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1、安徽省立医院 重症医学科 周树生,真菌性脓毒症诊治进展,The Epidemiology of Sepsis in the United States from 1979 through 2000,N Engl J Med 2003; 348:1546-1554,Long-term mortality and medical care charges in patients with severe sepsis.,Crit Care Med. 2003 Sep;31(9):2316-23.,Cumulative mortality rate among patients with severe
2、 sepsis,Distribution of various microorganisms and sites of infection in severe sepsis patients and the outcome according to the microorganisms and sites of infection in severe sepsis patients,Crit Care Med 2007; 35: 2538-2546,Epidemiology of severe sepsis in critically ill surgical patients in ten
3、university hospitals in China,Characteristics of critically ill patients in ICUs in mainland China,Crit Care Med. 2013 Jan;41(1):84-92,Patient Outcome and Risk Factors There were 1,034 survivors: 986 (76.0%) were discharged home, and 48 (3.7%) were still in the hospital on November 30, 2009. There w
4、ere 263 nonsurvivors (20.3%): 211 died in the ICU, and the other 52 died in the general wards.,Bin Du, MD; Youzhong An, MD; Yan Kang, MD et al;,2004年，11个国际医学组织的感染和脓毒症诊治方面的专家，出版了第一个改进重症脓毒症和脓毒症休克预后的指南。这个工作组联合其他工作组在2006年和2007年再次举行会议，用新的循证方法论系统来评估证据的质量和推荐力度，以更新该指南文件。这些建议的目的是用来指导临床医生治疗重症脓毒症和脓毒症性休克的病人。需要指
5、出的是，当医生面对具体病人独特的临床指标时，这些指南中的建议不能取代临床医生的决策。,2008 2012 11个国际组织 15个国际组织 29个国际组织 44位委员 55位委员 69位委员 135篇参考文献 341篇参考文献 636篇参考文献,Chest.1992 Jun;101(6):1644-55,不足之处：标准存在的敏感性高但特异性差的问题,ACCP/SCCM 1992,Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis,New diag
6、nostic Criteria for Sepsis:2012,Crit Care Med. 2013 Feb;41(2):580-637.,New diagnostic Criteria for Sepsis:2012,Crit Care Med. 2013 Feb;41(2):580-637.,One case:女性，85岁，住院号：2260073,主诉：患者系“反复咳嗽、咳痰三年，加重一周”入院 入院时间：2013年3月26日 转入时间：2013年4月05日 诊疗过程：入我院干部病房后出现发热现象，同时伴有胸闷、气喘加重，痰培养示细菌（嗜麦芽窄食假单胞菌及热带念珠菌）；2012年5月行肺
7、CT检查示“间质性肺炎”,One case:女性，85岁，住院号：2260073,2013年4月5日出现呼吸困难加重，氧饱和度下降至82%，予以积极的对症处理后，症状 不能改善，故转入我科加强治疗。,转入后检查,急诊生化 K5.05mmol/L,Na141.1mmol/L,CL113.0mmol/L,Ca1.46mmol/L,CREA248.4umol/L CO2 15.8 mmol/L,AG 17.30,GLU 3.01mmol/L,ALB 16.3g/L,入科诊断：重症医院获得性肺炎(吸入性)；感染性休克？；呼吸衰竭(型)；间质性肺疾病(IPF/IIP)；3级高血压，极高危；老年性痴呆；慢
8、性肾衰竭。诊疗计划： 1、一般治疗，纠正休克； 2、气管插管、机械通气（轻度镇痛镇静）； 3、抗感染治疗（头孢哌酮舒巴坦 2.0 静脉滴注 q12h ;灭滴灵注射液 0.5g 静脉滴注 bid;）； 4、补液、营养支持及维持水电解质平衡等对症支持处理；,血气分析+乳酸: PH 7.072,PCO2 32.6mmHg,PO2 47.2mmHg,ABE -19.1mmol/L SBE -19.0mmol/L，Lac 5.5mmol/L。 CURB-65评分:4分,同时，进一步完善病原学诊断（血培养，痰培养等）,Because invasion of the lung parenchyma by C
9、andida species with resulting Candida pneumonia is a rare event, controversy surrounds this entity. In fact, the isolation of candidal species from respiratory secretions is most often not clinically significant.,Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128.,An official American Thoracic Soci
10、ety statement: Treatment of fungal infections in adult pulmonary and critical care patients.,At Memorial Hospital and New York Hospital, 30 patients.The Candida pulmonary disease appeared to be significant clinical factor in only three cases.Pulmonary disease caused by Candida species. Am J Med. 197
11、7 Dec;63(6):914-25.,To date, few data are available on the Candida species that cause PC, It is of note that in our series, the various non-albicans species of Candida did not appear to be more likely to cause PC than is Candida albicans.,Pulmonary candidiasis in patients with cancer: an autopsy stu
12、dy. Clin Infect Dis. 2002 Feb 1;34(3):400-3. Epub 2001 Dec 17.,ANCA：C-ANCA（-）及P-ANCA（-）,尿常规：阴性,4月07日,4月08日,4月09日,4月10日,4月11日,4月12日,4月13日,升压药物去甲肾难以撤除，尿量逐渐减少,调整抗生素 （替考拉宁）,?,转入后检查,复查床边胸片无明显进展性改变。,It is a clinical syndrome in which focal infiltrates begin with some clinical association of acute pulmonar
13、y infection(i.e.fever,expectoration,malaise,or dyspnea)and despite a minimum of 10 days of antibiotic therapy patients either do not improve or worsen clinically or radiographic opacities fail to resolve within 12 weeks of the onset of the pneumonia.,Nonresolving pneumonia（无反应性肺炎）,Curr Opin Pulm Med
14、. 2005 May;11(3):247-52.,Progressive and nonresolving pneumonia.,Nonresolving pneumonia definitions（无反应性肺炎）,Failure to respond to antimicrobial treatment was classified as nonresponding or progressive pneumonia.Nonresponding pneumonia was defined as persisting fever38and/or clinical symptoms (malais
15、e,cough,expectoration,dyspnea)after at least72h of antimicrobial treatment.,Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications. Am J Respir Crit Care Med. 2000 Jul;162(1):154-60.,444 patients, 49 patients (11%) had a repeated investigat
16、ion because of antimicrobial treatment failure.,Considerations when a patient with community-acquired pneumonia is not improving,1、女性，85岁； 2、“反复咳嗽、咳痰三年，加重一周伴胸闷、气喘”，长期服用抗生素及激素； 3、抗生素治疗效果差（无反应）； 4、CD4/CD8=1.1,总结分析病史特点：,诊断：无反应性肺炎,Results: Treatment failure occurred in 215 patients (15.1%): 134 early failure (62.3%) and 81 late failure (37.7%).The causes were infectious in 86 patients (40%),non-infectious in 34 (15.8%).,
