mmHg或平均動脈壓(MAP)<65mmHg,SBP比基礎(chǔ)值下降>40mmHgg,雙肺浸潤并需吸氧才能維持SPO2>90%雙肺浸潤性改變氧合指數(shù)(PaO2/FiO2)<

34、300,血肌酐>2.0mg/dl(176.8µmol/L)或者尿量2.0mg/dl(34.2µmol/L),血小板計數(shù)<100×109/L,凝血功能異常(INR>1.5或APTT>60秒)乳酸>2mmol/L(18.0mg/dl),（三）急診就診,11.必需檢查項目：,（1）血常規(guī)+血型、尿常規(guī)+酮體、大便常規(guī)+潛血；,（2）凝血功能、肝腎功能、血糖、血脂、電解質(zhì)、血沉、C

35、,反應(yīng)蛋白（CRP）、血乳酸、血氣分析、血培養(yǎng)；,（3）胸部正側(cè)位片、心電圖、腹部B超。,2.根據(jù)患者情況進行：胸腹部CT、D-二聚體、心臟超聲、診,斷性穿刺等有創(chuàng)性檢查，條件允許血流動力學(xué)監(jiān)測等。,3. 評估病情嚴重程度、Apache II 和SOFA 評分。,（四）治療方案的選擇2004年及2008年嚴重膿毒癥及膿毒性休克治療指南，嚴重膿毒癥治療方案包括,1.22.3.44.5.6.,早期復(fù)蘇治

36、療：抗生素治療：感染源的控制：液體療法：血管加壓類藥物及正性肌力藥物：支持治療：機械通氣、鎮(zhèn)靜麻醉藥物應(yīng)用、血糖控制、腎臟替代治療、碳酸氫鹽治療、預(yù)防深靜脈血栓、預(yù)防應(yīng)激性潰瘍。,Severe Sepsis Resuscitation BundleComplete tasks within 6 hours of identifying severe sepsis.,1.2.33.4.5

37、.,a.b.a.b.,Measure serum lactate.Obtain blood cultures prior to antibiotic administration.Administer broad--spectrum antibiotic within 3 hours of ED admission andwithin 1 hour of non-ED admission.In the

38、event of hypotension and/or serum lactate > 4 mmol/L:Deliver an initial minimum of 20 mL/kg of crystalloid or equivalent.Begin vasopressors for hypotension not responding to initial fluidresuscitation to maintai

39、n MAP > 65 mm Hg.In the event of persistent hypotension despite fluid resuscitation (septicshock) and/or lactate > 4 mmol/L:Achieve a central venous pressure (CVP) of > 8 mm HgAchieve a central venous oxyg

40、en saturation (ScvO2) > 70% or mixedvenous oxygen saturation (ScvO2) > 65%,Severe Sepsis Management BundleComplete tasks within 24 hours of identifying severe sepsis.,1.,Administer low--dose steroids for sep

41、tic shock in accordance with a,standardized hospital policy.2. Administer recombinant human activated protein C (rhAPC) in accordancewith a standardized hospital policy.3. Maintain glucose control 80--150 mg/dL

42、.4. Maintain a median inspiratory plateau pressure (IPP) ≤30 cm H20 formechanically ventilated patients.,22. 液體復(fù)蘇,血乳酸≥4mmol/L的嚴重膿毒癥患者，開始標準,液體復(fù)蘇：,2h內(nèi)輸注≥20ml/kg晶體液或等量膠體液(如白蛋白和人工膠體液)。,經(jīng)上述補液后，復(fù)測血乳酸≥4mmol/L，及早放置,中心靜脈導(dǎo)管

43、或肺動脈導(dǎo)管。,33.輸血治療,中心靜脈血氧飽和度降低，Hb <70g/L或紅細胞壓積<30%，輸注懸浮紅細胞。,酌情補充血細胞成分，新鮮冰凍血漿、血小板、凝血因子、纖維蛋白原等。,注意輸血不良反應(yīng)甚至嚴重并發(fā)癥。,44. 抗生素治療,經(jīng)驗治療，聯(lián)合或單用，依據(jù)本地區(qū)常見的致,病菌及藥敏結(jié)果。,血培養(yǎng)（應(yīng)用抗生素前）,針對可能的致病菌及早應(yīng)用廣譜抗生素（急診,患者在來院3h內(nèi)，住院患者在1h內(nèi)）,55.控制感染源,應(yīng)用抗

44、生素,外科感染灶如局部軟組織、肝膿腫、腹腔膿,腫等可以清創(chuàng)、引流或切開手術(shù)治療。,66.嚴重膿毒癥及膿毒性休克的支持治療,機械通氣,鎮(zhèn)靜、麻醉和神經(jīng)肌肉阻斷,血糖控制,腎臟替代治療,碳酸氫鹽治療,深靜脈血栓、應(yīng)激性潰瘍預(yù)防,入選篩查流程圖患者的病史是否支持新出現(xiàn)的感染，并符合表SIRS中的兩項是抽血化驗肝功、腎功、電解質(zhì)、凝血功能，血乳酸、血糖，胸部X線是診斷嚴重膿毒癥或

45、膿毒性休克抗生素應(yīng)用前血培養(yǎng)接診3h內(nèi)應(yīng)用廣譜抗生素是,SBP≤90mmHg，MAP≤65mmHg或血乳酸≥4mmol/L治療方案A＋控制血糖3.88-8.33mmol/L,不存在休克或血乳酸<4mmol/L控制血糖3.88-8.33mmol/L,中心靜脈置管,晶體液或等量膠體液,11. 急診治療流程SBP≤90mmHg或MAP≤65mmHg

46、或乳酸≥4mmol/L開始液體復(fù)蘇(初始至少20ml/kg晶體液或等量膠體液)SBP仍<90mmHg或 MAP仍<65mmHg或初期乳酸≥4mmol/LCVP<8mmHg,MAP<65mmHg,血管活性藥物(首選去甲腎上腺素或多巴胺)血紅蛋白<70g/L輸壓積紅細胞,CVP≥8 mmHgMAPMAP≥65mmHg

47、ScvO270%,66.嚴重膿毒癥的支持治療,機械通氣,鎮(zhèn)靜、麻醉和神經(jīng)肌肉阻斷,血糖控制,腎臟替代治療,碳酸氫鹽治療,深靜脈血栓、應(yīng)激性潰瘍預(yù)防,Source of Infection (MW)MW SS patients,Pneumonia14%UTI21%Abdominal17%,Wound14%Skin3%Unknown14%

48、Catheter17%,Wang Z, Schorr C, Trzeciak SW, Parrillo JE, Dellinger RP. Does patient origin attime of septic shock presentation alter outcomes? Chest 2007; 132(Suppl): 560.,USA,Source of Infection,China,60%

49、40%20%0%,Pneumonia,UT I,Abdominal,Skin,Meningitis,Catheter,Other,Wang Z, Schorr C, Dellinger RP. Comparison of guideline compliance between US and chinain severe sepsis patients from emergence d