2012+2016感染性休克指南解读

2013SSCInternationalGuidelinesforManagementofSevereSepsisandSepticShock2016中国急诊感染性休克临床实践指南Speaker:CaiHanThe1stAffiliatedHospitalofFujianMedicalUniversityIndexcase•Name:SunZuYuAge:63yearsSex:femaleID:0680716admissiontime:2015.06.29—2015.07.06•主诉:：repeatedfatigue13years•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。Indexcase•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Baseline（6.29）（7.3）WBC6.104.54N%51.449.5Lac//PH//TB67.2↑56.5↑ALB24.5↓30.4↑ALT29↓35↓CHE1197↓1281↓Cr74.675GRR56.8358.11CRP9.26↑14.22↑PCT0.05/IL-6117.4↑/Pro-BNP168/INR1.53↑1.53↑肺部CT上腹部MRI+增强6.296.307.17.27.37.47.57.6Baseline（6.29）（7.3）SIRS（7.5）sepsis/Septicshock（7.6）WBC6.104.542.05↓5.65N%51.449.565.777.7↑Lac//9.04↑12↑PH///7.25↓TB67.2↑56.5↑46.9↑ALB24.5↓30.4↑25.7↑ALT293531CHE1197↓1281↓772↓Cr74.675121.1↑212.6↑GRR56.8358.11CRP9.26↑14.22↑13.28↑22.92↑PCT0.05/2.04↑39.5↑IL-6117.4↑/317↑5000↑Pro-BNP168/4100↑INR1.53↑1.53↑2.19↑culturesEscherichiacoli(+)*2Indexcase•Name:ChenYiMingAge:75yearsSex:maleID:Madmissiontime:2016.02.14—2016.02.17•主诉：suddenfeverandshiver6hours•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WBC12.44×109/L，N11.30×109/L，N％90.8％，急诊生化：AST123U/L，糖9.73mmol/L；肺部CT：双肺炎症Indexcase•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，薄芝糖肽提高免疫力，易善复保肝及补液营养支持门诊（2.14）变症（2.14）WBC12.44↑11.89↑N11.30↑10.86↑N%90.8↑91.4↑Cr83.3CRP120↑PCT10↑Pro-BNP4800↑INR1.43↑2.1419:00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。Problemlist:SIRSSepsis脓毒症SepticshockInessence,atdifferentstagesoftheonesamediseaseSIRSsystemicinflammatoryresponsesyndromeGeneralvariables①Fever(38.3°C)，Hypothermia低体温(coretemperature36°C)②Heartrate90/min–1ormorethantwosdabovethenormalvalueforage③Tachypnea呼吸急促（20次/min,PaCO232mmHg)④Inflammatoryvariables炎症反应参数Leukocytosis(WBCcount12,000/μL)Leukopenia(WBCcount4000/μL)NormalWBCcountwithgreaterthan10%immatureformsDefinitionSIRS⑤Alteredmentalstatus⑥Significantedemaorpositivefluidbalance(20ml/kgover24hr)⑦Hyperglycemia高血糖症(plasmaglucose140mg/dlor7.7mmol/L)intheabsenceofdiabetesDefinitionSepsisSIRSissecondarytodocumentedorsuspectedinfection.Sepsis-inducedhypotensionLactate乳酸aboveupperlimitslaboratorynormalUrineoutput0.5mL/kg/hrCreatinine176.8μmol/LAcutelunginjurywithPao2/Fio2（OI）250mmHgBilirubin胆红素34.2μmol/LPLT100,000μLCoagulopathy凝血障碍(INR1.5)DefinitionDefinitionSepticshockisdefinedassepsis-inducedhypotensionpersistingdespiteadequatefluidresuscitation.Diagnostic•1.Culturesasclinicallyappropriatebeforeantimicrobialtherapyifnosignificantdelay(45mins)inthestartofantimicrobial(s)(grade1C).Atleast2setsofbloodcultures(bothaerobic需氧andanaerobic厌氧bottles)beobtainedbeforeantimicrobialtherapywithatleast1drawnpercutaneously经皮地and1drawnthrougheachvascularaccessdevice，unlessthedevicewasrecently(48hrs)inserted(grade1C).2.diagnosisoffungus真菌infection--Useofthe1,3beta-D-glucanassay(grade2B),mannanandanti-mannanantibodyassays(2C).葡聚糖试验、半乳甘露聚糖试验3.Imagingstudies、PlasmaC-reactiveprotein（CRP）、Plasmaprocalcitonin（PCT）Contributetoconfirmapotentialsourceofinfection(UG).DiagnosticRecommendations:SourceControlAntimicrobialTherapyVasopressorsCorticosteroidsAdjunctiveTherapyBloodProductAdministratioMechanicalVentilationofSepsis-InducedARDsGlucoseControlStressUlcerProphylaxisDeepVeinThrombosisProphylaxisNutritionRenalReplacementTherapySedation,Analgesia,andNeuromuscularBlockadeinSepsisEvidence-basedmedicineSourceControl1）recommendcrystalloids晶体液beusedastheinitialfluidofchoiceintheresuscitationofseveresepsisandsepticshock(grade1B).2）addtouseofalbumin白蛋白inthefluidresuscitationwhenpatientsrequiresubstantialamountsofcrystalloids(grade2C).3）recommendagainsttheuseofhydroxyethylstarches(羟乙基淀粉）forfluidresuscitationofseveresepsisandsepticshock(grade1B).SourceControl•；achieve≥30mL/kgofcrystalloidsadministrationQuantity量MAP、SVV、CO、SBP、HRmonitoringIndex监测指标•CVP8-12mmH2O，•MAP≥65mmHg，•Urineoutput≥0.5ml/kg/h，•ScvO2≥70%或SvO2≥65%GoalsforInitialResuscitation(6hrs)复苏目标AntimicrobialTherapy•1.Administrationofeffectiveintravenousantimicrobialswithin1sthour•2a.Initialempiricanti-infectivetherapyofoneormoredrugs，haveactivityagainstalllikelypathogens(bacterialand/orfungalorviral)(grade1B)•2b.Antimicrobialregimen抗菌药物组合shouldbereassessedda