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1、全身性感染与感染性休克 What is New?,北京协和医院 杜 斌,严重全身性感染与感染性休克,非特异性损伤引 起的临床反应, 满足 2条标准: T 38C or 90 bpm RR 20 bpm WCC 12,000/mm3 or 10%杆状核,SIRS = systemic inflammatory response syndrome,SIRS及可疑或 明确的感染,Chest 1992;101:1644.,全身性感染 伴器官衰竭,顽固性低血压,SIRS,Sepsis,Severe Sepsis,Septic Shock,全身性感染(sepsis): 定义,确证或可疑的感染, 以及 某些
2、下列指标 一般指标 炎症指标 血流动力学指标 器官功能不全指标 组织灌注指标,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全
3、身性感染(sepsis): 定义,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 定义,Levy
4、MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256,全身性感染(sepsis): 改变定义的原因,诊断标准应当 普遍适用于临床医疗及临床试验
5、具有较高的敏感性和特异性 避免过于复杂以至难以记忆或应用 采用普遍应用的试验指标 适用于成人, 儿童和新生儿,Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, For the International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;
6、 31: 1250-1256,全身性感染(sepsis): 流行病学,Martin GS, Mannino DM, Stephanie Eaton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,全身性感染(sepsis): 流行病学,致病菌 革兰阳性菌 平均每年增加26.3% 真菌 1979年5,231例 2000年16,042例 增加207%,Martin GS, Mannino DM, Stephanie E
7、aton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,全身性感染(sepsis): 流行病学,Martin GS, Mannino DM, Stephanie Eaton S, et al. The Epidemiology of Sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-54.,严重全身性感
8、染: 与常见病的比较,National Center for Health Statistics, 2001. American Cancer Society, 2001. *American Heart Association. 2000. Angus DC et al. Crit Care Med. 2001 (In Press).,全身性感染的医疗费用,2000年 ICU医疗费用的40% 欧洲每年花费 7,600,000,0001 美国每年花费 $16,700,000,0002,Davies A et al. Abstract 581. 14th Annual Congress of t
9、he European Society of Intensive Care Medicine, Geneva, Switzerland, 30 September-3 October 2001 Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:13031310,Surviving
10、Sepsis Campaign: Why?,过去5年间阳性结果的干预措施 严重全身性感染与感染性休克 EGDT 激素 APC 小潮气量通气策略 危重病患者的一般治疗 镇静 严格血糖控制 脱机方案,Surviving Sepsis Campaign (SSC) Guidelines for Management of Severe Sepsis and Septic Shock,Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker
11、 MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM and the SSC Management Guidelines CommitteeCrit Care Med 2004; 32: 858-873 Intensive Care Med 2004; 30: 536-555 available online at www.sccm.org The guidelines were published in both Critical Care Medicine and in Intensive care Medicine, and are ava
12、ilable on-line,Surviving Sepsis Campaign Guideline,最初复苏(initial resuscitation) 诊断(diagnosis) 抗生素治疗(antibiotic therapy) 感染源控制(source control) 液体治疗(fluid therapy) 升压药物(vasopressors) 强心药物(inotropic therapy) 激素(steroids) 活化蛋白C (recombinant human activated protein C) 血液制品(blood product administration),AR
13、DS机械通气(mechanical ventilation of sepsis-induced ALI/ARDS) 镇静(sedation, analgesia, and NMB in sepsis) 血糖控制(glucose control) 肾脏替代(renal replacement) 碳酸氢钠(bicarbonate therapy) DVT预防(DVT prophylaxis) 应激性溃疡预防(stress ulcer prophylaxis) 考虑限制支持治疗水平(consideration for limitation of support),严重全身性感染与感染性休克的治疗,S
14、IRS,Sepsis,Severe Sepsis,Septic Shock,血糖控制非常重要: 最初病情稳定后静脉输注胰岛素 1B 目标范围? 血糖 150 mg/dL 2C血糖控制方案 2C葡萄糖热卡及监测 1B,强化胰岛素治疗严格控制血糖,外科患者的强化胰岛素治疗,Van Den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345:1359-1367,外科患者的强化胰岛素治疗,至随访第12个月, 强化胰
15、岛素治疗可以降低病死率3.4% (p 0.04) 强化胰岛素治疗还可以 住院病死率 34% 血行性感染率 46% 需要肾脏替代治疗的急性肾功能衰竭 41% 输血的中位数 50%,Van Den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345:1359-1367,危重病患者的强化胰岛素治疗,平均血糖水平下降 152.3 vs. 130.7 mg/dL (P .001) 高血糖( 200 mg/dL)者减少
16、56.3% 低血糖患者比例未增加 新发肾脏功能不全减少75% (P=.03) 需要输注红细胞的患者比例减少18.7% (P=.04) 住院病死率下降29.3% (P=.002),Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004;79:992-1000,内科患者的强化胰岛素治疗,van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R. Intensive Insulin Therapy in the Medical ICU. N Engl J Med 2006; 354: 449-61,
