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1、2013 SSC International Guidelines for Management of Severe Sepsis and Septic Shock 2016中国急诊感染性休克临床实践指南,Speaker: Cai Han The 1st Affiliated Hospital of Fujian Medical University,Index case,Name: Sun Zu Yu Age: 63years Sex: female ID:0680716admission time:2015.06.292015.07.06 主诉:： repeated fatigue 13
2、years 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。,Index case,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
3、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,Index case,Name: Chen Yi Ming Age: 75years Sex: male ID:Madmission time:2016.02.142016.02.17 主诉：sudden fever and shiver 6 hours 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WBC 12.44
4、109/L，N 11.30109/L，N 90.8，急诊生化：AST 123U/L，糖 9.73mmol/L；肺部CT：双肺炎症,Index case,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
5、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
6、糖肽提高免疫力，易善复保肝及补液营养支持,2.14 19:00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。,Problem list:,In essence, at different stages of the one same disease,SIRS,systemic inflammatory response syndrome General variab
7、les Fever( 38.3C)，Hypothermia低体温 (core temperature 90/min1 or more than two sd above the normal value for age Tachypnea呼吸急促 （20次/min, PaCO2 12,000/ L)Leukopenia (WBC count 20ml/kg over 24hr) Hyperglycemia高血糖症(plasma glucose 140mg/dl or 7.7 mmol/L) in the absence of diabetes,Definition,Sepsis,SIRS is
8、 secondary to documented or suspected infection. Sepsis-induced hypotension Lactate乳酸 above upper limits laboratory normal Urine output 176.8 mol/L Acute lung injury with Pao2/Fio2（OI） 34.2 mol/L PLT 1.5),Definition,Definition,Septic shock is defined as sepsis-induced hypotension persisting despite
9、adequate fluid resuscitation.,Diagnostic,1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay ( 45 mins) in the start of antimicrobial(s) (grade 1C).At least 2 sets of blood cultures (both aerobic需氧 and anaerobic厌氧 bottles) be obtained before antimicrobial thera
10、py with at least 1 drawn percutaneously经皮地 and 1 drawn through each vascular access device，unless the device was recently (48hrs) inserted (grade 1C).,2. diagnosis of fungus真菌 infection-Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C).葡聚糖试验、半乳甘露聚糖试验 3. Imagi
11、ng studies、Plasma C-reactive protein（CRP）、 Plasma procalcitonin（PCT） Contribute to confirm a potential source of infection (UG).,Diagnostic,Recommendations:,Source Control Antimicrobial Therapy Vasopressors Corticosteroids,Adjunctive Therapy,Blood Product Administratio Mechanical Ventilation of Seps
12、is-Induced ARDs Glucose Control Stress Ulcer Prophylaxis Deep Vein Thrombosis Prophylaxis Nutrition Renal Replacement Therapy Sedation, Analgesia, and Neuromuscular Blockade in Sepsis,Evidence-based medicine,Source Control,1）recommend crystalloids晶体液 be used as the initial fluid of choice in the res
13、uscitation of severe sepsis and septic shock (grade 1B). 2）add to use of albumin白蛋白 in the fluid resuscitation when patients require substantial amounts of crystalloids (grade 2C). 3）recommend against the use of hydroxyethyl starches (羟乙基淀粉）for fluid resuscitation of severe sepsis and septic shock (
14、grade 1B).,Source Control,；,Antimicrobial Therapy,1.Administration of effective intravenous antimicrobials within 1st hour 2a. Initial empiric anti-infective therapy of one or more drugs， have activity against all likely pathogens (bacterial and/or fungal or viral) (grade 1B) 2b. Antimicrobial regim
15、en抗菌药物组合 should be reassessed daily for potential de-escalation降阶梯 (grade 1B),Antimicrobial Therapy,3. Use of low PCT levels or similar biomarkers to assist the cliniciansin the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infec
16、tion (grade 2C),4.duration of therapy :7 to 10 days,Antimicrobial Therapy,5.Antiviral therapy抗病毒治疗 initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).,Antimicrobial Therapy,if the Initial fluid resuscitation did not target a mean arterial pressure (MAP) of 65 mmHg，Vasopressor therapy can be added (grade 1C).,
